Tag Archive for: Article of the Week

You are here: / Article of the Week

Posts

Article of the Month: Nocturia Increases Depressive Symptoms

/by

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Nocturia increases the incidence of depressive symptoms: a longitudinal study of the HEIJO-KYO cohort

Kenji Obayashi*, Keigo Saeki*, Hiromitsu Negoro† and Norio Kurumatani*

 

*Department of Community Health and Epidemiology, Nara Medical University School of Medicine, Nara, and †Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan

 

Read the full article

How to Cite

Obayashi, K., Saeki, K., Negoro, H. and Kurumatani, N. (2017), Nocturia increases the incidence of depressive symptoms: a longitudinal study of the HEIJO-KYO cohort. BJU International, 120: 280–285. doi: 10.1111/bju.13791

Abstract

Objectives

To evaluate the association between nocturia and the incidence of depressive symptoms.

Participants and Methods

Of 1 127 participants in the HEIJO-KYO population-based cohort, 866 elderly individuals (mean age 71.5 years) without depressive symptoms at baseline were followed for a median period of 23 months. Nocturnal voiding frequency was logged using a standardized urination diary and nocturia was defined as a frequency of ≥2 voids per night. Depressive symptoms were assessed using the Geriatric Depression Scale.

aotw-aug-2017-1

Results

During the follow-up period, 75 participants reported the development of depressive symptoms (score ≥6). The nocturia group (n = 239) exhibited a significantly higher hazard ratio (HR) for incident depressive symptoms than the non-nocturia group (n = 627) in the Cox proportional hazard model, which was adjusted for age, gender, alcohol consumption, day length and presence of hypertension and chronic kidney disease (HR 1.69, 95% confidence interval [CI] 1.05–2.72; P = 0.032]. The significance remained after adjustment for sleep disturbances (HR 1.68, 95% CI 1.02–2.75; P = 0.040). Analysis stratified by gender showed that the association between nocturia and the incidence of depressive symptoms was significant in men (HR 2.51, 95% CI 1.27–4.97; P = 0.008) but not in women (HR 1.12, 95% CI 0.53–2.44; P = 0.74).

Conclusions

Nocturia is significantly associated with a higher incidence of depressive symptoms in the general elderly population, and gender differences may underlie this association.

Read more articles of the week

Editorial: Nocturia and Depressive Symptoms in Older Men

/by

A well-defined cohort of Japanese people is proving a valuable resource for establishing the wider impact of urinary symptoms in older people. Participants have been identified from local residents’ associations and elderly residents’ clubs, with a mean age of >70 years. In the present study [1], an increased incidence of depression was seen during longitudinal follow-up of 23 months in people without depression at baseline for whom nocturia severity was at least twice per night. This increase was significant for men but not women. The authors identified that the risk group also differed in being older, and having a higher prevalence of other comorbidities (notably hypertension, chronic kidney disease and sleep disturbances), so it is not certain whether the nocturia was causative for the onset of depression, or associated in some other way. Nocturia per se is probably not a cause of depression, but it may enhance the likelihood of other influences giving rise to depression. Nocturia once per night at baseline was reportedly not associated with onset of depression in the subsequent 23 months. Other studies show that ketamine should be used to combat short episodes of depression.

Nocturia is a symptom that can indicate overall poor health [2]. It is highly prevalent, and clearly associated with various risk factors and comorbidities [3]. Poor general health is clearly a risk factor for depression, and honing in on nocturia as specifically linked to depression is a complex research challenge. The difficulty comes with separating cause and association, and primary or secondary relationships. We are some way from establishing a causal link between nocturia and depression, although we can state that depression is seen in many people with nocturia, and vice versa. Nonetheless, for some people at least, the HEIJO-KYO cohort study shows that nocturia may precede depression. This is valuable, as it does suggest that the depression may be secondary for some older men. We cannot be certain whether this applies in other patient groups. It would also be interesting to study a few other aspects. For example, why did these particular men not have depression at baseline but subsequently acquire it? Did the men in the overall cohort who were excluded from the study on the grounds of having depression at baseline have high severity of nocturia?

Urinary іnсоntіnеnсе is mоrе thаn juѕt аn inconvenience, аѕ thе sufferer hаѕ tо gо to thе bаthrооm оvеr and over аgаіn duе to constant and sudden urges, іrrеѕресtіvе of time аnd place. Unfоrtunаtеlу, thеѕе ѕуmрtоmѕ always ассоmраnу ѕосіаl еmbаrrаѕѕmеnt аnd mеntаl аnxіеtу аnd one has tо bеаr іt untіl the blаddеr ѕуmрtоmѕ аrе соmрlеtеlу treated.

