Sean A. Fletcher

Characterizing trends in treatment modalities for localized muscle-invasive bladder cancer in the pre-immunotherapy era

IntroductionMuscle-invasive bladder cancer (MIBC) is an aggressive disease for which treatment strategies are continuously evolving. We characterized trends in treatment modalities for MIBC from 2004 to 2013 (the “pre-immunotherapy era”) and identified predictors of receiving the current standard of care treatment: neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC).MethodsWe used the National Cancer Database to identify individuals diagnosed with clinically localized MIBC from 2004 to 2013. We calculated the yearly prevalence of NAC followed by RC, RC as first treatment, trimodal therapy, chemotherapy and/or radiation alone, and no treatment. We then identified factors associated with receiving NAC prior to RC.ResultsThere was a notable increase in the use of NAC followed by RC over the study period, from 3.68% in 2004 to 14.83% in 2013 (Pu2009<u20090.001). Factors associated with decreased odds of receiving this regimen included being older, Black, uninsured, less educated, and more burdened by comorbidities. Rates of trimodal therapy and chemotherapy and/or radiation alone remained relatively constant (approximately 5 and 17%, respectively). There was a consistent decline in the proportion of patients who did not receive any treatment, down to 34.20% in 2013.ConclusionTrends in localized MIBC treatment have evolved substantially since the early 2000s, and certain patient characteristics are associated with lower odds of receiving the current standard of care. This serves as a foundation from which to judge the impact of the upcoming immunotherapy era on the treatment landscape for this disease.

The effect of treatment at minority-serving hospitals on outcomes for bladder cancer

OBJECTIVESnHealthcare for racial minorities is densely concentrated at a small subset of hospitals in the United States. Understanding long-term outcomes at these minority-serving hospitals is highly relevant to elucidating the sources of racial disparities in cancer care. We investigated the effect of treatment at a minority-serving hospital on overall survival and receipt of definitive treatment for bladder cancer.nnnMATERIALS AND METHODSnUsing the National Cancer Database, we identified all patients diagnosed with clinically localized, muscle-invasive bladder cancer between 2004 and 2012. We defined minority-serving hospitals as institutions in the top decile by proportion of Black and Hispanic patients within this cohort. Univariate and multivariable analyses were performed to assess the sociodemographic, clinical, and hospital-level factors influencing overall survival and receipt of definitive treatment for bladder cancer.nnnRESULTSnIn adjusted analyses, there was no significant difference in overall survival between patients treated at minority-serving hospitals versus those treated at nonminority-serving hospitals (hazard ratio = 0.95, 95% CI: 0.90-1.01). There was also no significance in receipt of definitive treatment between the two hospital types (odds ratio [OR] = 0.85, 95% CI: 0.68-1.06). Black race was independently associated with increased likelihood of mortality (hazard ratio = 1.08, 95% CI: 1.03-1.14) and decreased odds of receiving appropriate definitive treatment (OR = 0.73, 95% CI: 0.66-0.82).nnnCONCLUSIONSnThere was no difference between minority-serving and nonminority-serving hospitals in overall survival or receipt of definitive treatment. Black patients suffered worse survival and were less likely to receive definitive treatment for bladder cancer regardless of the type of hospital in which they were treated.

Impact of Accountable Care Organizations on Prostate Cancer Screening & Biopsies in the United States

