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Rocktober – Keep on rocking #urojc

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We celebrated the two-year anniversary of the international urology journal club this month (@iurojc) with record participation. There were over 500 tweets in the 48 hour discussion of this month’s article, published in New England Journal of Medicine on September 18, 2014, Ultrasound versus Computed Tomography for Suspected Nephrolithiasis. It was a true multidisciplinary discussion with nephrologists, EM docs, and study author, radiologist Rebecca Smith-Bindman tweeting.

This was a multi-institutional prospective randomized control study evaluating bedside and radiology ultrasonography versus CT as the first test performed for patients presenting to the ED with flank or abdominal pain. Patients who initially underwent ultrasound could also receive a CT if the provider felt necessary based on clinical presentation and ultrasound findings. In terms of the primary endpoints, authors found no significant difference across the three groups in high-risk diagnoses with complications related to missed or delayed diagnoses. There was significantly less 6-month cumulative radiation exposure in patients assigned to the ultrasonography groups compared to those assigned to CT. Conclusions of this study in the form of a tweet: Get US first #noharmdone #lessradiation.

Conversation first focused on clarifying the main conclusions of this article. Notably, ED physicians were the focus of this study, who care whether the patient will be admitted or sent home. Information about size, location, etc of stones was omitted from the study since the goal was not definitive stone treatment.

Some of the limitations of the study were brought up early on. First of all, obese patients were excluded (men >129 kg and women >113 kg).

Additionally, the definition of being diagnosed with a stone only applied to individuals who reported passing a stone or having a stone surgically removed.

Much of the conversation focused on how this approach may be beneficial in recurrent stone-formers, although at least a KUB likely needed before taking a patient to the OR.

One of the main issues seemed to be the practicality of universally applying the “ultrasound first” approach. Many institutions do not have ultrasound readily available during night or weekend hours.

ER folks disagreed, and thought that point-of-care ultrasound could be easily adopted.

@soph_cash suggested urologists be the ones to perform ultrasound. Although an important skill to learn, the idea was quickly put to rest.

Author Rebecca Smith-Bindman made a brief appearance in support of the evidence in the study.

Coincidentally, the twitter-based nephrology journal club, #nephjc, discussed the same article this month. @hswapnil tweeted a useful chart comparing radiation doses (think about this next time you eat a banana) https://www.xkcd.com/radiation/

Although the conclusions among nephrologists were similar, @uretericbud said it best:

Overall, the consensus seemed to be that the paper presents good evidence for starting with ultrasound in the ED but applying this in all institutions may be difficult. Ultrasound also has limited use for urologists who are focused on stone treatment rather than catastrophic misses. Finally, some concluding thoughts from participants:

Thank you to all the tweeps over the last two years who have provided knowledge, insight, and a healthy dose of comedy to make #urojc such a huge success. Plugging an idea floated by @CanesDavid…

This month’s best tweet prize was sponsored by one beautiful thing vintage furniture.

Lastly, here are the symplur analytics for the month.

Ariel Fredrick is a PGY-2 urology resident at Lahey Hospital in Burlington, Massachusetts.

 

sLND for Prostate Cancer Nodal Recurrence: #urojc September 2014 summary

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The September 2014 edition of the International Urology Journal Club (#urojc) returned to familiar territory – prostate cancer. In particular, the discussion focused on salvage lymph node dissection following radical prostatectomy. For the second time (first in July 2014), two journal articles were selected. Both were kindly made available to open access by The Journal of Urology (@JUrology).

The first paper from the Mayo Clinic by Karnes et al., titled ‘Salvage Lymph Node Dissection (sLND) for Prostate Cancer Nodal Recurrence Detected by 11C-Choline Positron Emission Tomography/Computed Tomography (PET/CT)’, reported on a retrospective single-surgeon series of 52 men who underwent salvage lymph node dissection for nodal recurrence post radical prostatectomy. Median follow-up was 20 months. Three-year Biochemical recurrence (BCR)-free survival rate was 45.5% (PSA <0.2). Metastatic/systemic progression-free and cancer-specific survival rates were 46.9% and 92.5% respectively. They concluded that sLND may delay further progression of disease but highlighted the need for randomised controlled trials.