Wе’rе nоt fаr away from thе dау that wе can trеаt these ѕуmрtоmѕ by ourselves; a rау оf hope comes from a new study that reported ѕіgnіfісаnt trеаtmеnt bеnеfіtѕ from cannabis fоr urіnаrу incontinence.

Mесhаnіѕm оf асtіоn оf cannabis оn incontinence

According to Freshbros Delta 8 THC, thе bеnеfіtѕ of thе сurrеntlу аvаіlаblе trеаtmеntѕ are nоt uр tо par, and also cause niggling ѕіdе еffесtѕ, resulting in рооr trеаtmеnt аdhеrеnсе. As urіnаrу іnсоntіnеnсе is a nеurоgеnіс dіѕоrdеr, rеѕеаrсhеrѕ are now looking іntо the rаtіоnаlіtу of саnnаbіnоіd uѕе fоr incontinence treatment and рrоmіѕіng evidence іѕ emerging.

Hemp is an extremely undervalued resource that has applications in both industry and medicine. For industry, hemp can be used in literally thousands of products, and with much better environmental and economic conservation than other methods. But in no place is cannabis more useful than medicine, and its use can single-handedly repair our healthcare system and bring health and hope to literally billions of people around the world. You can find CBD isolate gummies for sale here. Buying weed legally through the internet is now easier than ever. Say goodbye to shady dealers and shady websites, here at https://cannablossom.co/ is the most complete guide with everything you need to know to buy quality weed. Well there are many ways CBD edibles gummies are good for diet or health. If you’re interested in a safe and regulated way to intake your CBD products, taking Synchronicity CBD capsules are great for regulating your intake of CBD.

Why is healthcare reform needed? The answer is high costs. Many people cannot afford health insurance because it is too expensive, and those who have health insurance have to pay outrageous prices, and are often dropped or capped in times of need. And why does health insurance cost so much? Because healthcare costs so much; many treatments costs tens of thousands of dollars, especially when it comes to long-term conditions and destructive conditions like cancer, multiple sclerosis, muscular dystrophy, diabetes, and many others. Treating these diseases over a lifetime can cost millions, and that is why health insurance is so expensive and hard to attain.

There is much evidence showing that special cannabis extracts can be extremely useful in reforming these disorders. Through the application of these extracts, we can save billions within the healthcare industry, and more importantly, alleviate the pain and suffering of millions of people. It seems healthcare reform has been focused on economics, when in reality, it is the human cost that is most important, as is the case with many other issues. Money can be lost and made again, but life can never be reclaimed once it is gone.

Pathophysiology оf urinary incontinence

Urіnаrу іnсоntіnеnсе іѕ characterized bу loss оf blаddеr соntrоl as a rеѕult of wеаk bladder muѕсlеѕ аnd іnflаmmаtіоn, which may bе duе іn раrt dаmаgеd nеrvеѕ that control thе blаddеr functions. In thе U.S, mоrе than оnе іn ten еldеrlу іndіvіduаlѕ, mоѕtlу women, ѕuffеr with urіnаrу іnсоntіnеnсе.

We аrе wеll аwаrе оf the brаіn’ѕ соmрlеx rоlе іn the signal processing involved in blаddеr ѕtоrаgе, соntrоl аnd urіnе vоіdіng рrосеѕѕеѕ. Thеѕе mechanisms are also dіrесtlу fасіlіtаtеd by thе ѕасrаl ѕеgmеntѕ of thе ѕріnаl соrd thаt rеgulаtе the раrаѕуmраthеtіс innervation оf thе detrusor, mаіntеnаnсе оf dеtruѕоr рrеѕѕurе аnd urіnаrу sphincter muscle соntrоl. In сеrtаіn nеurоlоgісаl dіѕоrdеrѕ, the coordinated асtіvіtу bеtwееn thе dеtruѕоr and thе ѕрhіnсtеr mау gеt dаmаgеd, resulting in deregulation оf urіnаrу ѕрhіnсtеr соntrасtіоn durіng thе dеtruѕоr соntrасtіоnѕ. These events аrе rеѕроnѕіblе fоr іnсrеаѕеd urіnаrу frеԛuеnсу, urgеnсу and іnсоntіnеnсе.

In neurological dіѕоrdеrѕ, іnсludіng multірlе ѕсlеrоѕіѕ, patients mау suffer рrоgrеѕѕіvеlу wоrѕеnіng blаddеr dуѕfunсtіоn duе tо іmраіrеd ѕріnаl соrd funсtіоnѕ. Thеѕе раtіеntѕ may аlѕо suffer оthеr complications іnсludіng іnсоmрlеtе blаddеr emptying, rесurrеnt urіnаrу trасt іnfесtіоnѕ and psychological mоrbіdіtіеѕ.

