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Article of the month: Targeting the androgen receptor

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Every week the Editor-in-Chief selects the 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 video of a lecture from Professor David Neal, filmed at the Society of Academic Research and Surgery: 2013 Annual Meeting.

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

The transcriptional programme of the androgen receptor (AR) in prostate cancer

Alastair D. Lamb, Charlie E. Massie and David E. Neal

Cambridge University Department of Urology, Addenbrooke’s Hospital and Cancer Research UK (CRUK) Cambridge Institute, Cambridge, UK

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ABSTRACT

• The androgen receptor (AR) is essential for normal prostate and prostate cancer cell growth.

• AR transcriptional activity is almost always maintained even in hormone relapsed prostate cancer (HRPC) in the absence of normal levels of circulating testosterone.

• Current molecular techniques, such as chromatin-immunoprecipitation sequencing (ChIP-seq), have permitted identification of direct AR-binding sites in cell lines and human tissue with a distinct coordinate network evident in HRPC.

• The effectiveness of novel agents, such as abiraterone acetate (suppresses adrenal androgens) or enzalutamide (MDV3100, potent AR antagonist), in treating advanced prostate cancer underlines the on-going critical role of the AR throughout all stages of the disease.

• Persistent AR activity in advanced disease regulates cell cycle activity, steroid biosynthesis and anabolic metabolism in conjunction with regulatory co-factors, such as the E2F family, c-Myc and signal transducer and activator of transcription (STAT) transcription factors. Further treatment approaches must target these other factors.

LINK TO VIDEO

Lecture filmed at the Society of Academic Research and Surgery: 2013 Annual Meeting. Video available from The Royal Society of Medicine https://www.rsmvideos.com/videoPlayer/?vid=340

 

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Article of the week – Prostate cancer: Sun shines light on surgical survival

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Every week the Editor-in-Chief selects the 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.

Radical prostatectomy vs radiotherapy vs observation among older patients with clinically localized prostate cancer: a comparative effectiveness evaluation

Maxine Sun*, Jesse D. Sammon†, Andreas Becker*, Florian Roghmann*, Zhe Tian*, Simon P. Kim‡, Alexandre Larouche*, Firas Abdollah*, Jim C. Hu§, Pierre I. Karakiewicz* and Quoc-Dien Trinh**

*Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada, †VUI Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health Systems, Detroit, MI, ‡Department of Urology, Yale University, New Haven, CT, §Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA, Department of Urology, University of Montreal Health Center, Montreal, Canada and **Department of Surgery, Division of Urology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA

MS and J.D.S contributed equally to the work.

Read the full article
OBJECTIVE

• To compare efficacy between radical prostatectomy (RP), radiotherapy and observation with respect to overall survival (OS) in patients with clinically localized prostate cancer (PCa).

METHODS

• Using data (1988–2005) from the Surveillance, Epidemiology, and End Results–Medicare linked database, 67 087 men with localized PCa were identified.

• The prevalence of the initial treatment strategy was quantified according to patients’ life expectancy ([LE] <10 vs ≥10 years) at initial diagnosis and according to tumour stage. To reduce the unmeasured bias associated with treatment, we performed an instrumental variable analysis.

• Stratified (by stage and LE) Cox regression and competing-risks regression analyses were generated for the prediction of OS and cancer-specific mortality, respectively.

RESULTS

• Among patients with <10 years of LE, most were treated with radiotherapy (49%) or observation (47%). Among patients with ≥10 years of LE, most received radiotherapy (49%), followed by RP (26%).

• In men with <10 years of LE, RP and radiotherapy were not different with respect to OS (hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.45–1.48, P = 0.499). Conversely, in men with ≥10 years of LE, RP was associated with an improved OS compared with observation (HR: 0.59, 95% CI: 0.49–0.71, P < 0.001) and radiotherapy (HR: 0.66, 95% CI: 0.56–0.79, P < 0.001).

• Similar results were recorded in competing-risks regression analyses.

CONCLUSION

• In patients with an estimated LE ≥10 years at initial diagnosis, RP was associated with improved survival compared with radiotherapy and observation, regardless of disease stage.

Editorial – Prostate cancer surgery vs radiation: has the fat lady sung?