The second paper from German group Tilki et al., titled ‘Salvage Lymph Node Dissection for nodal recurrence of prostate cancer after Radical Prostatectomy’, also reported on a retrospective series of 58 patients who underwent sLND for nodal recurrence on PET/CT post radical prostatectomy. Median follow-up was 39 months. All but 1 patient had BCR. Five-year clinical recurrence-free and cancer-specific survival rates were 35.9% and 71% respectively.  Tilki et al. concluded that while most patients had BCR, sLND may delay ADT and clinical recurrence in selected cases.

A common sentiment shared during the discussion related to the lack of randomised evidence for sLND:

There were some serious concerns about the methodology and results from the two articles:

Discussions quickly shifted away from the two articles to the actual clinical question of sLND in oligometastatic disease and delay to ADT. Matthew Katz provided useful links to the use of stereotactic radiation therapy.

Issues surrounding sLND training and the paradigm shift in recent years were also highlighted:

Opinions were divided on the question of surgical morbidity versus the potential increase in time to ADT:

Pop culture references were in vogue this month. An article by the Mayo Clinic on the 11C-Choline PET scan sparked the linked exchange:

Some take home messages pertained to the uncertainty regarding patient selection and the role of sLND in the broader multidisciplinary arena of prostate cancer treatment:

The winner of the Best Tweet Prize is Brian Chapin (@ChapinMD) for his tweet above.  We thank the Journal of Clinical Urology for supporting this month’s prize by way of a one year electronic subscription to their journal.  We also thank the Journal of Urology for supporting this month’s discussion by way of allowing time limited open access of both articles.

Staying true to form, this month’s edition of #urojc provided a forum for lively international discussion. We look forward to next month’s installment and especially encourage trainees to make use of this excellent educational opportunity.

 

Isaac Thangasamy is a second year Urology Trainee currently working at the Royal Brisbane and Women’s Hospital, Brisbane, Australia. He is passionate about education and social media. Follow him on Twitter @iThangasamy

 

SoMe Guidelines in Urology: #urojc August 2014 summary

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The August 2014 twitter-based international urology journal club (#urojc) took an introspective look at the newly published European Association of Urology recommendations on the appropriate use of social media.

This month’s article hit close to home as a panel of international urologists (many who are active on Twitter and #urojc) attempted to bring social media (SoMe) to the general public of urologists with some basic guidelines on effective, safe and honest communication. The article described the various social networks frequently used by physicians, highlighted some benefits of SoMe involvement, and pointed out the possible risks of SoMe. Recommendation statements emphasized clear, confidentiality, refraining from self-promotion, limits on patient-physician interaction and caution in engaging in SoMe.

From the start, it was evident that this was not a fluff piece and there was discussion to be had:

 

@CBayneMD started it off with concern about the recommendation to keep personal and professional content separate. Many argued that adding something personal kept the communication more interesting and reminded readers that behind the online persona is a person.

 

Good arguments were made on both sides. Using different SoMe outlets for personal and professional posts may make it easier to keep it appropriate.

 

The guideline section on refraining from self-promotion was generally well accepted, though some clarification was called for.

 

Another criticism was of the group of EAU panelists chosen to write the guideline. An excellent choice was made to include the twitter handles of the guidelines authors in the byline.

 

Several of the authors are undoubtedly SoMe experts.

 

@wandering_gu, one of the authors, defended the decision to include authors with varied levels of SoMe experience.

A common twitter disclaimer, amongst physicians, “RT (retweets) are not E (endorsements)” may or may not be worth much.

…but may be necessary, nonetheless.

@Dr_RPM summarizes the message of this guideline document.