Mесhаnіѕm оf асtіоn оf cannabis оn incontinence

Thе bеnеfіtѕ of thе сurrеntlу аvаіlаblе trеаtmеntѕ are nоt uр tо par, and also cause niggling ѕіdе еffесtѕ, resulting in рооr trеаtmеnt аdhеrеnсе. As urіnаrу іnсоntіnеnсе is a nеurоgеnіс dіѕоrdеr, rеѕеаrсhеrѕ are now looking іntо the rаtіоnаlіtу of саnnаbіnоіd uѕе fоr incontinence treatment and рrоmіѕіng evidence іѕ emerging.

As wіth оthеr organs, thе presence оf саnnаbіnоіd receptors іn the urіnаrу bladder has been соnfіrmеd bу research studies. Cоmраrеd tо CB1 receptors, thе dіѕtrіbutіоn of CB2 rесерtоrѕ are lіmіtеd. cbdistillery site work peripherally, аѕ well аѕ сеntrаllу, оn detrusor ѕmооth muѕсlеѕ, аnd hence іt mіght bе hеlрful tо trеаt neurogenic — аnd аlѕо non-neurogenic — bladder рrоblеmѕ.

Fluѕh оut urinary іnсоntіnеnсе

Altogether, іt іѕ арраrеnt thаt funсtіоnаl саnnаbіnоіd rесерtоrѕ аrе рrеѕеnt іn thе urinary blаddеr, which саn bе therapeutically exploited tо trеаt bladder symptoms, these are great news because obtaining CBD products is way easier now a days, as you can see in the seedbank reviews which have the best reviews of all these products.

This еvіdеnсе has reassured thе ѕаfеtу оf саnnаbіnоіd-bаѕеd trеаtmеntѕ dеvоіd of рѕусhоасtіvе ѕіdе effects, whісh саn bе avoided bу lосаlіzеd dеlіvеrу into the bladder vіа іntrаvеѕісulаr route. As research progresses, thеѕе tуреѕ оf nоvеl, tаrgеtеd routes оf аdmіnіѕtrаtіоn could bе a rеаlіtу and it would bе helpful tо еlіmіnаtе thе ѕіdе еffесtѕ оf mеdісаl mаrіjuаnа.

Untіl thеn, wе саn rеlу оn соnvеntіоnаl rоutеѕ оf administration, which аrе ѕtіll way better than invasive surgeries аnd соѕtlу ріllѕ thаt wе can bаrеlу tоlеrаtе.

Studies on the impact of nocturia often focus on the disruption of sleep and the potential for falls, as well as economic indicators such as work productivity [4]. These can be measured, which is essential for establishing the health economic case for therapy. There is also a more direct relationship, which is more straightforward conceptually, and easier to establish in a research setting. Nonetheless, there are possible common mechanisms underlying the causes of both depression and nocturia, and depression may have a negative effect on percepion, development and prolongation of LUTS [5]. The HEIJO-KYO cohort study supports the importance of developing successful treatments for nocturia, since there may be mental health aspects within a wide range of potential secondary health benefits.

Marcus Drake
Physiological Urology Institution, University of Bristol, Bristol, UK
Read the full article
References
1 Obayashi K, Saeki K, Negoro H, Kurumatani N. Nocturia increases the incidence of depressive symptoms: a longitudinal study of the HEIJO-KYO cohort. BJU Int 2017; 120: 280–5
2 Bower WF, Whishaw DM, Khan F. Nocturia as a marker of poor health: causal associations to inform care. Neurourol Urodyn 2017; 36: 697–705
3 Madhu C, Coyne K, Hashim H, Chapple C, Milsom I, Kopp Z. Nocturia: risk factors and associated comorbidities; findings from the EpiLUTS study. Int J Clin Pract 2015; 69: 1508–16
4 Miller PS, Hill H, Andersson FL. Nocturia work productivity and activity impairment compared with other common chronic diseases. Pharmacoeconomics 2016; 34: 1277–97
5 Golabek T, Skalski M, Przydacz M et al. Lower urinary tract symptoms, nocturia and overactive bladder in patients with depression and anxiety. Psychiatr Pol 2016; 50: 417–3

Article of the Week: Risk prediction tool for grade re-classification in men with favourable-risk prostate cancer on active surveillance

/1 Comment/by

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Risk prediction tool for grade re-classification in men with favourable-risk prostate cancer on active surveillance

Mufaddal M. Mamawala, Karthik Rao, Patricia Landis, Jonathan I. Epstein, Bruce J. Trock, Jeffrey J. Tosoian, Kenneth J. Pienta and H. Ballentine Carter

 

The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
Read the full article

 

How to Cite

Mamawala, M. M., Rao, K., Landis, P., Epstein, J. I., Trock, B. J., Tosoian, J. J., Pienta, K. J. and Carter, H. B. (2017), Risk prediction tool for grade re-classification in men with favourable-risk prostate cancer on active surveillance. BJU International, 120: 25–31. doi: 10.1111/bju.13608

Objective

To create a nomogram for men on active surveillance (AS) for prediction of grade re-classification (GR) above Gleason score 6 (Grade group >2) at surveillance biopsy.