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The current article by Sun et al. [1] representing a number of institutions involved in prostate cancer treatment provision is thought-provoking and hypothesis-generating. The authors contention when mining Surveillance, Epidemiology and End Results data for 67 000 men who had localized prostate cancer between 1988 and 2005 is that those with a life expectancy >10 years had less likelihood of prostate cancer death when treated with surgery rather than by radiotherapy or being left to observation. The Scandinavians have already shown, in the randomized study by Hugosson et al. [2], that if you have your prostate cancer removed you have less likelihood of symptomatic local recurrence, lower likelihood of metastasis and progression, and a 29% reduced likelihood of prostate cancer death. The current study asks the question ‘Is radiation therapy less likely to provide a long-term cure for prostate cancer than surgery?’ and gives an answer in the affirmative.

The current paper, in its way, neatly encapsulates the contemporary angst generated in the community when prostate cancer screening, diagnosis and therapy are discussed. The Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) trial [3] allegedly shows no benefit from treatment over observation and contends perhaps that we surgeons and radiation oncologists are harm-workers, not life-savers. The PLCO has a 52% PSA contamination in its control arm [3]. That flawed trial compared screening with de facto screening and produced, in my view, a null hypothesis. How do we explain the paradox of a 44% reduction in prostate cancer-specific mortality between 1993 and 2009? How do we explain the disconnect between these trials and the facts? What do we do with the data not yet considered by the expert panels showing that early PSA testing at age <50 years is highly predictive of subsequent lethal prostate cancer? [4]

Clinicians are rapidly moving to an era of judicious risk assessment. This can only be done after biopsy is performed. We now frequently enrol patients with apparently indolent prostate cancer into surveillance protocols [5]. So the question should be ‘If the disease found on biopsy is moderate to high risk, and potentially lethal for that man, should we remove his prostate surgically or radiate it with intensity-modulated radiation therapy, brachytherapy, proton therapy, +/- hormone therapy?’.

As a surgeon I have an inherent dislike of combining hormone therapy in primary treatment. At least 50% of men in high-risk prostate cancer cohorts who receive radiation therapy also receive hormone therapy as adjuvant or neoadjuvant treatment [6]. Hormone therapy has a myriad of side effects. Even if the playing field was level between surgery and radiation therapy, the avoidance of hormone therapy as a first-line treatment gives surgery a seductive advantage.

The authors of the current report show a significant survival advantage in the cohort for surgery over radiation therapy and observation. There will never be a randomized trial between the two potentially curative treatment methods surgery and radiation. The scourge of commercial interest with spurious claims of superiority of one form of therapy over another, proton beam vs intensity-modulated radiation therapy, robotics vs high-intensity focused ultrasonography, means that we risk having our decisions regarding appropriate therapy formed by multibillion dollar technology companies with powerful marketing capacity. The current paper confirms what is self-evident: untreated localized prostate cancer can be lethal. Surgery and radiation therapy lower the morbidity and mortality from prostate cancer. Which is the better method of curative therapy is moot, but we do know that cure is very much predicated on the expertise and location of the practitioner.

We know mostly when and who to treat and what treatments work well. In my view, the prostate cancer testing debate resonates with the contemporary discussion about childhood immunization for infectious diseases. Some parents now, who clearly cannot remember the devastating epidemics of polio and other childhood illnesses, refuse to immunize their children. Prostate cancer practitioners who did not live in the quite recent era where the initial presentation of prostate cancer was bone metastasis +/− crush fracture to the vertebra and sometimes paraplegia, may be unknowingly steering us backwards.

At the recent 2013 AUA meeting, Adams et al. [7] reported on the fate of men not screened for prostate cancer, i.e. those men who presented with a PSA >100 ng/mL. There was a 3-year survival rate of 9.7%, a 19.7% cord compression rate and a 64% hospitalization rate. Those who do not learn the lessons of history are condemned to repeat them.

