Simon P. Kim

Impact of Prostate-specific Antigen (PSA) Screening Trials and Revised PSA Screening Guidelines on Rates of Prostate Biopsy and Postbiopsy Complications.

BACKGROUNDnProstate biopsy and postbiopsy complications represent important risks of prostate-specific antigen (PSA) screening. Although landmark randomized trials and updated guidelines have challenged routine PSA screening, it is unclear whether these publications have affected rates of biopsy or postbiopsy complications.nnnOBJECTIVEnTo evaluate whether publication of the 2008 and 2012 US Preventive Services Task Force (USPSTF) recommendations, the 2009 European Randomized Study of Screening for Prostate Cancer and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, or the 2013 American Urological Association (AUA) guidelines was associated with changes in rates of biopsy or postbiopsy complications, and to identify predictors of postbiopsy complications.nnnDESIGN, SETTING, AND PARTICIPANTSnThis quasiexperimental study used administrative claims of 5279315 commercially insured US men aged ≥40 yr from 2005 to 2014, of whom 104584 underwent biopsy.nnnINTERVENTIONSnPublications on PSA screening.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnInterrupted time-series analysis was used to evaluate the association of publications with rates of biopsy and 30-d complications. Logistic regression was performed to identify predictors of complications.nnnRESULTS AND LIMITATIONSnFrom 2005 to 2014, biopsy rates fell 33% from 64.1 to 42.8 per 100000 person-months, with immediate reductions following the 2008 USPSTF recommendations (-10.1; 95% confidence interval [CI], -17.1 to -3.0; p<0.001), 2012 USPSTF recommendations (-13.8; 95% CI, -21.0 to -6.7; p<0 .001), and 2013 AUA guidelines (-8.8; 95% CI, -16.7 to -0.92; p=0.03). Concurrently, complication rates decreased 10% from 8.7 to 7.8 per 100000 person-months, with a reduction following the 2012 USPSTF recommendations (-2.5; 95% CI, -4.5 to -0.45; p=0.02). However, the proportion of men undergoing biopsy who experienced complications increased from 14% to 18%, driven by nonsepsis infectious complications (p<0.001). Predictors of complications included prior fluoroquinolone use (odds ratio [OR]: 1.27; 95% CI, 1.22-1.32; p<0.001), anticoagulant use (OR: 1.14; 95% CI, 1.04-1.25; p=0.004), and age ≥70 yr (OR: 1.25; 95% CI, 1.15-1.36; p<0.001). Limitations included the retrospective design.nnnCONCLUSIONSnAlthough there has been an absolute reduction in rates of biopsy and 30-d complications, the relative morbidity of biopsy continues to increase. These observations suggest a need to reduce the morbidity of biopsy.nnnPATIENT SUMMARYnAbsolute rates of biopsy and postbiopsy complications have decreased following landmark publications about prostate-specific antigen screening; however, the relative morbidity of biopsy continues to increase.

Understanding Treatment Disconnect and Mortality Trends in Renal Cell Carcinoma Using Tumor Registry Data

Background and Objectives: The paradoxical rise in overall and cancer-specific mortality despite increased detection and treatment of renal cell carcinoma (RCC) is termed “treatment disconnect.” We reassess this phenomenon by evaluating impact of missing data and rising incidence on mortality trends. Research Design, Subjects, and Measures: Using Surveillance, Epidemiology, and End Results data, we identified patients with RCC diagnosis from 1973 to 2011. We estimated mortality rates by tumor size after accounting for lags from diagnosis to death using multiple imputations for missing data from 1983. Mortality rates were estimated irrespective of tumor size after adjustment for prior cumulative incidence using ridge regression. Results: A total of 78,891 patients met inclusion criteria. Of 70,212 patients diagnosed since 1983, 10.4% had missing data. Significant attenuation in cancer-specific mortality was noted from 1983 to 2011 when comparing observed with imputed rates: &Dgr;obs0.05 versus &Dgr;imp0.10 (P=0.001, <2 cm tumors); &Dgr;obs0.29 versus &Dgr;imp0.18 (P=0.005, 2–4 cm tumors); &Dgr;obs0.46 versus &Dgr;imp–0.20 (P<0.001, 4–7 cm tumors); &Dgr;obs0.93 versus &Dgr;imp–0.15 (P<0.001, >7 cm tumors). Holding incidence of RCC constant to 2011 rates, temporal increase in overall mortality for all patients was attenuated (P<0.001) when comparing observed estimates (3.9–6.8) with 2011 adjusted estimates (5.9–7.1), suggesting that rapidly rising incidence may influence reported overall mortality trends. These findings were supported by assessment of mortality to incidence ratio trends. Conclusions: Missing data and rising incidence may contribute substantially to the “treatment disconnect” phenomenon when examining mortality rates in RCC using tumor registry data. Caution is advised when basing clinical and policy decisions on these data.

