Jonathan Bergman

Hospice Use and High-Intensity Care in Men Dying of Prostate Cancer

BACKGROUND Hospice programs improve the quality of life and quality of death for men dying of cancer. We sought to characterize hospice use by men dying of prostate cancer and to compare the use of high-intensity care between those who did or did not enroll in hospice. METHODS We used linked Surveillance, Epidemiology, and End Results-Medicare data to identify a cohort of Medicare beneficiaries who died of prostate cancer between 1992 and 2005. We created 2 multivariable logistic regression models, one to identify factors associated with hospice use and one to determine the association of hospice use with the receipt of diagnostic and interventional procedures and physician visits at the end of life. RESULTS Of 14,521 men dying of prostate cancer, 7646 (53%) used hospice for a median of 24 days. Multivariable modeling demonstrated that African American ethnicity (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.68-0.88) and higher Charlson comorbidity index (OR, 0.49; 95% CI, 0.44-0.55) were associated with lower odds of hospice use, while having a partner (OR, 1.23; 95% CI, 1.14-1.32) and more recent year of death (OR, 1.12; 95% CI, 1.11-1.14) were associated with higher odds of hospice use. Men dying of prostate cancer who enrolled in hospice were less likely (OR, 0.82; 95% CI, 0.74-0.91) to receive high-intensity care, including intensive care unit admissions, inpatient stays, and multiple emergency department visits. CONCLUSIONS The proportion of individuals using hospice is increasing, but the timing of hospice referral remains poor. Those who enroll in hospice are less likely to receive high-intensity end-of-life care.

Correlates of Bother Following Treatment for Clinically Localized Prostate Cancer

PURPOSE We determined factors associated with bother, the distress patients experience as a result of functional detriments after treatment for localized prostate cancer. MATERIALS AND METHODS A prospective cohort of men treated for clinically localized prostate cancer completed a questionnaire comprising the UCLA-PCI, Medical Outcomes Study Short Form-36, American Urological Association Symptom Index and Memorial Anxiety Scale for Prostate Cancer fear of recurrence subscale. We used nonlinear mixed models to identify factors associated with severe urinary, sexual and bowel bother. RESULTS Worse function scores were associated with severe urinary, sexual and bowel bother following treatment (OR 0.88-0.94, p <0.001). Worse American Urological Association Symptom Index score was associated with severe urinary bother (OR 1.22, 95% CI 1.16-1.28). Time since treatment was inversely associated with urinary (OR 0.68, 95% CI 0.54-0.83) and bowel bother (OR 0.63, 95% CI 0.47-0.80) early after treatment but not for the entire 48-month study period. Receipt of concomitant androgen deprivation therapy was not associated with bother 48 months after radiation. CONCLUSIONS Addressing functional detriment may confer improvement in urinary, sexual and bowel bother. Patient distress related to dysfunction improves with time. Measuring health related quality of life after prostate cancer treatment should incorporate functional and bother assessments.

Prostate Cancer Severity Among Low Income, Uninsured Men

PURPOSE The proportion of American men with organ confined, low risk prostate cancer has increased significantly during the last 2 decades. Whether this trend also applies to men at the extremes of socioeconomic disadvantage remains unknown. Therefore, we evaluated trends in prostate cancer severity in an ethnically diverse cohort of low income, uninsured men served by a state funded public health program in California. MATERIALS AND METHODS We performed a retrospective cohort study of 570 disadvantaged men enrolled in the California program from 2001 through 2006. Using routinely collected clinical variables we defined 2 measures of cancer severity as 1) the proportion of enrollees with metastases at diagnosis and 2) the proportions of men with nonmetastatic tumors whose cancers had low, intermediate or high risk features at diagnosis. We performed bivariate analyses to assess time trends in cancer severity. RESULTS Prostate specific antigen levels at diagnosis exceeded 10 ng/ml for 51% of enrollees, 50% had a Gleason score 7 or greater and 43% had clinical T stage T2 or greater. Of disadvantaged men 19% had metastatic cancer at diagnosis and this proportion remained stable over time (p = 0.66). Among men with nonmetastatic cancers 24% had tumors with low risk features and the proportion of low risk cancers did not increase over time (p = 0.34). CONCLUSIONS Unlike the broader United States population the proportion of disadvantaged men with organ confined, low risk prostate cancer has not been increasing. Thus, while much attention focuses on potential overdiagnosis and overtreatment of men with screen detected prostate cancer, our findings suggest that for low income, uninsured men, underdetection and undertreatment remain significant concerns.

