Satyan K. Shah

Phase II Study of Dutasteride for Recurrent Prostate Cancer During Androgen Deprivation Therapy

PURPOSE We determined the response rate to and safety of a dual 5alpha-reductase inhibitor, dutasteride, in men with castration recurrent prostate cancer. MATERIALS AND METHODS A total of 28 men with asymptomatic castration recurrent prostate cancer were treated with 3.5 mg dutasteride daily (luteinizing hormone-releasing hormone treatment continued), and evaluated monthly for response and toxicity. Eligibility included appropriate duration antiandrogen withdrawal, baseline prostate specific antigen 2.0 ng/ml or greater and a new lesion on bone scan, increase in measurable disease using Response Evaluation Criteria in Solid Tumors criteria, or 2 or more consecutive prostate specific antigen measurements increased over baseline. Outcomes were progression, stable disease, partial response (prostate specific antigen less than 50% of enrollment for 4 or more weeks) or complete response. RESULTS There were 25 evaluable men with a mean age of 70 years (range 57 to 88), a mean prostate specific antigen of 61.9 ng/ml (range 5.0 to 488.9) and mean Gleason score 8 (range 6 to 10), 15 of whom had bone metastases. Eight men had 10 grade 3 or higher adverse events using National Cancer Institute Common Terminology Criteria, all of which were judged to be unrelated to treatment. Of the 25 men 14 had disease progression by 2 months, 9 had stable (2.5, 3, 3, 4, 4, 5, 5, 8.5, 9 months) disease, 2 had a partial response and none had a complete response. Overall median time to progression was 1.87 months (range 1 to 10, 95% CI 1.15-3.91). CONCLUSIONS Dutasteride rarely produces biochemical responses in men with castration recurrent prostate cancer. However, further study is warranted given its favorable safety profile.

Estimation and Prediction of Renal Function in Patients With Renal Tumor

PURPOSE The goals of surgery for renal tumors include the preservation of renal function. When considering surgical options, it is important to accurately assess renal function and the risk of postoperative chronic kidney disease. MATERIALS AND METHODS An institutional database was used to identify 359 patients who underwent nephrectomy or partial nephrectomy. Creatinine clearance was estimated using 14 previously published models and compared with creatinine clearance measured using a 24-hour urine collection. Models were generated for predicting renal function following nephrectomy or partial nephrectomy. All models were validated with an external data set of 245 patients. RESULTS Models that accurately estimated creatinine clearance preoperatively and postoperatively were the Cockcroft-Gault model based on actual weight, and the Mawer, Björnsson, Hull and Martin models. In patients with an estimated creatinine clearance between 60 and 89 ml per minute preoperatively the risk of chronic kidney disease (creatinine clearance less than 60 ml per minute) after nephrectomy and partial nephrectomy was 58% and 15%, respectively (p <0.001). In patients undergoing nephrectomy age and weight were independent predictors of decreased creatinine clearance. A predictive model based on age and weight was highly accurate when applied to an external population (R = 0.757). A model for predicting renal function after partial nephrectomy based on age and tumor size was highly accurate in the external population (R = 0.848). A Web based tool was developed to estimate current and predict postoperative creatinine clearance (http://www.roswellpark.org/Patient_Care/Specialized_Services/Renal_Function_Estimator). CONCLUSIONS The Cockcroft-Gault model based on actual weight is 1 of 5 models that accurately estimates renal function in patients with a kidney tumor. Models were developed and externally validated to predict renal function following nephrectomy.

Randomized Evaluation of a Web Based Interview Process for Urology Resident Selection

PURPOSE We determined whether a web based interview process for resident selection could effectively replace the traditional on-site interview. MATERIALS AND METHODS For the 2010 to 2011 match cycle, applicants to the University of New Mexico urology residency program were randomized to participate in a web based interview process via Skype or a traditional on-site interview process. Both methods included interviews with the faculty, a tour of facilities and the opportunity to ask current residents any questions. To maintain fairness the applicants were then reinterviewed via the opposite process several weeks later. We assessed comparative effectiveness, cost, convenience and satisfaction using anonymous surveys largely scored on a 5-point Likert scale. RESULTS Of 39 total participants (33 applicants and 6 faculty) 95% completed the surveys. The web based interview was less costly to applicants (mean

SEER Coding Standards Result in Underestimation of Positive Surgical Margin Incidence at Radical Prostatectomy: Results of a Systematic Audit

171 vs

Early growth response 1 and fatty acid synthase expression is altered in tumor adjacent prostate tissue and indicates field cancerization

364, p=0.05) and required less time away from school (10% missing 1 or more days vs 30%, p=0.04) compared to traditional on-site interview. However, applicants perceived the web based interview process as less effective than traditional on-site interview, with a mean 6-item summative effectiveness score of 21.3 vs 25.6 (p=0.003). Applicants and faculty favored continuing the web based interview process in the future as an adjunct to on-site interviews. CONCLUSIONS Residency interviews can be successfully conducted via the Internet. The web based interview process reduced costs and improved convenience. The findings of this study support the use of videoconferencing as an adjunct to traditional interview methods rather than as a replacement.