Anthony J. Costello
Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia

Read the full article

References

  1. Sun M, Sammon JD, Becker A et al. Radical prostatectomy vs radiotherapy vs observation among older patients with clinically localized prostate cancer: a comparative effectiveness evaluation. BJU Int 2014; 113: 200–208
  2. Hugosson J, Carlsson S, Aus G et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010; 11: 725–732
  3. Andriole GL, Crawford ED, Grubb RL 3rd et al. Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up. J Natl Cancer Inst 2012; 104: 125–132
  4. Vickers AJ, Ulmert D, Sjoberg DD et al. Strategy for detection of prostate cancer based on relation between prostate specific antigen at age 40–55 and long term risk of metastasis: case-control study. BMJ 2013; 346: f2023
  5. Evans SM, Millar JL, Davis ID et al. Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011. Med J Aust 2013; 198: 540–545
  6. Cooperberg MR, Vickers AJ, Broering JM, Carroll PR. Comparative risk-adjusted mortality outcomes after primary surgery, radiotherapy, or androgen-deprivation therapy for localized prostate cancer. Cancer 2010; 116: 5226–5234
  7. Adams W, Elliott CS, Reese JH. The fate of men presenting with PSA over 100 ng/mL: what happens when we do not screen for prostate cancer? AUA 2013. Abstract 2696

 

Article of the week: Quality of life after robotic cystectomy

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Every week the Editor-in-Chief selects the 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.

Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC)

Michael A. Poch, Andrew P. Stegemann, Shabnam Rehman, Mohamed A. Sharif, Abid Hussain, Joseph D. Consiglio*, Gregory E. Wilding* and Khurshid A. Guru

Departments of Urology and *Biostatistics, Roswell Park Cancer Institute, Buffalo, NY, USA

Read the full article
OBJECTIVE

• To determine short-term health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC) using the Bladder Cancer Index (BCI) and European Organisation for Research and Treatment of Cancer (EORTC) Body Image Scale (BIS).

PATIENTS AND METHODS

• All patients undergoing RARC were enrolled in a quality assurance database.

• The patients completed two validated questionnaires, BCI and BIS, preoperatively and at standardised postoperative intervals.

• The primary outcome measure was difference in interval and baseline BCI and BIS scores.

• Complications were identified and classified by Clavien grade.

RESULTS

• In all, 43 patients completed pre- and postoperative questionnaires.

• There was a decline in the urinary domain at 0–1 month after RARC (P = 0.006), but this returned to baseline by 1–2 months.

• There was a decline in the bowel domain at 0–1 month (P < 0.001) and 1–2 months (P = 0.024) after RARC, but this returned to baseline by 2–4 months.

• The decline in BCI scores was greatest for the sexual function domain, but this returned to baseline by 16–24 months after RARC.

• Body image perception using BIS showed no significant change after RARC except at the 4–10 months period (P = 0.018).

CONCLUSIONS

• Based on BCI and BIS scores HRQL outcomes after RARC show recovery of urinary and bowel domains ≤6 months. Longer follow-up with a larger cohort of patients will help refine HRQL outcomes.

 

Editorial: The evolution of robotic cystectomy

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A decade has passed since the publication of the first series of robot-assisted radical cystectomies in the BJUI by Menon et al. [1]. New technologies are fascinating, and many surgeons who aspire to leave a mark in history take the lead in pioneering new procedures. Others follow without waiting for any evidence to justify the adoption of new procedures. In this race, the opinion of the most important stakeholder, the patient, gets ignored.

Although their study has many methodological flaws, Guru et al. [2] have made the effort to collect data on patients’ health-related quality of life (HRQL) after robot-assisted radical cystectomy for bladder cancer. Radical cystectomy is a morbid procedure with a serious impact on patients’ HRQL, no matter how it is performed. Loosing an organ which is responsible for the storage and evacuation of urine several times a day and replacing it with alternatives of continent or incontinent diversion has a serious impact on quality of life, as is evident from this study.

Robotic cystectomy is still evolving. With more experience, a few experts have ventured to perform intracorporeal reconstruction of the urinary diversion. While we await the long-term functional outcomes of this switch over in surgical approach, Guru et al. report the short-term HQRL outcomes in a series of 43 patients undergoing robot-assisted radical cystectomy and intracorporeal urinary diversion at their institution. Most patients (n = 38) had ileal conduit urinary diversion. The authors went on to compare the postoperative outcomes of this cohort with another group of 70 patients who only completed the questionnaire after having undergone robot-assisted radical cystectomy and extracorporeal urinary diversion.