Discerning the survival advantage among patients with prostate cancer who undergo radical prostatectomy or radiotherapy: The limitations of cancer registry data

The objective of this study was to compare the overall survival of patients who undergo radical prostatectomy or radiotherapy versus noncancer controls to discern whether there is a survival advantage according to prostate cancer treatment and the impact of selection bias on these results.

Increased use of partial nephrectomy to treat high‐risk disease

To evaluate partial nephrectomy (PN) use in patients at higher risk for clinical progression, using a large national database of American patients.

Asian Americans and prostate cancer: A nationwide population-based analysis

INTRODUCTIONnIt remains largely unknown if there are racial disparities in outcomes of prostate cancer (PCa) for Asian American and Pacific Islanders (PIs) (AAPIs). We examined differences in diagnosis, management, and survival of AAPI ethnic groups, relative to their non-Hispanic White (NHW) counterparts.nnnMETHODSnPatients (n = 891,100) with PCa diagnosed between 1988 and 2010 within the surveillance, epidemiology, and end results database were extracted and stratified by ethnic group: Chinese, Japanese, Filipino, Hawaiian, Korean, Vietnamese, Asian Indian/Pakistani, PI, and Other Asian. The effect of ethnic group on stage at presentation, rates of definitive treatment, and PCa-specific mortality was assessed. The severity at diagnosis was defined as: localized (TxN0M0), regional (TxN1M0), or metastatic (TxNxM1).nnnRESULTSnRelative to NHWs, Asian Indian/Pakistani, Filipino, Hawaiian, and PI men had significantly worse outcomes. Filipino (odds ratio [OR] = 1.38, 95% CI: 1.27-1.51), Hawaiian, (OR = 1.70, 95% CI: 1.41-2.04), Asian Indian/Pakistani (OR = 1.37, 95% CI: 1.15-1.64), and PI men (OR = 1.90, 95% CI: 1.46-2.49) were more likely to present with metastatic PCa (P<0.001). In patients with localized PCa, Filipino men were less likely to receive definitive treatment (OR = 0.91; 95% CI: 0.84-0.97; P = 0.005). Most AAPI groups had lower rates of PCa death except for Hawaiian (hazard ratio = 1.52; 95% CI: 1.30-1.77; P<0.0001) and PI men (hazard ratio = 1.43; 95% CI: 1.12-1.82; P<0.0001).nnnCONCLUSIONSnCompared with NHWs, AAPI groups were more likely to present with advanced PCa but had better cancer-specific survival. Conversely, Hawaiian and PI men were at greater risk for PCa-specific mortality. Given the different cancer profiles, our results show that there is a need for disaggregation of AAPI data.

Reexamining the Association Between Positive Surgical Margins and Survival After Partial Nephrectomy in a Large American Cohort

PURPOSEnTo investigate the impact of positive surgical margins (PSM) on overall survival (OS) in a large American cohort with intermediate-term follow-up.nnnPATIENTS AND METHODSnUsing the National Cancer Data Base, we identified 6038 cases of pathological T1-T3a, nonmetastatic renal-cell carcinoma managed with partial nephrectomy (PN) from 2003 to 2006. Patients were stratified into two groups based on margin status. Predictors of positive margins were evaluated using multivariable logistic regression analysis. OS by margin status was evaluated using Kaplan-Meier analysis and the log-rank test. A multivariable Cox proportional hazards model was used to evaluate the adjusted association between margin status and survival.nnnRESULTSnOverall, 302 (5.3%) patients had positive margins. On multivariable analysis, higher pathological T stage and higher comorbidity score were the only factors significantly associated with positive margins (pu2009<u20090.001 and pu2009=u20090.015, respectively). At 71-month median follow-up, the unadjusted 5-year OS for the entire cohort was 92%. Positive margins were significantly associated with decreased 5-year OS (89% vs 92%, pu2009=u20090.002), and this association remained significant in healthy patients (pu2009=u20090.027). On multivariable survival analysis, positive margins significantly predicted hastened time to all-cause death (hazards ratio 1.34; 95% CI 1.01, 1.78; pu2009=u20090.038).nnnCONCLUSIONnIn the largest observational study to date, PSM were associated with worse OS after PN. Further study on cancer-specific outcomes with long-term follow-up is needed.