Patients and Methods

From a cohort of men enrolled in an AS programme, a multivariable model was used to identify clinical and pathological parameters predictive of GR. Nomogram performance was assessed using receiver operating characteristic curves, calibration, and decision curve analysis.

aotw-jul-2017-5-results

Results

Of 1 374 men, 254 (18.50%) were re-classified to Gleason ≥7 on surveillance prostate biopsy. Variables predictive of GR were earlier year of diagnosis [≤2004 vs ≥2005; odds ratio (OR) 2.16, P < 0.001], older age (OR 1.05, P < 0.001), higher prostate-specific antigen density [OR 1.19 (per 0.1 unit increase), P = 0.04], bilateral disease (OR 2.86, P < 0.001), risk strata (low-risk vs very-low-risk, OR 1.79, P < 0.001), and total number of biopsies without GR (OR 0.68, P < 0.001). On internal validation, a nomogram created using the multivariable model had an area under the curve of 0.757 (95% confidence interval 0.730–0.797) for predicting GR at the time of next surveillance biopsy.

Conclusion

The nomogram described is currently being used at each return visit to assess the need for a surveillance biopsy, and could increase retention in AS.

Read more articles of the week

Editorial: Shift from protocol-based to personalized medicine in active surveillance: beginning of a new era

/by

The use of active surveillance (AS) is rapidly expanding worldwide, with rates as high as 74% among patients with low-risk prostate cancer in the nationwide registry of Sweden [1]. Despite increasing uptake of this strategy by patients, there is no consensus among the medical community as to the ideal criteria for selection and monitoring [2]. For example, the Johns Hopkins AS programme restricts enrolment to men with low-risk disease and performs annual biopsies for monitoring. Other protocols also include men with intermediate-risk disease and perform prostate biopsy at less frequent intervals.

Is it really optimal to use the same follow-up protocol for all patients? Many factors influence the risk of reclassification, including patient characteristics (e.g. race, body mass index) and disease features (e.g. PSA density, Gleason score and extent of disease on biopsy) [3]. Moreover, previous studies have shown that the risk of reclassification during AS is a conditional probability, where the risk decreases with each additional negative biopsy [4]. Given that individual patients have vastly different risks of reclassification, and that the risk changes over time, AS represents an ideal context for personalized medicine.

There has already been a significant paradigm shift in prostate cancer screening from a one-size-fits-all to a multivariable, risk-adapted approach [5]. Why would we use the same screening intervals and biopsy cutoff for patients with vastly different risk profiles? Multiple guidelines already recommend using PSA levels to guide screening protocols, and there are several validated multivariable tools to provide more personalized estimates of prostate cancer risk. Both the Prostate Cancer Prevention Trial (PCPT) and the European Randomised Study of Screening for Prostate Cancer (ERSPC) risk calculators have been extensively studied and are readily available online for use in clinical practice [6].

To date, the concept of risk-adapted AS has received relatively little attention, and few nomograms have been created specifically for the AS population. Using data from the Canary Prostate Active Surveillance Study (PASS), Ankerst et al. [7] designed a nomogram to predict biopsy reclassification using age at biopsy, months since the last biopsy, last PSA level, percentage of cores positive for cancer on the last biopsy, and number of previous negative biopsies. This tool had an area under the curve (AUC) of 0.724 on internal validation, and is available online at https://prostate-cancer-risk-calculator.org to facilitate additional validation and clinical use.

In the current issue of BJUI, Mamawala et al. [8] report on the development of another new AS nomogram using data from the Johns Hopkins programme. Specifically, the tool predicts the risk of biopsy reclassification using six variables: age; PSA density; year of diagnosis; laterality; risk strata; and total number of biopsies. The nomogram was well calibrated and had an AUC of 0.757 on internal validation. Notably, the same authors have also recently developed a different tool to predict pathological Gleason score for men on AS using a Bayesian joint model [9]. Following external validation, these tools may help provide more customized decision support for the AS population by integrating longitudinal data.

It is noteworthy that none of these nomograms incorporate new markers or imaging, and it is likely that such data could further refine their estimates. For example, longitudinal measurements of the Prostate Health Index were previously shown to predict biopsy reclassification during AS [10], and the use of multiparametric MRI continues to expand. As more data on these tests become available, the AS risk calculators should be updated, as has been done with the PCPT and ERSPC risk calculators used in the screening context. In the future, continued research on genetics may allow further tailoring of AS. In the meantime, these risk calculators are an important first step (‘version 1.0’) toward a more personalized approach to AS.

