Ted A. Skolarus

American Cancer Society prostate cancer survivorship care guidelines.

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Use of Advanced Treatment Technologies Among Men at Low Risk of Dying From Prostate Cancer

IMPORTANCE The use of advanced treatment technologies (ie, intensity-modulated radiotherapy [IMRT] and robotic prostatectomy) for prostate cancer is increasing. The extent to which these advanced treatment technologies have disseminated among patients at low risk of dying from prostate cancer is uncertain. OBJECTIVE To assess the use of advanced treatment technologies, compared with prior standards (ie, traditional external beam radiation treatment [EBRT] and open radical prostatectomy) and observation, among men with a low risk of dying from prostate cancer. DESIGN, SETTING, AND PATIENTS Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified a retrospective cohort of men diagnosed with prostate cancer between 2004 and 2009 who underwent IMRT (n = 23,633), EBRT (n = 3926), robotic prostatectomy (n = 5881), open radical prostatectomy (n = 6123), or observation (n = 16,384). Follow-up data were available through December 31, 2010. MAIN OUTCOMES AND MEASURES The use of advanced treatment technologies among men unlikely to die from prostate cancer, as assessed by low-risk disease (clinical stage ≤T2a, biopsy Gleason score ≤6, and prostate-specific antigen level ≤10 ng/mL), high risk of noncancer mortality (based on the predicted probability of death within 10 years in the absence of a cancer diagnosis), or both. RESULTS In our cohort, the use of advanced treatment technologies increased from 32% (95% CI, 30%-33%) to 44% (95% CI, 43%-46%) among men with low-risk disease (P < .001) and from 36% (95% CI, 35%-38%) to 57% (95% CI, 55%-59%) among men with high risk of noncancer mortality (P < .001). The use of these advanced treatment technologies among men with both low-risk disease and high risk of noncancer mortality increased from 25% (95% CI, 23%-28%) to 34% (95% CI, 31%-37%) (P < .001). Among all patients diagnosed in SEER, the use of advanced treatment technologies for men unlikely to die from prostate cancer increased from 13% (95% CI, 12%-14%), or 129.2 per 1000 patients diagnosed with prostate cancer, to 24% (95% CI, 24%-25%), or 244.2 per 1000 patients diagnosed with prostate cancer (P < .001). CONCLUSION AND RELEVANCE Among men diagnosed with prostate cancer between 2004 and 2009 who had low-risk disease, high risk of noncancer mortality, or both, the use of advanced treatment technologies has increased.

Delays in diagnosis and bladder cancer mortality

Mortality from invasive bladder cancer is common, even with high‐quality care. Thus, the best opportunities to improve outcomes may precede the diagnosis. Although screening currently is not recommended, better medical care of patients who are at risk (ie, those with hematuria) has the potential to improve outcomes.

Growth Of High-Cost Intensity-Modulated Radiotherapy For Prostate Cancer Raises Concerns About Overuse

To study the impact of new, expensive, and unproven therapies to treat prostate cancer, we investigated the dissemination of intensity-modulated radiotherapy (IMRT). IMRT is an innovative treatment for prostate cancer that delivers higher doses of radiation with improved precision compared to alternative radiotherapies. We observed rapid adoption of this new treatment among men diagnosed with prostate cancer from 2001 through 2007, despite uncertainty about its relative effectiveness. We compared patient and disease characteristics of those receiving IMRT and the previous radiation standard of care, three-dimensional conformal therapy; assessed intermediate-term outcomes; and examined potential factors associated with the increased use of IMRT. We found that in the early period of IMRT adoption (2001-03) men with high-risk disease were more likely to receive IMRT, whereas after IMRTs initial dissemination (2004-07) men with low-risk disease had fairly similar likelihoods of receiving IMRT as men with high-risk disease. This raises concerns about overtreatment, as well as considerable health care costs, because treatment with IMRT costs

Survivorship and improving quality of life in men with prostate cancer

15,000-

Sharpening the focus on causes and timing of readmission after radical cystectomy for bladder cancer

20,000 more than other standard therapies. As health care delivery reforms gain traction, policy makers must balance the promotion of new, yet unproven, technology with the risk of overuse.