Whether or not you agree with the EAU SoMe guidelines or the previously published BJUI SoMe Guidelines, it’s clear that SoMe in medicine, and especially urology, is an important part of the future. We should all continue to be thoughtful in our involvement with SoMe and encourage our friends and colleagues to participate. Thank you all for another exciting discussion. Make sure to keep an eye on @iurojc and #urojc for next month’s International Urology Journal Club!

 

Parth K. Modi is a PGY-4 urology resident at Rutgers-RWJMS in New Brunswick, NJ. He has an interest in urologic oncology, robotics and bioethics and tweets @marthpodi.

 

#UroJC July 2014 – Is there a place for laser techniques in our current schema of bladder cancer diagnosis and management?

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This month’s International Urology Journal Club (@iurojc) truly engaged a global audience with participants from ten countries including author Thomas Herrman (@trwhermann) from Hannover, Germany.  A landmark 2000 followers was reached during July, nearly two years since @iurojc’s conception in late 2012. In fact, since this time nearly 1100 people have participated in the journal club from around the world.

Bladder cancer was up for debate for the first time this year and @iurojc trialled the discussion of two complementary articles recently published online ahead of print in the World Journal of Urology.  The first article provided an update of the current evidence for transurethral Ho:YAG and Tm:YAG in the endoscopic treatment of bladder cancer, and the second was a randomised controlled trial (RCT) comparing laser to the gold standard transurethral resection of bladder tumour (TURBT).  Authorship groups were from Germany and China respectively; our Chinese authors unfortunately unable to join the dialogue due to restriction on all twitter activity in the country.

Initial conversation focussed on the methodology, results and limitations of the RCT, however this soon extended to a more general discussion around the current difficulties with the diagnosis and management of bladder cancer and the pros and cons of using laser for this purpose.  Key themes debated over the 48-hour period included the importance of accurate staging, current standards of TURBT, advantages of en bloc resection and the learning curve, cost and usefulness of laser technology.

Both studies reiterated one of the major goals outlined in the EAU guidelines for non-muscle invasive bladder cancer (NMIBC), to achieve correct staging with inclusion of detrusor muscle and complete resection of tumours.  This is important in limiting second resection and consequently has a resulting cost offset.  In the review article, only 3 studies commented on staging quality and another two commented that laser was suitable for staging but did not specify if detrusor muscle was identified.

@ChrisFilson and @CBayneMD expressed their concern over the RCT by Chen and Colleagues

@linton_kate astutely pointed out another limitation

and author of the review article @trwherrmann summed this up nicely

In the RCT by Chen et al. there was a significantly greater number of pT1 tumours detected with laser than TURBT, the authors suggested this might be due to better sampling.  It remains unclear if this would impact on management and this did not enter the arena for discussion during this @iurojc.

Many argued that TURBT techniques and practices should be optimised before newer techniques are introduced.

‘En bloc’ was touted as the new trendy word in endourology.  EAU guidelines recommend en bloc resection for smaller tumours.  The articles suggested that en bloc resection of bladder tumours should provide more accurate staging however conclusive data is missing to substantiate this in the current literature. 

@DrHWoo discussed potential advantages of the laser technique

@linton_kate pointed out that en bloc resection is not limited to the laser technique

Further to this, the lack of obturator nerve reflection with laser was emphasised in the RCT.  Obturator kick was noted during TURBT in 18 patients and none during laser resection, however none of these patients suffered bladder perforation.  The significance of this was debated and usefulness of obturator block in this context discussed.

The pendulum seemed to the swing out of favour of laser during the discussion, with several limitations outlined including reduced ability for re-resection, cost and the presence of a learning curve.

Regarding additional cost, the host rebutted

The flow of academic dialogue was interrupted midstream (pardon the pun) by a light-hearted discussion around the ergonomics of TURBT.

Below are some of the key take home messages that arose from the usual culprits in this month’s @iruojc discussion

Kindly author @trwherrmann invited us to his upcoming en bloc resection workshop.  Keep an eye out for this.