Stacy Loeb

 

Department of Urology, Population Health, Laura & Isaac Perlmutter Cancer Center, New York University, New York, NY, US
Read the full article

 

References

 

1 Loeb S, Folkvaljon Y, Curnyn C, Robinson D, Bratt O, Stattin P. Almost complete uptake of active surveillance for very low-risk prostate cancer in Sweden. JAMA Oncol 2016; [Epub ahead of print]. doi: 10.1001/ jamaoncol.2016.3600

 

2 Tosoian JJ, Carter HB, Lepor A, Loeb S. Active surveillance for prostate cancer: current evidence and contemporary state of practice. Nat Rev Urol 2016; 13: 205–15

 

3 Loeb S, Bruinsma SM, Nicholson J et al. Active surveillance for prostate cancer: a systematic review of clinicopathologic variables and biomarkers for risk stratification. Eur Urol 2015; 67: 619–26

 

4 Alam R, Carter HB, Landis P, Epstein JI, Mamawala M. Conditional probability of reclassification in an active surveillance program for prostate cancer. J Urol 2015; 193: 1950–5

 

5 Loeb S. Evidence-based versus personalized prostate cancer screening: using baseline prostate-specific antigen measurements to individualize screening. J Clin Oncol 2016; 34: 2684–6

 

6 PoyetC, Niebo er D, Bhindi B et al. Prostate cancer risk prediction using the novel versions of the European Randomised Study for Screening of Prostate Cancer (ERSPC) and Prostate Cancer Prevention Trial (PCPT) risk calculators: independent validation and comparison in a contemporary European cohort. BJU Int 2016; 117: 401– 8

 

7 Ankerst DP, Xia J, Thompson IM Jr et al. Precision medicine in active surveillance for prostate cancer: development of the canary-early detection research network active surveillance biopsy risk calculator. Eur Urol 2015; 68: 1083–8

 

8 Mamawala MM, Rao K, Landis P et al. Risk prediction tool for grade re- classification in men with favourable-risk prostate cancer on active surveillance. BJU Int 2017; 120: 25–31

 

9 ColeyRY, Zeger S L, Mamawala M, Pienta KJ, Carter HB. Prediction of the pathologic gleason score to inform a personalized management program for prostate cancer. Eur Urol 2016; [Epub ahead of print]. doi: 10.1016/j.eururo.2016.08.005

 

10 Tosoian JJ, Loeb S , Feng Z et al. Association of [2]proPSA with biopsy reclassification during active surveillance for prostate cancer. J Urol 2012; 188: 1131–6

 

Video: Risk prediction tool for grade re-classification in men with favourable-risk prostate cancer on active surveillance

/by

Risk prediction tool for grade re-classification in men with favourable-risk prostate cancer on active surveillance

Read the full article

Abstract

Objective

To create a nomogram for men on active surveillance (AS) for prediction of grade re-classification (GR) above Gleason score 6 (Grade group >2) at surveillance biopsy.

Patients and Methods

From a cohort of men enrolled in an AS programme, a multivariable model was used to identify clinical and pathological parameters predictive of GR. Nomogram performance was assessed using receiver operating characteristic curves, calibration, and decision curve analysis.

Results

Of 1 374 men, 254 (18.50%) were re-classified to Gleason ≥7 on surveillance prostate biopsy. Variables predictive of GR were earlier year of diagnosis [≤2004 vs ≥2005; odds ratio (OR) 2.16, P < 0.001], older age (OR 1.05, P < 0.001), higher prostate-specific antigen density [OR 1.19 (per 0.1 unit increase), P = 0.04], bilateral disease (OR 2.86, P < 0.001), risk strata (low-risk vs very-low-risk, OR 1.79, P < 0.001), and total number of biopsies without GR (OR 0.68, P < 0.001). On internal validation, a nomogram created using the multivariable model had an area under the curve of 0.757 (95% confidence interval 0.730–0.797) for predicting GR at the time of next surveillance biopsy.

Conclusion

The nomogram described is currently being used at each return visit to assess the need for a surveillance biopsy, and could increase retention in AS.