Prostate cancer survivorship care guideline: American society of clinical oncology clinical practice guideline endorsement

PURPOSE The guideline aims to optimize health and quality of life for the post-treatment prostate cancer survivor by comprehensively addressing components of follow-up care, including health promotion, prostate cancer surveillance, screening for new cancers, long-term and late functional effects of the disease and its treatment, psychosocial issues, and coordination of care between the survivors primary care physician and prostate cancer specialist. METHODS The American Cancer Society (ACS) Prostate Cancer Survivorship Care Guidelines were reviewed for developmental rigor by methodologists. The American Society of Clinical Oncology (ASCO) Endorsement Panel reviewed the content and recommendations, offering modifications and/or qualifying statements when deemed necessary. RESULTS The ASCO Endorsement Panel determined that the recommendations from the 2014 ACS Prostate Cancer Survivorship Care Guidelines are clear, thorough, and relevant, despite the limited availability of high-quality evidence to support many of the recommendations. ASCO endorses the ACS Prostate Cancer Survivorship Care Guidelines, with a number of qualifying statements and modifications. RECOMMENDATIONS Assess information needs related to prostate cancer, prostate cancer treatment, adverse effects, and other health concerns and provide or refer survivors to appropriate resources. Measure prostate-specific antigen (PSA) level every 6 to 12 months for the first 5 years and then annually, considering more frequent evaluation in men at high risk for recurrence and in candidates for salvage therapy. Refer survivors with elevated or increasing PSA levels back to their primary treating physician for evaluation and management. Adhere to ACS guidelines for the early detection of cancer. Assess and manage physical and psychosocial effects of prostate cancer and its treatment. Annually assess for the presence of long-term or late effects of prostate cancer and its treatment.

Surveillance of patients with bladder carcinoma using fluorescent in-situ hybridization on bladder washings.

To compare the sensitivity and specificity of the UroVysionTM (Abbott Laboratories Inc., Downers Grove, IL, USA) fluorescent in‐situ hybridization (FISH) assay to that of urinary cytology obtained from bladder irrigation during cystoscopic surveillance in patients with bladder carcinoma.

Quality of life in men undergoing active surveillance for localized prostate cancer.

Active surveillance is an important arrow in the quiver of physicians advising men with prostate cancer. Quality-of-life considerations are paramount for patient-centered decision making. Although the overall deleterious impact on health is less dramatic than for those who pursue curative treatment, men on active surveillance also suffer sexual dysfunction and distress. Five-year outcomes revealed more erectile dysfunction (80% vs 45%) and urinary leakage (49% vs 21%) but less urinary obstruction (28% vs 44%) in men undergoing prostatectomy. Bowel function, anxiety, depression, well-being, and overall health-related quality of life (HRQOL) were similar after 5 years, but at 6-8 years, other domains of HRQOL, such as anxiety and depression, deteriorated significantly for those who chose watchful waiting. Further research is needed to compare prospectively HRQOL outcomes in men choosing active surveillance and those never diagnosed with prostate cancer, in part to help weigh the potential benefits and harms of prostate cancer screening.

How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients

OBJECTIVES Our goal was to evaluate the utility of the pelvic ring stability examination for detection of mechanically unstable pelvic fractures in blunt trauma patients. METHODS Retrospective chart review. RESULTS We enrolled 1,502 consecutive blunt trauma patients and found 115 patients with pelvic fractures including 34 patients with unstable pelvic fractures (Tile classification B and C). Unstable pelvic ring on physical examination had a sensitivity and specificity of 8% (95% CI 4-14) and 99% (95% CI 99-100), respectively, for detection of any pelvic fracture and 26% (95% CI 15-43) and 99.9% (95% 99-100), respectively, for detection of mechanically unstable pelvic fractures. The sensitivity and specificity of pelvic pain or tenderness in patients with Glasgow Coma Scale >13 were 74% (95% CI 64-82) and 97% (95% CI 96-98), respectively for diagnosing any pelvic fractures, and 100% (95% CI 85-100) and 93% (95% CI 92-95), respectively for diagnosing of mechanically unstable pelvic fractures. The sensitivity and specificity of the presence of pelvic deformity were 30% (95% CI 22-39) and 98% (95% CI 98-99), respectively for detection of any pelvic fracture and 55% (95% CI 38-70) and 97% (95% CI 96-98), respectively for detection of mechanically unstable pelvic fractures. CONCLUSIONS The presence of either pelvic deformity or unstable pelvic ring on physical examination has poor sensitivity for detection of mechanically unstable pelvic fractures in blunt trauma patients. Our study suggests that blunt trauma patients with Glasgow Coma Scale >13 and without pelvic pain or tenderness are unlikely to suffer an unstable pelvic fracture. A prospective study is needed to determine whether a set of clinical criteria can safely detect or exclude the presence of an unstable pelvic fracture.