It is interesting to note that there was no significant difference in HRQL between those undergoing extracorporeal and those undergoing intracorporeal reconstruction. These outcomes reinforce the need to gather robust scientific evidence from properly conducted multi-centre, multinational randomized trials before the introduction of new procedures, instead of evaluation with retrospective studies. The urological community has embraced new technologies and patients have benefited a great deal from these innovative approaches; however, it is incumbent upon us to develop a culture of independent, unbiased data collection on outcomes. In this regard we must make the HQRL one of the most important quality indicators in assessment of the new procedures. Such an approach will enable us to justify the extra cost which society has to bear for our innovative trends in the management of old problems [3].

Read the full article

Muhammad Shamim Khan
Guy’s and St Thomas’s Hospital and King’s College London, London, UK

References

  1. Menon M, Hemal AK, Tewari A et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int 2003; 92: 232–236
  2. Poch MA, Stegemann AP, Rehman S et al. Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC). BJU Int 2014; 113: 260–265
  3. Wang TT, Ahmed KA, Khan MS et al. Quality-of-care framework in urological cancers: where do we stand? BJU Int 2011; 109: 1436–1443

 

Article of the Month: The Melbourne Consensus Statement

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Every month the Editor-in-Chief selects an Article of the Month 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, we feature a video from Tony Costello and Declan Murphy discussing the Melbourne Statement.

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

The Melbourne Consensus Statement on the early detection of prostate cancer

Declan G. Murphy1,2,3, Thomas Ahlering4, William J. Catalona5, Helen Crowe2,3, Jane Crowe3, Noel Clarke10, Matthew Cooperberg6, David Gillatt11, Martin Gleave12, Stacy Loeb7, Monique Roobol14, Oliver Sartor8, Tom Pickles13, Addie Wootten3, Patrick C. Walsh9 and Anthony J. Costello2,3

1Peter MacCallum Cancer Centre, 2Royal Melbourne Hospital, University of Melbourne, 3Epworth Prostate Centre, Australian Prostate Cancer Research Centre, Epworth Healthcare Richmond, Melbourne, Vic., Australia, 4School of Medicine, University of California, Irvine, 5Northwestern University Feinberg School of Medicine, Chicago, IL, 6Helen Diller Family Comprehensive Cancer Centre, University of California, San Francisco, 7New York University, 8Tulane University School of Medicine, Tulane, 9The James Buchanan Brady Urological Institute, Johns Hopkins University, USA, 10The Christie Hospital, Manchester University, Manchester, 11Bristol Urological Institute, University of Bristol, Bristol, UK, 12The Vancouver Prostate Centre, 13BC Cancer Agency, University of British Columbia, Vancouver, Canada, and 14Erasmus University Medical Centre, Rotterdam, The Netherlands

Read the full article

• Various conflicting guidelines and recommendations about prostate cancer screening and early detection have left both clinicians and their patients quite confused. At the Prostate Cancer World Congress held in Melbourne in August 2013, a multidisciplinary group of the world’s leading experts in this area gathered together and generated this set of consensus statements to bring some clarity to this confusion.

• The five consensus statements provide clear guidance for clinicians counselling their patients about the early detection of prostate cancer.

 

Read Previous Articles of the Week

 

Video: Why the Melbourne Statement?

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The Melbourne Consensus Statement on the early detection of prostate cancer

Declan G. Murphy1,2,3, Thomas Ahlering4, William J. Catalona5, Helen Crowe2,3, Jane Crowe3, Noel Clarke10, Matthew Cooperberg6, David Gillatt11, Martin Gleave12, Stacy Loeb7, Monique Roobol14, Oliver Sartor8, Tom Pickles13, Addie Wootten3, Patrick C. Walsh9 and Anthony J. Costello2,3

1Peter MacCallum Cancer Centre, 2Royal Melbourne Hospital, University of Melbourne, 3Epworth Prostate Centre, Australian Prostate Cancer Research Centre, Epworth Healthcare Richmond, Melbourne, Vic., Australia, 4School of Medicine, University of California, Irvine, 5Northwestern University Feinberg School of Medicine, Chicago, IL, 6Helen Diller Family Comprehensive Cancer Centre, University of California, San Francisco, 7New York University, 8Tulane University School of Medicine, Tulane, 9The James Buchanan Brady Urological Institute, Johns Hopkins University, USA, 10The Christie Hospital, Manchester University, Manchester, 11Bristol Urological Institute, University of Bristol, Bristol, UK, 12The Vancouver Prostate Centre, 13BC Cancer Agency, University of British Columbia, Vancouver, Canada, and 14Erasmus University Medical Centre, Rotterdam, The Netherlands

Read the full article

• Various conflicting guidelines and recommendations about prostate cancer screening and early detection have left both clinicians and their patients quite confused. At the Prostate Cancer World Congress held in Melbourne in August 2013, a multidisciplinary group of the world’s leading experts in this area gathered together and generated this set of consensus statements to bring some clarity to this confusion.