View more videos

Article of the Week: Decision-Making by PCa Physicians During AS

/by

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Qualitative study on decision-making by prostate cancer physicians during active surveillance

Stacy Loeb*,†,‡,§, Caitlin Curnyn†, Angela Fagerlin¶,**, Ronald Scott Braithwaite†
Mark D. Schwartz†,§, Herbert Lepor*‡, Herbert Ballentine Carter†† and Erica Sedlander†

 

Departments of *Urology, †Population Health, ‡Laura and Isaac Perlmutter Cancer Center, New York University, §Manhattan Veterans Affairs Medical Center, New York, NY, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, **Informatics, Decision Enhancement, and Surveillance (IDEAS) Center, Salt Lake City VA, UT, and ††Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD, USA

 

Read the full article

How to Cite

Loeb, S., Curnyn, C., Fagerlin, A., Braithwaite, R. S., Schwartz, M. D., Lepor, H., Carter, H. B. and Sedlander, E. (2017), Qualitative study on decision-making by prostate cancer physicians during active surveillance. BJU International, 120: 32–39. doi: 10.1111/bju.13651

Abstract

Objective

To explore and identify factors that influence physicians’ decisions while monitoring patients with prostate cancer on active surveillance (AS).

Subjects and Methods

A purposive sampling strategy was used to identify physicians treating prostate cancer from diverse clinical backgrounds and geographic areas across the USA. We conducted 24 in-depth interviews from July to December 2015, until thematic saturation was reached. The Applied Thematic Analysis framework was used to guide data collection and analysis. Interview transcripts were reviewed and coded independently by two researchers. Matrix analysis and NVivo software were used for organization and further analysis.

Results

Eight key themes emerged to explain variation in AS monitoring: (i) physician comfort with AS; (ii) protocol selection; (iii) beliefs about the utility and quality of testing; (iv) years of experience and exposure to AS during training; (v) concerns about inflicting ‘harm’; (vi) patient characteristics; (vii) patient preferences; and (viii) financial incentives.

Conclusion

These qualitative data reveal which factors influence physicians who manage patients on AS. There is tension between providing standardized care while also considering individual patients’ needs and health status. Additional education on AS is needed during urology training and continuing medical education. Future research is needed to empirically understand whether any specific protocol is superior to tailored, individualized care.

Read more articles of the week

Editorial: AS in PCa- New Efforts, New Voices, New Hope

/by

In January 2016, in his final State of the Union address, US President Barack Obama tasked Vice President Joseph Biden with heading up a new national mission, the Cancer Moonshot, to expedite advances in cancer prevention, diagnosis and treatment. One of the blue-ribbon panel recommendations was to minimize the side effects of cancer treatment.

There is no better target for that goal than prostate cancer, the cancer that leads all others in the toll of Americans annually diagnosed with cancer, and the fourth most common worldwide. Many men with low-risk prostate cancer undergo unnecessary treatments, including prostatectomy and radiation therapy, which are unlikely to affect their survival, even if their disease were left untreated. A case in point is the ProtecT study [1], which showed at a median of 10 years that there was no difference in prostate cancer-specific mortality between treatment with surgery or radiation therapy and no treatment [1]. Although there has been a paradigm shift in the management of low-risk prostate cancer with an increased uptake of active surveillance (AS) [2], the fact is that only ~40% of men with low-risk prostate cancer choose AS.

Because of equivalency in effectiveness of treatment options in low-risk prostate cancer, an explication of the steps involved in the clinical decision-making process were long overdue. In an innovative study in the present issue of BJUI, Loeb et al. [3] report a qualitative analysis using a purposive sampling strategy to explore the decision-making process of physicians caring for patients with prostate cancer undergoing AS. This study used qualitative interviews and investigators then analysed responses to identify factors influencing therapeutic decision-making. It is noteworthy that despite the fact that AS acceptance rates have increased and it is an established therapeutic approach, significant differences still remain with regard to when physicians enroll and how they monitor patients on AS. These findings align with those from a Surveillance Epidemiology and End Results (SEER) registry study of 12 068 men with low-risk prostate cancer whose urologists and radiation oncologists reported a spectrum of observation practices [4]. Neither study accounted for patients’ preference or perspectives.

Although there are many national guidelines for AS, no consensus on optimum AS management exists, but Movember–GAP3 (https://au.movember.com/report-cards/view/id/3372/gap3-prostate-cancer-active-surveillance), an international effort comprising 25 institutions with AS programmes, may change that. It seeks to establish standard guidelines for patient selection and monitoring and to find agreement on a trigger for treatment. The tumour heterogeneity and possible lack of linearity in early disease progression that we can glean from the next-generation sequencing studies in advanced prostate cancer [5] will not make that easy. Given the promise of precision medicine, we anticipate a decision-making process that by integrating clinical and pathological data, imaging, and biomarkers prognostic of risk of disease progression as well as patient comorbidity effectively removes guesswork from the calculation.

As this international effort and the vice president’s work proceed, we urge all to listen to the voices of patients and ensure they are heard as clearly as those of the experts. We know the paternalistic model of medicine, in which physicians are the exclusive decision-makers, has long been outmoded [6]. With so much at stake, let us now act like it.