Redefining and Contextualizing the Hospital Volume-Outcome Relationship for Robot-Assisted Radical Prostatectomy: Implications for Centralization of Care

Purpose: Robot‐assisted radical prostatectomy has undergone rapid dissemination driven in part by market forces to become the most frequently used surgical approach in the management of prostate cancer. Accordingly, a critical analysis of its volume‐outcome relationship has important health policy implications. Therefore, we evaluated the association of hospital robot‐assisted radical prostatectomy volume with perioperative outcomes, and examined the distribution of hospital procedure volume to contextualize the volume‐outcome relationship. Materials and Methods: We identified 140,671 men who underwent robot‐assisted radical prostatectomy from 2009 to 2011 in NIS (Nationwide Inpatient Sample). The associations of hospital volume with perioperative outcomes and total hospital costs were evaluated using multivariable logistic regression and generalized linear models. Results: In 2011, 70% of hospitals averaged 1 robot‐assisted radical prostatectomy per week or less, accounting for 28% of surgeries. Compared to patients treated at the lowest quartile hospitals, those treated at the highest quartile hospitals had significantly lower rates of intraoperative complications (0.6% vs 1.4%), postoperative complications (4.8% vs 13.9%), perioperative blood transfusion (1.5% vs 4.0%), prolonged hospitalization (4.3% vs 13.8%) and mean total hospital costs (

Assessment of healthcare quality metrics: Length-of-stay, 30-day readmission, and 30-day mortality for radical nephrectomy with inferior vena cava thrombectomy.

12,647 vs

Racial Disparities in Prostate Cancer Outcome among Prostate-Specific Antigen Screening Eligible Populations in the United States.

15,394, all ptrend <0.001). When modeled as a nonlinear continuous variable, increasing hospital volume was independently associated with improved rates of each perioperative end point up to approximately 100 robot‐assisted radical prostatectomies per year, beyond which there appeared to be marginal improvement. Conclusions: Increasing hospital robot‐assisted radical prostatectomy volume was associated with improved perioperative outcomes up to approximately 100 surgeries per year, beyond which there appeared to be marginal improvement. A substantial proportion of these procedures is performed at low volume hospitals.

Perioperative outcomes and hospital reimbursement by type of radical prostatectomy: results from a privately insured patient population

INTRODUCTIONnLength-of-stay (LOS), 30-day readmission, and 30-day mortality are metrics used to assess quality of care and provider reimbursement. Therefore, we investigated patient- and hospital-level characteristics associated with the three healthcare quality metrics for radical nephrectomy with inferior vena cava (IVC) thrombectomy.nnnMETHODSnUsing the National Cancer Data Base, we established a cohort of patients who received radical nephrectomy following the diagnosis of renal cell carcinoma (RCC) stage cT3b between 1998 and 2011. We then assessed the associations between patient- or hospital-level characteristics and LOS using multivariable negative binomial regression. We used multivariable logistic regression to determine the associations between the characteristics and 30-day readmission or 30-day mortality.nnnRESULTSnDuring the study period, 5768 patients were diagnosed with RCC stage cT3b and underwent radical nephrectomy. LOS ≤2 days and ≥9 days were associated with a higher likelihood of 30-day readmission (respective odds ratio [OR] 1.61 and 1.58) and 30-day mortality (respective OR 11.62 and 11.87). Older patients (60-79 years vs. <50 years) were less likely to experience 30-day readmission (OR 0.46-0.52). Older patients (≥80 years vs. <50 years, OR 3.67) and patients with a high index of comorbidity (Charlson comorbidity score ≥ 2 vs. 0, OR 1.95) were more likely to suffer 30-day mortality.nnnCONCLUSIONSnLOS is an important predictor of short-term readmission and mortality following radical nephrectomy with IVC thrombectomy. Older age and a high index of comorbidity also predict short-term mortality after the surgery.