• The five consensus statements provide clear guidance for clinicians counselling their patients about the early detection of prostate cancer.

 

Article of the week: Obese patients should not be denied RARP

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Every week the Editor-in-Chief selects the 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.

Perioperative and early oncological outcomes after robot-assisted radical prostatectomy (RARP) in morbidly obese patients: a propensity score-matched study

Haidar Abdul-Muhsin, Camilo Giedelman, Srinivas Samavedi, Oscar Schatloff, Rafael Coelho, Bernardo Rocco, Kenneth Palmer, George Ebra and Vipul Patel

Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA

Read the full article
OBJECTIVE

• To evaluate the perioperative and pathological outcomes associated with robot-assisted radical prostatectomy (RARP) in morbidly obese men.

PATIENTS AND METHODS

• Between January 2008 and March 2012, 3041 patients underwent RARP at our institution by a single surgeon (V.P.).

• In all, 44 patients were considered morbidly obese with a body mass index (BMI) of ≥40 kg/m2.

• A propensity score-matched analysis was conducted using multivariable analysis to identify comparable groups of patients with a BMI of ≥40 and <40 kg/m2.

• Perioperative, pathological outcomes and complications were compared between the two matched groups.

RESULTS

• There was no significant difference in operative time. However, the mean estimated blood loss was higher in morbidly obese patients, at a mean (sd) of 113 (41) vs 130 (27) mL (P = 0.049).

• Anastomosis was more difficult in morbidly obese patients (P = 0.001).

• There were no significant differences in laterality, ease of nerve sparing, or transfusion rate between the groups.

• There were no intraoperative complications in either group. Postoperative pathological outcomes were similar between the groups.

• Differences in positive surgical margins and ease of nerve sparing approached statistical significance (P = 0.097, P = 0.075 respectively). Postoperative complication rates, pain scores, length of stay and indwelling catheter duration were similar in the groups.

CONCLUSIONS

• RARP in morbidly obese patients is technically demanding. However, it can be accomplished with acceptable morbidity and resource use.

• In the hands of an experienced surgeon, it is a safe procedure and offers beneficial clinical outcomes.

 

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Editorial: How should we best manage obesity in urology?

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Abdul-Muhsin et al. [1] are to be congratulated on an excellent study involving >3000 patients undergoing robot-assisted radical prostatectomy over a 4-year period. In their study they demonstrate that the morbidly obese patient can be managed in a just about equal way to the non-morbidly obese patient for removal of the prostate. The complications and recovery characteristics in morbidly obese patients are reviewed and it is concluded that, in this single-operator single-centre study, the morbidly obese male with prostate cancer should not be overlooked as a candidate for radical surgery.

We are all faced with more obese patients presenting to our clinical care; in the UK 20% of the adult population are obese and >3% are morbidly obese. There are an increasing number of studies looking at the outcome of surgery in the obese and morbidly obese populations. These studies have drawn mixed conclusions, with some suggesting an increased risk and morbidity and others suggesting no difference when compared with a non-obese population. This is confusing: perhaps the use of body mass index alone to assess obesity is limited and misleading [2]. This is because the distribution of fat varies considerably among individuals, with the most at-risk patients being those with a centripetal fat distribution producing a large abdominal girth. In middle-aged men, a waist size of >102 cm is the best predictor of metabolic syndrome with all its concomitant risk factors [3]. It is these patients who represent the greatest risk for surgery and it is these same patients who urgently need to improve their lifestyle and shed weight in order to achieve a normal life expectancy both to aid surgery and thereafter. Factors such as hypoventilation, hypertension and the risk of thromboembolism are greatly increased in this group. Diabetes, abnormal lipids, bone and joint diseases and reflux are common. These factors will probably contribute to multiple potential peri-operative complications. Cardiopulmonary exercise testing is very useful in detecting the patients most at risk and likely to require most intensive care postoperatively. There are too few studies to date that include this test and that specifically looking at the morbidly obese population, but results are encouraging and will very probably detect those patients most likely to require critical care facilities [4].