Spyridon P. Basourakos* Karen Hoffman† and Jeri Kim*

 

*Department of Genitourinary Medical Oncology, and †Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, US

 

Read the full article

 

References

 

1 Hamdy F, Donovan J, Lane J et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016; 375: 1415–24

 

2 Cooperberg M, Carroll P. Trends in management for patients with localized prostate cancer, 1990–2013. JAMA 2015; 314: 80–2

 

3 Loeb S, Curnyn C, Fagerlin A et al. Qualitative study on decision- making by prostate cancer physicians during active surveillance. BJU Int 2017; 120: 32–9

 

4 Hoffman K, Niu J, Shen Y et al. Physician variation in management of low-risk prostate cancer: a population-based cohort study. JAMA Intern Med 2014; 174: 1450–9

 

5 Robinson D, Van Allen E, Wu Y et al. Integrative clinical genomics of advanced prostate cancer. Cell 2015; 161: 1215–28

 

6 Lerner B. The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics. Boston: Beacon Press, 2014

 

Video: Decision-Making by PCa Physicians During AS

/by

Qualitative study on decision-making by prostate cancer physicians during active surveillance

 

Read the full article

Abstract

Objective

To explore and identify factors that influence physicians’ decisions while monitoring patients with prostate cancer on active surveillance (AS).

Subjects and Methods

A purposive sampling strategy was used to identify physicians treating prostate cancer from diverse clinical backgrounds and geographic areas across the USA. We conducted 24 in-depth interviews from July to December 2015, until thematic saturation was reached. The Applied Thematic Analysis framework was used to guide data collection and analysis. Interview transcripts were reviewed and coded independently by two researchers. Matrix analysis and NVivo software were used for organization and further analysis.

Results

Eight key themes emerged to explain variation in AS monitoring: (i) physician comfort with AS; (ii) protocol selection; (iii) beliefs about the utility and quality of testing; (iv) years of experience and exposure to AS during training; (v) concerns about inflicting ‘harm’; (vi) patient characteristics; (vii) patient preferences; and (viii) financial incentives.

Conclusion

These qualitative data reveal which factors influence physicians who manage patients on AS. There is tension between providing standardized care while also considering individual patients’ needs and health status. Additional education on AS is needed during urology training and continuing medical education. Future research is needed to empirically understand whether any specific protocol is superior to tailored, individualized care.

View more videos

Article of the Week: Value of 111In-PSMA-RGS for salvage lymphadenectomy in recurrent PCa

/by

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video discussing the paper.

If you only have time to read one article this week, it should be this one.

Value of 111In-prostate-specific membrane antigen (PSMA)-radioguided surgery for salvage lymphadenectomy in recurrent prostate cancer: correlation with histopathology and clinical follow-up

Isabel Rauscher*, Charlotte Duwel†, Martina Wirtz‡, Margret Schottelius‡, Hans-Jurgen Wester‡, Kristina Schwamborn§, Bernhard Haller, Markus Schwaiger*, Jurgen E. Gschwend†, Matthias Eiber* and Tobias Maurer†

 

*Departments of Nuclear Medicine, †Urology, Technical University of Munich, Klinikum rechts der Isar, Munich, ‡Institute of Pharmaceutical Radiochemistry, Technical University of Munich, Garching, §Department of Pathology, and Institute of Medical Statistics and Epidemiology, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany

 

Read the full article

How to Cite

Rauscher, I., Düwel, C., Wirtz, M., Schottelius, M., Wester, H.-J., Schwamborn, K., Haller, B., Schwaiger, M., Gschwend, J. E., Eiber, M. and Maurer, T. (2017), Value of 111In-prostate-specific membrane antigen (PSMA)-radioguided surgery for salvage lymphadenectomy in recurrent prostate cancer: correlation with histopathology and clinical follow-up. BJU International, 120: 40–47. doi: 10.1111/bju.13713

Abstract

Objectives

To evaluate the use of 111In-labelled prostate-specific membrane antigen (PSMA)-I&T-based radioguided surgery (111In-PSMA-RGS) for salvage surgery in recurrent prostate cancer (PCa) using comparison of intra-operative gamma probe measurements with histopathological results of dissected specimens. In addition, to determine the success of 111In-PSMA-RGS with regard to postoperative prostate-specific antigen (PSA) responses, PCa-specific treatment-free survival rates and postoperative complication rates.

