Huai-Ching Kuo

A prospective cohort study of treatment decision-making for prostate cancer following participation in a multidisciplinary clinic

BACKGROUND Patients diagnosed with prostate cancer (PCa) are presented with several treatment options of similar efficacy but varying side effects. Understanding how and why patients make their treatment decisions, as well as the effect of treatment choice on long-term outcomes, is critical to ensuring effective, patient-centered care. This study examined treatment decision-making in a racially diverse, equal-access, contemporary cohort of patients with PCa counseled on treatment options at a multidisciplinary clinic. METHODS A prospective cohort study was initiated at the Walter Reed National Military Medical Center (formerly Walter Reed Army Medical Center) in 2006. Newly diagnosed patients with PCa were enrolled before attending a multidisciplinary clinic. Patients completed surveys preclinic and postclinic to assess treatment preferences, reasons for treatment choice, and decisional regret. RESULTS As of January 2014, 925 patients with PCa enrolled in this study. Surgery (54%), external radiation (20%), and active surveillance (12%) were the most common primary treatments for patients with low- and intermediate-risk PCa, whereas patients with high-risk PCa chose surgery (34%) or external radiation with neoadjuvant hormones (57%). Treatment choice differed by age at diagnosis, race, comorbidity status, and calendar year in both univariable and multivariable analyses. Patients preferred to play an active role in the decision-making process and cited doctors at the clinic as the most helpful source of treatment-related information. Almost all patients reported satisfaction with their decision. CONCLUSIONS This is one of the first prospective cohort studies to examine treatment decision-making in an equal-access, multidisciplinary clinic setting. Studies of this cohort would aid in understanding and improving the PCa decision-making process.

Alkaline phosphatase velocity predicts overall survival and bone metastasis in patients with castration-resistant prostate cancer

INTRODUCTION AND OBJECTIVES Identifying patients with prostate cancer (CaP) who will ultimately develop bone metastasis (BM) or die of disease is essential. Alkaline phosphatase velocity (APV) has been shown to predict overall survival (OS) and bone metastasis-free survival (BMFS) in an earlier study of an equal access military patient cohort of patients with castrate-resistant prostate cancer (CRPC). To confirm these findings, we examined a cohort of patients from a high-volume cancer center to validate a previous observation that faster alkaline phosphatase (AP) kinetics are predictive of OS and BMFS in this second cohort of patients. MATERIALS AND METHODS A retrospective cohort study was conducted of patients with CRPC treated at Memorial Sloan Kettering Cancer Center between 1989 and 2010. All patients who received androgen deprivation therapy (ADT) as primary treatment in response to a rising PSA after definitive surgery for CaP were eligible. For those who received primary ADT or surgery followed by ADT, CRPC was defined as one rising PSA value after a PSA nadir ≤4ng/ml, and confirmed by a second rising PSA value, with concurrently documented testosterone levels <50ng/dl. APV was computed as the slope of the linear regression line of all AP values (>2 values per patient) plotted against time. Study outcome included BMFS and OS. Univariable Kaplan-Meier analysis was used to examine time-to-event outcomes. Multivariable Cox proportional hazards regression analysis was used to model time to BMFS and OS. RESULTS Of 89 patients with CRPC with evaluable data and CRPC, 17 (19%) experienced BM and 26 (29%) died. APV was dichotomized at the uppermost quartile split of all observed APV values:≥5.42U/l/y vs. the lower 3 quartiles combined,<5.42U/l/y. Patients with faster APV had significantly worse outcomes, including faster progression to BM and poorer OS when compared with those with slower APV (P = 0.0451 and P = 0.0109, respectively). There was strong correlation between PSA doubling time (PSADT) (<10,≥10mo) and APV (≥5.42U/l/y vs.<5.42U/l/y) (P = 0.0289), preventing simultaneous evaluation of both factors in multivariable analysis. Kaplan-Meier analysis showed that PSADT was also predictive of BM and OS (log-rank P<0.0001). Separate multivariable Cox proportional hazards regression models were used to examine PSADT and APV, as predictors of each study outcome (BMFS and OS). Both PSADT and APV were strongly predictive of BMFS and OS (respectively). CONCLUSIONS APV and PSADT were predictors of BM and OS in patients with CRPC, respectively. These data are additional evidence of the potential value of AP kinetics in patients with advanced CaP. Prospective studies will be required to clarify these associations. However, given the restrictions on the current patient population in excluding metastatic disease within 12 months of ADT and a PSA nadir >4ng/ml, the findings are not inappropriately generalized to other men.

