Tag: #BJUI

It is now my turn to welcome you to the BJUI blog. We [the editorial team] hope that you will be as excited as we are about the future. For my first blog posts, I decided to recap the year 2012 in ten stories. These are topics that caught my attention in 2012, and are certainly not representative of what others might think as ‘important’. Nonetheless, I hope that you will find this curated collection of some interest, and maybe stir a little controversy or two. Happy 2013!

In no particular order, part 1 of 2:

+ The re-election of Barack Obama

The bottom line is that the Patient Protection and Affordable Care Act, AKA Obamacare, will happen. What does this mean for American Urologists? Read the excellent review article by Kirk Keagan and Dave Penson on this sweeping piece of legislation aimed at addressing health care costs and disparities. From the paper: “Perhaps most germane to urologists, the ACA will restrain revenues generated from ancillary services, such as in-office imaging and via a bolstered Stark law that will prohibit physicians from referring Medicare patients to a hospital in which they have an investment or ownership interest.” Word on the street is that the AUA is not too happy. Is America ready for Cheesecake medicine?

+ Is robot-assisted radical prostatectomy really better?

Against a background of Jim Hu’s landmark JAMA paper, we learned new things with respect to the robot-assisted (RARP) vs. open RP (ORP) polemic. First, objective data shows that RARP has overtaken ORP as the main surgical approach for prostate cancer in the U.S (Link)(Link). Second, perioperative outcomes of RARP are better (Link)(Link)(Link). Third, RARP costs more. Fourth, nobody knows for functional outcomes (Link)(Link)(Link). Either way, some people really seem to hate robotic surgery, with a vengeance.

+ PSA screening – the controversy that refuses to die…

2012 will be forever (well, at least for nerdy urologists) remembered as the year the USPSTF downgraded PSA screening to a ‘D’ recommendation. In case you live in a cave, that means that “the science shows that more men will be harmed by PSA screening than will benefit. The expected harms are greater than the small potential benefit.” Nice rebuttal by Carlsson et al from MSKCC here. Nonetheless, primary care providers don’t seem to care, as up to 43.9% of men above the age of 74 were still getting screened in 2010. Conversely, in an article emphatically subtitled ‘Less is More’, the evidence shows that the incidence of prostate cancer is, for the first time in decades, decreasing. Prostatectomists, better find something else to do (just trolling, no hate mail please).

+ PSA screening – the Twitter Wars

2012 was a breakthrough year for social media in Urology. In the past year, Twitter has gained considerable traction in our field, thanks to the presence of Tweet (and real world) leaders such as Matt Cooperberg, Tony Finelli, Alex Kutikov, Mike Leveridge, Stacy Loeb, our own Declan Murphy, Dave Penson, Maxine Sun and the self-proclaimed King of Twitter himself, Ben Davies. That said, December hosted some lively exchanges on PSA screening. It started with a nicely-written-yet-a-little-oversimplistic blog post and accompanying tweet by @CBayneMD in favour of PSA screening, which led to some epic jostling between @cooperberg_ucsf (pro-screening) and @kennylinafp (against screening, wrote the evidence review for the USPSTF), amongst others. @daviesbj summary here. Oh yeah, be sure to follow me on Twitter as well as the BJUI itself.

+ The PIVOT trial

Timothy Wilt, of USPSTF fame, strikes again. Here’s one man who won’t be getting a Christmas card from an Urologist anytime soon. After representing the USPSTF at the 2012 AUA Town Hall Meeting (brave), Wilt et al’s PIVOT trial demonstrated that “among men with localized prostate cancer detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate-cancer mortality, as compared with observation, through at least 12 years of follow-up.” Despite its many limitations and flaws (read Ian Thompson’s excellent accompanying editorial here), the lay press suggested in light of this trial that RP does not save lives.

Quoc-Dien Trinh
@qdtrinh

Quoc-Dien Trinh is a minimally-invasive urologist and co-director of the Cancer Prognostics and Health Outcomes Unit. His research focuses on patterns of care, costs and outcomes in prostate cancer treatment.

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The controversies surrounding a physician’s best treatment strategy advice to an individual patient with clinically localized prostate cancer create a continuing need for advanced statistics. Historically, the Partin tables [1] were one of the first statistical tools that physicians and patients found readily usable. The tables have been updated and always focused on prediction of pathologic stage from standard clinical variables. The next commonly cited/used tool was the Kattan nomogram [2] that carried the prediction the next step to the endpoint of biochemical relapse. By 2008, Shariat et al catalogued over 100 predictive tools published from 1966 to 2007 on various endpoints of prostate cancer [3].

What have we learned from this update of the Partin tables?

The pre-operative grade distribution has shifted up slightly with no change in prostatectomy grade/stage distribution. The authors discuss possible causes such as changes in interpreting the Gleason scoring system, shifts in selection for surgery away from lower grade patients, and a possible plateau in stage migration.
The tables have split off Gleason 3+4, 4+3, 8, and 9–10, and found the latter significantly more aggressive, while Gleason 4+3 and 4+4 are more similar. Gleason 9–10 must have a pattern 5 component >5% and may therefore have more aggressive biology. On the other hand, two cases of prostate cancer may have identical volumes of 4 pattern, but if one adds additional 3 pattern, that additional tumour foci paradoxically lowers the sum to 7, but perhaps not the risk of non-organ confined stage.
In the past, the tables were commonly used to predict pT3 stage, with possible change in management away from surgery as that risk increased. Clearly the literature on surgery for higher risk disease has matured, and augmented by the adjuvant/salvage radiation literature such that it is less likely to use the tables for this reason any more. On the other hand, prediction of N1 disease for the purpose of omitting a lymph node dissection remains a useful tool. In this update, using a <2% cut-off you would essentially omit all node dissections in Gleason 6 with PSA < 10 and cT1c/cT2a, while continuing with a dissection for any dominant Gleason 4 pattern. It is noteworthy that this experience was largely based upon standard templates, and those advocating extended templates will find these N1 rates too low. Indeed, when our center adopted the extended template using a robotic technique, the N1 rate for high-risk disease was 39% and 9% for intermediate risk [4]. Moving forward, what tools do we need to provide useful statistics to our patients? Updating old tools with more contemporary patient cohorts is certainly a worthy exercise. Multicentre study based tools will be required for endpoints such as positive surgical margins, quality of life, biochemical recurrence, and other endpoints that may be significantly affected by the experience of the treating physician. Beyond this, the next step should be adaptive nomograms that update in real time rather than en masse every 4–5 years [5].

John W. Davis
Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

References
1 Eifler JB, Feng Z, Lin BM et al. An updated prostate cancer staging nomogram (Partin tables) based on cases from 2006 to 2011. BJU Int 2013; 111: 26–33
2 Kattan MW, Eastham JA, Stapleton AM et al. A preoperative nomogram for disease recurrence following radical prostatectomy for prostate cancer. J Natl Cancer Inst 1998; 90: 766–71
3 Shariat SF, Karakiewicz PI, Roehborn CG, Kattan MW. An updated catalog of prostate cancer predictive tools. Cancer 2008; 113: 3075–99
4 Davis JW, Shah JB, Achim M. Robot-assisted extended pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP): a video-based illustration of technique, results, and unmet patient selection needs. BJUI 2011; 108: 993–8
5 Vickers AJ, Fearn P, Scardino PT et al. Why can’t nomograms be more like Neflix? Urology 2010; 75: 511–3

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Ten stories of 2012, part I

Editorial: What have we learned from the Partin table update?

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