Patients and Methods

A total of 31 consecutive patients with localized recurrent PCa undergoing salvage surgery with PSMA-targeted radioguided surgery using a 111In-labelled PSMA ligand between April 2014 and July 2015 were retrospectively included in this study. The preoperative (interquartile range; range) median PSA level was 1.3 (0.57–2.53 ng/mL; 0.2–13.9 ng/mL). Results of ex vivo radioactivity rating (positive vs negative) of resected tissue specimens were compared with findings of postoperative histological analysis. Best PSA response without additional treatment was determined after 111In-PSMA-RGS, and salvage-surgery-related postoperative complications and PCa-specific additional treatments were recorded.

aotw-jul-2017-3-results

Results

In 30/31 patients, 111In-PSMA-RGS allowed intra-operative identification of metastatic lesions. In total, 145 surgical specimens were removed and 51 showed metastatic involvement at histological analysis. According to 111In-PSMA-RGS ex vivo measurements, 48 specimens were correctly classified as metastatic and 87 as cancer-free, four were false-negative and six were false-positive compared with histological evaluation. Follow-up information was available for 30/31 patients. PSA declines of >50% and >90% were observed in 23/30 patients and in 16/30 patients, respectively. In 18/30 patients, a PSA decline to <0.2 ng/mL was observed. In 10/30 patients further PCa-specific treatment was given after a median (range) of 125 (48–454) days post-111In-PSMA-RGS. The remaining 20 patients remained treatment-free at a median (range) follow-up of 337 (81–591) days. Of 30 patients, 10 presented with surgery-related complications (Clavien–Dindo grade 1, n = 6, Clavien–Dindo grade 3b, n = 4).

Conclusion

111In-PSMA-RGS proved to be of high value for intra-operative detection of even small metastatic lesions in patients with PCa scheduled for salvage lymphadenectomy. It allows the exact localization and resection of metastatic tissue during 111In-PSMA-RGS and is therefore anticipated to have a beneficial influence on further disease progression; however, identification of suitable patients on the basis of PSMA-positron-emission tomography imaging as well as clinical variables is essential for satisfactory results to be obtained.

Read more articles of the week

Video: Value of 111In-PSMA-RGS for salvage lymphadenectomy in recurrent PCa

/by

Value of 111In-prostate-specific membrane antigen (PSMA)-radioguided surgery for salvage lymphadenectomy in recurrent prostate cancer: correlation with histopathology and clinical follow-up

 

Read the full article

 

Abstract

Objectives

To evaluate the use of 111In-labelled prostate-specific membrane antigen (PSMA)-I&T-based radioguided surgery (111In-PSMA-RGS) for salvage surgery in recurrent prostate cancer (PCa) using comparison of intra-operative gamma probe measurements with histopathological results of dissected specimens. In addition, to determine the success of 111In-PSMA-RGS with regard to postoperative prostate-specific antigen (PSA) responses, PCa-specific treatment-free survival rates and postoperative complication rates.

Patients and Methods

A total of 31 consecutive patients with localized recurrent PCa undergoing salvage surgery with PSMA-targeted radioguided surgery using a 111In-labelled PSMA ligand between April 2014 and July 2015 were retrospectively included in this study. The preoperative (interquartile range; range) median PSA level was 1.3 (0.57–2.53 ng/mL; 0.2–13.9 ng/mL). Results of ex vivo radioactivity rating (positive vs negative) of resected tissue specimens were compared with findings of postoperative histological analysis. Best PSA response without additional treatment was determined after 111In-PSMA-RGS, and salvage-surgery-related postoperative complications and PCa-specific additional treatments were recorded.

Results

In 30/31 patients, 111In-PSMA-RGS allowed intra-operative identification of metastatic lesions. In total, 145 surgical specimens were removed and 51 showed metastatic involvement at histological analysis. According to 111In-PSMA-RGS ex vivo measurements, 48 specimens were correctly classified as metastatic and 87 as cancer-free, four were false-negative and six were false-positive compared with histological evaluation. Follow-up information was available for 30/31 patients. PSA declines of >50% and >90% were observed in 23/30 patients and in 16/30 patients, respectively. In 18/30 patients, a PSA decline to <0.2 ng/mL was observed. In 10/30 patients further PCa-specific treatment was given after a median (range) of 125 (48–454) days post-111In-PSMA-RGS. The remaining 20 patients remained treatment-free at a median (range) follow-up of 337 (81–591) days. Of 30 patients, 10 presented with surgery-related complications (Clavien–Dindo grade 1, n = 6, Clavien–Dindo grade 3b, n = 4).

Conclusion

111In-PSMA-RGS proved to be of high value for intra-operative detection of even small metastatic lesions in patients with PCa scheduled for salvage lymphadenectomy. It allows the exact localization and resection of metastatic tissue during 111In-PSMA-RGS and is therefore anticipated to have a beneficial influence on further disease progression; however, identification of suitable patients on the basis of PSMA-positron-emission tomography imaging as well as clinical variables is essential for satisfactory results to be obtained.

View more videos
© 2024 BJU International. All Rights Reserved.