Longitudinal regret after treatment for low‐ and intermediate‐risk prostate cancer

Prostate cancer patients diagnosed with low‐ and intermediate‐risk disease have several treatment options. Decisional regret after treatment is a concern, especially when poor oncologic outcomes or declines in health‐related quality of life (HRQoL) occur. This study assessed determinants of longitudinal decisional regret in prostate cancer patients attending a multidisciplinary clinic and treated with radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy (BT), or active surveillance (AS).

Abstract A005: Patterns in distant metastasis at diagnosis in a racially diverse, longitudinal cohort of prostate cancer patients: 1989-2013

Introduction: The introduction of PSA screening in the U.S. and its nationwide use as a prostate cancer (PCa) screening modality led to a spike in the incidence of localized PCa in the early 1990s. With this shift toward earlier stage disease at presentation, concerns were raised for overdetection and overtreatment of clinically insignificant PCa. In response to such concerns, professional guidelines on PSA screening practices have changed over time. In 2008 the US Preventive Services Task Force (USPSTF) gave PSA screening for detection of prostate cancer a Grade D recommendation for older men (>=75 years), and in 2012 this grade D was extended to men of all age. More recently, in 2017 a draft of revised guidelines was released, elevating the letter Grade to C, only for men aged 55-69 years. Yet three compelling studies have been published that reveal increases in the diagnosis of metastatic PCa (mPCa) in U.S. men, with provocative associations in time to changes in PSA screening guidelines, prompting concern that a stage shift toward more advanced PCa at diagnosis may be occurring. The primary aim of this study was to examine time trends in mPCa at time of diagnosis, over a 20+-year study period, in a racially diverse longitudinal cohort with equal access to health care. The primary hypotheses were that mPCa at diagnosis declined after the introduction of PSA screening and that such declines would be comparable in both Caucasian (CA) and African American (AA) patients in this cohort. Methodology: The Center for Prostate Disease Research (CPDR) Multi-Center National Database was the source of patients for this study. Men under suspicion for PCa and undergoing TRUS-guided biopsy for PCa detection are eligible for enrolment in this database. This study focused on those with biopsy-confirmed PCa between January 1, 1989 and December 31, 2013. Trends in mPCa at the time of diagnosis were examined for the overall cohort, as well as stratified by race (AA and CA) and patient age at CaP diagnosis ( Results: A total of 462 men presented with mPCa and were eligible for inclusion. The decline in APC for the overall cohort was statistically significant (APC = -8.5%, p Conclusions: In this longitudinal, racially diverse cohort with equal health care access, significant declines in mPCa at diagnosis were observed over a 20+-year study period. This is contrast to other recent studies that have demonstrated increases in mPCa following changes in USPSTF guidelines. There was, however, a difference in the magnitude of decrease in oldest patients (≥75 years) compared to younger men, which may have been influenced by changing PSA screening recommendations in 2008 by the USPSTF. Continued attention to shifts in mPCa at diagnosis is needed to determine the impact of changes in screening recommendation. Citation Format: John McCauley, Huai-Ching Kuo, Inger L. Rosner, Yongmei Chen, Lauren Hurwitz, Sean Stroup, Joseph R. Sterbis, Christopher Porter, Timothy C. Brand, Shiv Srivastava, Jennifer Cullen. Patterns in distant metastasis at diagnosis in a racially diverse, longitudinal cohort of prostate cancer patients: 1989-2013 [abstract]. In: Proceedings of the AACR Special Conference: Prostate Cancer: Advances in Basic, Translational, and Clinical Research; 2017 Dec 2-5; Orlando, Florida. Philadelphia (PA): AACR; Cancer Res 2018;78(16 Suppl):Abstract nr A005.