Introduction: Accountable care organizations are designed to financially incentivize efficiency and reduce low value care. To determine if accountable care organizations have impacted prostate cancer screening patterns, we analyzed trends in prostate specific antigen screening and prostate biopsies by accountable care organization and nonaccountable care organization providers. Methods: Using a random 20% sample of Medicare claims, we selected men 66 years old or older. In 2014 beneficiaries were attributed to accountable care organization and nonaccountable care organization providers using a modified Medicare Shared Savings Program algorithm. Beneficiaries treated by these same providers in 2010 served as the control population. Inverse probability weighting and difference in differences analyses were used to compare trends in prostate specific antigen screening and prostate biopsies in 2010 and 2014. Analyses were stratified by the age groups 66 to 69 years old and 70 years old or older. Results: Among the beneficiaries treated by accountable care organization and nonaccountable care organization providers, prostate specific antigen screening rates were 62.4% and 60.5% in 2010 vs 55.9% and 54.4% in 2014 in men 66 to 69 years old, respectively (p=0.3). Prostate biopsy rates were 2.5% and 2.3% in 2010 vs 1.7% and 1.6% in 2014, respectively (p=0.6). In men 70 years old or older, prostate specific antigen screening rates were 54.3% and 54.2% in 2010 vs 46.0% and 46.4% in 2014, respectively (p=0.2). Similarly, prostate biopsy rates were 1.8% and 1.7% in 2010 vs 1.1% and 1.1% in 2014, respectively (p=0.7). Conclusions: Although decreasing the use of low value services is a fundamental goal of accountable care organizations, prostate specific antigen screening and prostate biopsy trends were similar for accountable care organization and nonaccountable care organization providers across all age groups in the study years. This finding suggests that accountable care organization implementation did not have an impact on prostate specific antigen screening or prostate biopsy use.

Investigating the effect of treatment at high-volume hospitals on overall survival following cytoreductive nephrectomy

PURPOSEnData revealed the benefit of high-volume care in many complex disease processes. Among patients undergoing nephrectomy, those receiving cytoreductive nephrectomy (CN) for metastatic renal cell cancer (mRCC) constitute a unique subset. They often have a greater medical and surgical complexity. Against this backdrop, we sought to investigate the effect of hospital volume on overall survival among patients undergoing CN for mRCC.nnnMATERIAL AND METHODSnWe identified 11,089 patients who received CN for mRCC in the National Cancer Database from 1998 to 2012. We ranked hospitals based on annual CN volume. Patients who received surgery in hospitals in the top vs. bottom deciles were compared. Inverse Probability of Treatment Weighting (IPTW)-adjusted Kaplan-Meier and Cox regression analyses were used to compare the primary endpoint of overall survival between balanced cohorts of patients. Secondary endpoints were 30-day mortality, 30-day readmissions, and receipt of subsequent systemic therapy.nnnRESULTSnMedian follow-up was 60.39 months (interquartile range [IQR] 35.09-95.95). Median overall survival was 17.61 months (IQR 7.16-44.58). Following propensity score weighting, surgery at a high-volume hospital was associated with a decreased risk of mortality (IPTW-adjusted Cox proportional Hazard Ratiou202f=u202f0.91; 95% confidence interval: 0.86-0.96). On our IPTW-adjusted Kaplan-Meier analysis, the median survival was 19.94 months (IQR 7.98-50.27) at high-volume hospitals vs. 15.97 months (IQR 6.6-41.56) at low-volume hospitals. With regard to secondary endpoints, the data did not reveal a significant advantage for treatment at a high-volume hospital.nnnCONCLUSIONnWe found a significant association between receipt of CN at high-volume hospitals and prolonged overall survival, demonstrated by a nearly 4 month survival benefit.

Evaluation of the contribution of demographics, access to health care, treatment, and tumor characteristics to racial differences in survival of advanced prostate cancer

BackgroundRacial differences in prostate cancer (PCa) outcomes in the United States may be due to differences in tumor biology and race-based differences in access and treatment. We designed a study to estimate the relative contribution of these factors on Black/White disparities in overall survival (OS) in advanced PCa.MethodsWe identified Black and White men agedu2009≥u200940 years with metastatic or locally advanced PCa (cN+ cM+ and/or T3/4) between 2004 and 2010 using the National Cancer Database. We employed sequential propensity score weighting procedures to generate simulated cohorts of Black and White patients with equal demographics, access to care, treatment, and tumor characteristics. Adjusted survival analyses were used to compare survival in these simulated cohorts. The changes in relative survival after each weighting procedure were used to infer the contribution of each set of variables on the excess risk of mortality in Blacks.ResultsIn total, 35,611 men met inclusion criteria, 5927 (16.77%) of whom were Black. Survival was significantly worse for Black men after adjusting for demographics and comorbidities (hazard ratio (HR) 1.27, 95%-confidence interval (95%-CI) 1.2–1.34, pu2009<u20090.001). After simulating equal access to care, there was no significant difference in survival between races (HR 1.04, 95%-CI 0.97–1.12, pu2009=u20090.276), despite worse tumor characteristics in Blacks. After simulating equal treatment and equivalent tumor characteristics, Black men had a better survival than Whites (HR 0.93, 95%-CI 0.86–1.01, pu2009=u20090.071 and HR 0.92, 95%-CI 0.84–1.00, pu2009=u20090.043, respectively). Overall, access-related variables explained 84.7% of the excess risk of death in Black men.ConclusionOur analysis of men with advanced PCa revealed worse OS among Blacks. However, when access to care, treatment, and cancer characteristics are accounted for, Black race was associated with better OS. These findings suggest that initiatives to improve access to care may represent an effective tool to reduce disparities in PCa outcomes.