Disparities in bladder cancer

CONTEXT Long-term survival following a diagnosis of cancer is improving in developed nations. However, living longer does not necessarily equate to living well. OBJECTIVE To search systematically and synthesise narratively the evidence from randomised controlled trials (RCTs) of supportive interventions designed to improve prostate cancer (PCa)-specific quality of life (QoL). EVIDENCE ACQUISITION A systematic search of Medline and Embase was carried out from inception to July 2014 to identify interventions targeting PCa QoL outcomes. We did not include nonrandomised studies or trials of mixed cancer groups. In addition to database searches, citations from included papers were hand-searched for any potentially eligible trials. EVIDENCE SYNTHESIS A total of 2654 PCa survivors from 20 eligible RCTs were identified from our database searches and reference checks. Disease-specific QoL was assessed most frequently by the Functional Assessment of Cancer Therapy-Prostate questionnaire. Included studies involved men across all stages of disease. Supportive interventions that featured individually tailored approaches and supportive interaction with dedicated staff produced the most convincing evidence of a benefit for PCa-specific QoL. Much of these data come from lifestyle interventions. Our review found little supportive evidence for simple literature provision (either in booklets or via online platforms) or cognitive behavioural approaches. CONCLUSIONS Physical and psychological health problems can have a serious negative impact on QoL in PCa survivors. Individually tailored supportive interventions such as exercise prescription/referral should be considered by multidisciplinary clinical teams where available. Cost-effectiveness data and an understanding of how to sustain benefits over the long term are important areas for future research. PATIENT SUMMARY This review of supportive interventions for improving quality of life in prostate cancer survivors found that supervised and individually tailored patient-centred interventions such as lifestyle programmes are of benefit.

Hospitalization Trends After Prostate and Bladder Surgery: Implications of Potential Payment Reforms

Readmissions after radical cystectomy are common, burdensome, and poorly understood. For these reasons, the authors conducted a population‐based study that focused on the causes of and time to readmission after radical cystectomy.

Evidence of Perineural Invasion on Prostate Biopsy Specimen and Survival After Radical Prostatectomy

Among men, bladder cancer is the fourth most common malignancy and ninth leading cause of death from cancer in the United States. In contrast, it is the 11th most common malignancy and 12th leading cause of death from cancer among women. The successful management of bladder cancer largely depends on its timely diagnosis and treatment. Unfortunately, barriers disproportionately delay detection and treatment for individuals with social, economic, and community disadvantages. This imbalance creates health disparities (i.e., differences in health outcomes that are closely linked to these disadvantages), which negatively affect vulnerable populations, such as racial and ethnic minority groups, those from lower socioeconomic classes, and the uninsured. To obtain a better understanding of this issue, we review the current state of bladder cancer disparities research.

Patient-reported quality of life after stereotactic body radiotherapy (SBRT), intensity modulated radiotherapy (IMRT), and brachytherapy

PURPOSE Hospital stays have decreased for patients undergoing surgery for urological cancer. However, there are concerns that patients are being discharged from the hospital prematurely. We examined associations between hospital stay and short-term outcomes for a low risk procedure (prostatectomy) and high risk procedure (cystectomy). MATERIALS AND METHODS We used SEER (Surveillance, Epidemiology and End Results)-Medicare data from 1992 through 2005 to identify 46,781 prostatectomy and 9,035 cystectomy cases. We assessed our main outcome (adjusted likelihood of hospital readmission within 30 days) using a logistic regression model. Secondary outcomes included mortality rates and discharge disposition. RESULTS In comparing patients from 1992 to 1993, to 2004 to 2005, hospital stay decreased approximately 3 days for both surgeries (relative decrease of more than 50% for prostatectomy and 21% for cystectomy). Hospital readmission rates were 4.5% and 25.2% for prostatectomy and cystectomy, respectively, and remained stable with time. Skilled nursing/intermediate care use was stable for patients who underwent prostatectomy (approximately 1%), but increased from 8.2% (95% CI 5.4-11.4) to 18.9% (95% CI 16.8-21.3) for those treated with cystectomy. Use of home care increased from 8.1% (95% CI 7.3-9.0) to 11.1% (95% CI 10.1-12.1) and from 34.2% (95% CI 29.7-38.7) to 47.5% (95% CI 44.5-50.1) for prostatectomy and cystectomy cases, respectively. CONCLUSIONS Reductions in hospital stay were more dramatic for patients who underwent prostatectomy and were associated with stable short-term outcomes. Conversely, smaller reductions in hospitalization for patients undergoing cystectomy were met with substantial increases in the use of post-acute care. Going forward, close surveillance of how imminent policy reforms affect patterns and quality of care will be necessary.