While the surgical results in the Abdul-Muhsin et al. study are excellent, one would not wish to dilute the key message to our patients that preparation for major surgery with weight loss is vital. Addressing nutrition and exercise activity in the preoperative period is extremely beneficial and highly successful. Achieving a 10% weight loss within weeks before surgery is entirely achievable with significant benefits to the medical comorbidities and, in particular, breathing and muscle activity [5]. One great advantage of prostate cancer surgery is the often slow-growing nature of the tumour and we can, therefore, often take the opportunity to postpone major surgery for just a matter of weeks to improve fitness and nutrition. This window of opportunity is more than enough to transform a high-risk patient to one with a much lower risk profile.

If we inspire our patients to join in the aim of the whole surgical team to safely cure prostate cancer using weight reduction and improved fitness then long-term life benefits will surely follow in addition to the immediate gains for surgery and anaesthesia.

Peter Amoroso
The London Clinic, 20 Devonshire Place, London W1G 6BW

Read the full article

References

  1. Abdul-Muhsin H, Giedelman C, Samavedi S et al. Perioperative and early oncological outcomes after robot-assisted radical prostatectomy (RARP) in morbidly obese patients: a propensity score-matched study. BJU Int 2014; 113: 84–91
  2. Mullen JT, Moorman DW, Davenport DL. The obesity paradox body mass index and outcomes in patients undergoing non-bariatric general surgery. Ann Surg 2009; 250: 166–172
  3. Balentine CJ, RobInson CN, Marshall CR et al. Waist circumference predicts increased complications in rectal cancer surgery. J Gastrointest Surg 2010; 14: 1669–1679
  4. Hennis PJ, Meale PM, Hurst RA et al. Cardiopulmonary exercise testing predicts post operative outcome in patients undergoing gastric bypass surgery. Br J Anaesth 2012; 109: 566–571
  5. Benotti PN, Still CD, Wood GC et al. Preoperative weight loss before bariatric surgery. Arch Surg 2009; 44: 1150–1155

 

Article of the week: PCa-specific mortality increased in older men with low-risk disease

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Every week the Editor-in-Chief selects the 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 prominent members 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 from Dr. Aizer discussing his paper.

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

Initial management of prostate-specific antigen-detected, low-risk prostate cancer and the risk of death from prostate cancer

Ayal A. Aizer*, Ming-Hui Chen‡, Jona Hattangadi* and Anthony V. D’Amico†

*Harvard Radiation Oncology Program, Boston, MA, †Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA, and, ‡Department of Statistics, University of Connecticut, Storrs, CT, USA

Read the full article
OBJECTIVE

• To evaluate whether older age in men with low-risk prostate cancer increases the risk of prostate cancer-specific mortality (PCSM) when non-curative approaches are selected as initial management.

PATIENTS AND METHODS

• The study cohort consisted of 27 969 men, with a median age of 67 years, with prostate-specific antigen (PSA)-detected, low-risk prostate cancer (clinical category T1c, Gleason score ≤6, and PSA ≤10) identified by the Surveillance, Epidemiology and End Results programme between 2004 and 2007.

• Fine and Gray’s competing risk regression analysis was used to evaluate whether management with non-curative vs curative therapy was associated with an increased risk of PCSM after adjusting for PSA level, age at diagnosis and year of diagnosis.

RESULTS

• After a median follow-up of 2.75 years, 1121 men died, 60 (5.4%) from prostate cancer.

• Both older age (adjusted hazard ratio [AHR] 1.05; 95% confidence interval (CI) 1.02–1.08; P < 0.001) and non-curative treatment (AHR 3.34; 95% CI 1.97–5.67; P < 0.001) were significantly associated with an increased risk of PCSM.

• Men > the median age experienced increased estimates of PCSM when treated with non-curative as opposed to curative intent (P< 0.001); this finding was not seen in men ≤ the median age (P = 0.17).

CONCLUSION

• Pending prospective validation, our study suggests that non-curative approaches for older men with ‘low-risk’ prostate cancer result in an increased risk of PCSM, suggesting the need for alternative approaches to exclude occult, high grade prostate cancer in these men.

 

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