@iurojc would like to thank Prostate Cancer Prostatic Diseases who have kindly provided the prize for this month which is a 12 month on line subscription to the journal. @nickbrookMD’s made efforts to sway the vote his way.

Whilst usually the Best Tweet Prize is reserved for some incisive comment, the repeated complaints from @nickbrookMD for his failure to ever win the Best Tweet prize has seen for the first and final time that the @iurojc has bowed to pressure. Congratulations to @nickbrookMD for finally having made it with the above tweet.

If you haven’t tuned into @iurojc, follow future journal club discussions via the hashtag #urojc, on the first Sunday/Monday of each month. 

 

Dr Marnique Basto (@DrMarniqueB) is a USANZ trainee from Victoria who recently completed a Masters of Surgery in the health economics of robotic surgery and has an interest in SoMe in Urology.

 

 

 

 

A new take on GPS navigation? Summary of the June #urojc twitter debate.

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The diagnosis and management of prostate cancer continues to rapidly evolve, with heavy debates at each stage of the evolution process. The key trade off between avoiding the over diagnosis and overtreatment of low risk indolent tumours, versus failing to diagnose and act on what may progress to aggressive disease, is an on going theme in the debate.

Research into various diagnostic tools to help both the patient and clinician stratify individual risk is on going, however the heavy consequence of undertreating perhaps leads more into active treatment than clinically necessary.

The June #urojc twitter debate focused on the new and hugely important paper by Klein E et al, to which we were given open access to courtesy of European Urology.  The authors of this US study focus on the potential underuse of Active Surveillance (AS), and propose a Genomic Prostate Score in order to help risk stratify patients considering both surveillance and active therapy. Based on three studies, a prostatectomy study, a biopsy study, and a validation study, a 17-gene assay was created which was shown to predict both high stage and high grade disease at diagnosis.

The debate kicked off with the suggestions from the hosts that at genomics may make their way into AS protocols

 

Which was rapidly agreed

However inevitably the issue of cost was raised

Parth Modi praised the study design and results, however raised a valid question

And the further issue of logistics of samples provided for genomic testing was debated

With the possibility of low disease volume in samples contributing

Which launched a debate as to whether for those with low volume disease, the discussion of opting for genomics was a discussion too far

Alternatives to genomics in predicting progressive disease were discussed. However again the cost of these tests were debated – although generally thought to be less expensive than genomic testing.

 

Followed by perhaps an early contender for best tweet…

 

The host again posed an on point question

With responses suggesting there remains room for further work until genomics plays a role in day-to-day treatment plans

David Canes helped to put the debate into real terms by using an example case for discussion, which raised the point of interpretation of results being dependent on likely treatment decision, not necessarily treatment decision based fully on results

Which raised some slightly more pragmatic suggestions

GPS results however are not necessarily clear-cut. Like all prognostic indicators, they can be interpreted in variable ways. Is there a possibility that they could add to the quagmire in the decision making process for patients?

Ultimately the theme of the debate was summed up excellently by Matt Cooperberg. GPS is not offering a definitive strategy to decide who will and will not progress, or who should decide on active treatment. It does however mark a movement into individualised care, which may well be the future for prostate cancer treatment

Congratulations to David Canes for winning the Best Tweet prize which is a complimentary manuscript to Research Reports in Urology published by @DovePress.

Many thanks to all of those who participated in the debate. We look forward to next month’s #urojc discussion!

Sophia Cashman is a first year urology trainee working in the East of England region, UK. Her main areas of interest are female and functional urology. @soph_cash

 

Ejaculatory Function and Treatment for Male LUTS due to BPH

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This month’s twitter-based international urology journal club discussed “Impact of Medical Treatments for Male LUTS due to BPH on Ejaculatory Function: A Systematic Review and Meta-analysis”, published online in the Journal of Sexual Medicine. The discussion was enriched by the participation of Asst. Prof. Giacomo Novara (@giacomonovara) of the University of Padua, the senior author of the paper.