Adoption of robotic surgery: driven by market competition or a desire to improve patient care?

Aggarwal, Ajay; Lewis, Daniel; Mason, Malcolm; Purushotham, Arnie; Sullivan, Richard; van der Meulen, Jan; (2018) Adoption of robotic surgery: driven by market competition or a desire to improve patient care? Authors’ reply. The lancet oncology, 19 (2). e67-. ISSN 1470-2045 DOI: https://doi.org/10.1016/S1470-2045(18)30022-6 Downloaded from: http://researchonline.lshtm.ac.uk/id/eprint/4646562/ DOI: https://doi.org/10.1016/S1470-2045(18)30022-6

Evaluation of magnetic resonance imaging and targeted biopsy: The difficulty of finding the right reference standard: Correspondence

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The new frontier of prostate biopsy: determining the role of image-guidance in moving the needle

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Use of Preventive Health Services Among Cancer Survivors in the U.S.

INTRODUCTIONnWith improvements in early detection and treatment, a growing proportion of the population now lives with a personal history of a cancer. Although many cancer survivors are in excellent health, the underlying risk factors and side effects of cancer treatment increase the risk of medical complications and secondary malignancies.nnnMETHODSnThe 2013 National Health Interview Survey was utilized to assess the association between personal history of cancer and receipt of U.S. Preventive Services Task Force-recommended services, comprising three cancer screening tests (mammography, colonoscopy, and Pap smear) and six general medical preventive care services (aspirin for prevention of cardiovascular disease; blood pressure, cholesterol, and diabetes screening; diet/activity counseling; and tobacco use counseling). For each preventive service, patients with a history that would preclude that test were excluded. One to three matching of cancer survivors to controls was performed using propensity scores generated from patient-level demographic variables. Conditional logistic regression models were employed to compare odds of screening between matched cohorts of cancer survivors and controls. The years of analysis were 2015 and 2017.nnnRESULTSnA total of 2,639 cancer patients and 31,885 controls were extracted from the merged 2013 National Health Interview Survey. In the propensity score-matched cohorts of eligible adults, only one of the three cancer screening tests, colorectal, was more common in cancer survivors (OR=1.52, 95% CI=1.32, 1.75, p<0.001), whereas breast and cervical cancer screening were not more common in survivors. By contrast, all of the medical screening tests, with the exception of diabetes screening, were more common among cancer survivors.nnnCONCLUSIONSnThe association between receipt of recommended preventive medical care and personal history of cancer varied, depending on the preventive service in question, but in the majority of preventive services assessed, cancer survivors had more frequent screening compared with non-cancer survivors.

Immortal-time bias: a crucial yet overlooked confounder in urological research

The measurement of treatment effect through observational studies has become commonplace in the medical literature. These cohort studies provide valuable data on outcomes that can be difficult to assess in randomized controlled trials, such as long-term mortality. Accurate interpretation of observational data, however, requires accounting for potential confounders of study design, including the immortal-time bias. In this issue of BJUI, Wallis et al. [1] show how accounting for this bias can influence the measured effect of cumulative testosterone exposure on mortality. The implications of their findings extend to several other studies, whose designs may also be subject to immortal-time bias.