Erectile Aid Use by Men Treated for Localized Prostate Cancer

PURPOSE We evaluated associations between demographic and clinical characteristics, quality of life outcome measures and erectile aids in men treated for localized prostate cancer. MATERIALS AND METHODS Patients had clinically localized prostate cancer, were not using erectile aids at baseline and chose treatment with radical prostatectomy (275), external beam radiotherapy (70) or brachytherapy (80). Patient characteristics and health related quality of life outcomes were prospectively assessed at baseline and at regular intervals up to 48 months after treatment. Outcomes were assessed with SF-36, the American Urological Association symptom index and UCLA-PCI. We categorized use of a phosphodiesterase type 5 inhibitor, urethral alprostadil suppositories, penile injection therapy or a vacuum erection device after treatment as erectile aid use. We created a multivariate model examining baseline demographic, clinical and health related quality of life covariates associated with erectile aid use. RESULTS Of the 425 patients 237 (56%) used an erectile aid at some point during the posttreatment period. In our multivariate model patients treated with external beam radiation were less likely to use an aid (OR 0.34, 95% CI 0.16-0.69) and men with significant sexual bother (OR 2.68, 95% CI 1.37-5.23), or with 1 or more comorbidities (OR 1.80, 95% CI 1.08-2.93) were more likely to use an aid. Patient demographic characteristics were not associated with erectile aids. CONCLUSIONS After treatment for localized prostate cancer more than half of men use erectile aids, especially when they are significantly bothered by dysfunction. This is most pronounced after radical prostatectomy and in men with significant comorbidity.

Readability of Health Related Quality of Life Instruments in Urology

PURPOSE The average American adult reads at a fifth to eighth-grade level, with wide variability, presenting challenges for the assessment of self-reported health related quality of life. We identified the health related quality of life instruments used in patients with urological diseases and evaluated their readability. MATERIALS AND METHODS We focused on the most burdensome urological diseases, based on total expenditures in the United States. We then identified disease specific instruments by systematically searching PubMed, the Cochrane Database of Systematic Reviews, Google, Google Scholar, the Patient Reported Outcome and Quality of Life Instruments Database (Mapi Research Institute, Lyon, France) and Yahoo! for health related quality of life studies in patients with these urological conditions. Where disease specific instruments were lacking, we noted the general health related quality of life measures most commonly used. For each instrument, we calculated the median Flesch-Kincaid grade level, the proportion of questionnaire items below an eighth-grade reading level, the mean Flesch Reading Ease, and the mean number of words per sentence and characters per word, all of which are validated measures of readability. RESULTS The average +/- SD of the median Flesh-Kincaid reading levels was 6.5 +/- 2.1 (range 1.0 to 12.0). Of the 76 instruments 61 (80%) were at or below an eighth-grade reading level. The mean reading ease was greater than 30 for each of the 76 questionnaires and greater than 60 for 66 (87%). Urinary tract infection, the costliest urological disease, has only 1 disease specific health related quality of life measure. Urolithiasis, the second costliest, has none. CONCLUSIONS The reading level of health related quality of life questionnaires in urology is appropriate for the reading ability of most adults in the United States. However, the most burdensome urological diseases lack disease specific health related quality of life instruments.

Lack of evidence to support routine digital rectal examination in pediatric trauma patients.

Background: Current advanced trauma life support guidelines recommend that a digital rectal examination (DRE) should be performed as part of the initial evaluation of all trauma patients. Our primary goal was to estimate the test characteristics of the DRE in pediatric patients for the following injuries: (1) spinal cord injuries, (2) bowel injuries, (3) rectal injuries, (4) pelvic fractures, and (5) urethral disruptions. Methods: We conducted a nonconcurrent, observational, chart review study of a consecutive series of pediatric trauma patients. We enrolled all patients younger than 18 years seen in our ED from January 2003 to February 2005, for whom the trauma team was activated and who had a documented DRE. For each patient, we reviewed all available clinical documents in a computerized medical record system to identify the DRE findings followed by review of radiological reports, operative reports, and discharge summaries to identify specific injuries. Results: Two hundred thirteen patients met our selection criteria and were included in the analysis. We identified 3 patients with spinal cord injury (1% prevalence), 13 patients with bowel injury (6%), 5 patients with rectal injury (2%), 12 patients with a pelvic fracture (6%), and 1 patient with urethral disruption (0.5%). The DRE failed to diagnose (false-negative rate) 66% of spinal cord injuries, 100% of bowel injuries, 100% of rectal wall injuries, 100% of pelvic fractures, and 100% of urethral disruption injuries. Conclusions: The DRE has poor sensitivity for the diagnosis of spinal cord, bowel, rectal, bony pelvis, and urethral injuries. Our findings suggest that the DRE should not be routinely used in pediatric trauma patients.