Trends in United States Prostate Cancer Incidence Rates by Age and Stage, 1995–2012

PURPOSE SEER (Surveillance, Epidemiology and End Results) is the leading source of population level data on prostate cancer, including the positive surgical margin incidence at radical prostatectomy. Recently studies showed wide ranges in positive surgical margin rates among individual registries, which we hypothesized was the result of coding inaccuracies. Thus, we systematically audited SEER prostate cancer data. MATERIALS AND METHODS The New Mexico Tumor Registry, a SEER core registry, was queried for incident prostate cancer cases in 2007 that met certain criteria, including 1) adenocarcinoma histology, 2) malignant behavior and 3) radical prostatectomy as the first course of therapy. Pathological stage codes were audited by examining original radical prostatectomy pathology reports in accordance with SEER coding guidelines. The incidence and sites of positive surgical margins were critically analyzed. RESULTS Of the 305 cases that met all study inclusion criteria with complete source documents available 92 (30%) were coded incorrectly. The most common error was failure to properly account for surgical margin status (46 of 92 cases or 50%). The incidence of positive surgical margins in organ confined disease cases was 13% by SEER coding rules but 28% by a more clinical definition of positive surgical margins (p<0.001). In organ confined cases positive surgical margins occurred principally at the apex but in nonorgan confined cases most were multifocal. CONCLUSIONS In this SEER registry 30% of radical prostatectomy cases in 2007 were coded inaccurately. SEER coding guidelines result in underestimating the positive surgical margin incidence. Clinicians and investigators should recognize the limitations of tumor registry data on positive surgical margins.

Urinary Symptoms After Robotic Prostatectomy in Men with Median Lobes

Field cancerization denotes the occurrence of molecular alterations in histologically normal tissues adjacent to tumors. In prostate cancer, identification of field cancerization has several potential clinical applications. However, prostate field cancerization remains ill defined. Our previous work has shown up‐regulated mRNA of the transcription factor early growth response 1 (EGR‐1) and the lipogenic enzyme fatty acid synthase (FAS) in tissues adjacent to prostate cancer.

Percutaneous ureteral elevation in laparoendoscopic single-site radical nephrectomy.

Background: The advent of PSA testing in the late 1980s substantially increased prostate cancer incidence rates. Concerns about overscreening and overdiagnosis subsequently led professional guidelines (circa 2000 and later) to recommend against routine PSA testing. We evaluated trends in prostate cancer incidence, including late-stage diagnoses, from 1995 through 2012. Methods: We used joinpoint regression analyses to evaluate all-, localized/regional-, and distant-stage prostate cancer incidence trends based on Surveillance, Epidemiology, and End Results (SEER) data. We stratified analyses by age (50–69, 70+). We reported incidence trends as annual percent change (APC). Results: Overall age-adjusted incidence rates for localized/regional stage prostate cancer have been declining since 2001, sharply from 2010 to 2012 [APC, −13.1; 95% confidence intervals (CI), −23.5 to −1.3]. Distant-stage incidence rates have declined since 1995, with greater declines from 1995 to 1997 (APC, −8.4; 95% CI, −2.3 to −14.1) than from 2003 to 2012 (APC, −1.0; 95% CI, −1.7 to −0.4). Distant-stage incidence rates declined for men ages 70+ from 1995 to 2012, but increased in men ages 50 to 69 years from 2004 to 2012 (APC, 1.7; 95% CI, 0.2 to 3.2). Conclusions: Guidelines discouraging routine prostate cancer screening were temporally associated with declining localized/regional prostate cancer incidence rates; however, incidence rates of distant-stage disease are now increasing in younger men. Impact: This trend may adversely affect prostate cancer mortality rates. Cancer Epidemiol Biomarkers Prev; 25(2); 259–63. ©2015 AACR.

Outcomes of laparoscopic partial nephrectomy after fellowship training.

Patients with median lobe enlargement of the prostate have different natural history of lower urinary tract symptoms following robotic prostatectomy as compared with patients without this finding.

Simplified repair technique for laparoscopic partial nephrectomy

Laparoendoscopic single-site radical nephrectomy may be feasible in select patients. Suture-assisted retraction of the ureteral and lower pole attachments facilitate safe dissection.