There was general consensus that this was a well constructed paper addressing an important and sometimes neglected side-effect of a group of medications that most urologists use commonly. The principal messages of the paper were:

  1. Ejaculatory dysfunction (EjD) was significantly more common with alphablockers (ABs) in general than placebo
  2. This effect was mainly seen with selective ABs (tamsulosin and sildosin). Non-selective ABs (doxazosin and terazosin) had similar rates of EjD to placebo.
  3. Finasteride and dutasteride both cause EjD, and to a similar extent as each other.
  4. Combination therapy (5ARI + AB) resulted in a three-fold increase in EjD compared to either monotherapy

The authors were congratulated on the amount of work that had obviously gone into the analysis. There was a discussion of some of the technical aspects of how to conduct a systematic review (SR) and meta-analysis. The PRISMA guidelines are a mandatory standard, and are recommended to anyone considering undertaking one. @LoebStacy also recommended the Cochrane handbook as a useful source of info. @DrHWoo asked whether Jadad scores had been used to rate RCT quality. They were not used in this study, but are one method of assessing RCT quality for an SR. @chrisfilson and @jleow advocated the Cochrane Collaboration’s tool for risk of bias assessment (found in Section 8.5 of the handbook), as an alternative.

After the technical aspects, discussion focussed on how best to avoid EjD in men who are concerned about it. @linton_kate asked whether PDE5 inhibitors were an option in this regard. General consensus was that they are an option, especially where LUTS and erectile dysfunction (ED) coexist, but concerns were expressed about the cost (which varied country by country, but is generally far in excess of the cost of ABs) and by @nickbrookMD about the uncertainty surrounding their mechanism of action for LUTS improvement.

Several correspondants were using PDE5Is in clinical practice for this indication however, including @VMisrai. It was pointed out however, that alfuzosin also offers a reduced risk of EjD compared to other ABs, and is substantially less expensive than PDE5Is. Alfuzosin was not evaluated in this paper, however @giacomonovara agreed that it was an option in men with LUTS who wish to avoid EjD, especially where ED is not a concern. @DrHWoo pointed out the Rosen data demonstrating the correlation between increasing LUTS and decreasing erectile function, but indeed (as suggested by @JCLinMD) treatment of LUTS, e.g. with an AB, may in itself improve erectile function.

Discussion moved on to 5ARIs. @giacomonovara stated that these agents had a broad spectrum of potential effects on ejaculatory/erectile function. @shomik_S raised the issue of whether 5ARIs could cause irreversible sexual side-effects. This is certainly a medicolegal concern, and undoubtedly some men report persistent effects on libido and sexual function, although a firm causal link has not been established.

The medicolegal theme was further explored with a discussion on what to warn patients of when commencing these medications. All were agreed that patients commencing ABs/5ARIs, including those undergoing medical expulsive therapy for stones should be warned about EjD. There was some discussion however, about whether patients commencing a 5ARI should be warned about the increased rates of high-grade prostate cancer seen in the PCPT and REDUCE trials. This increase may be an artefact of more effective cancer detection, but none-the-less @loebStacy was of the opinion that it should be included in pre-treatment counselling.

 

But is all the concern about sexual side-effects justified? It was pointed out that many patients are prepared to tolerate sexual side-effects in return for improvement in their LUTS.

Regardless, this paper from @giacomonovara and co-authors provided useful insight and stimulated a valuable discussion. Undoubtedly, some patients are very concerned about EjD and this paper will help all urologists who treat male LUTS to address these concerns.

Winner of the Best Tweet Prize was David Gillatt for his response to the discussion regarding the needs of various nationalities for PDE5I. Special thanks to the SIU for offering a prize of free registration to the 2014 SIU Congress in Glasgow. Also special thanks to Wiley for allowing open access of the article for the May #urojc discussion.

Ben Jackson has completed urological training in the East Midlands, and is now undertaking a fellowship at St. Vincent’s Hospital, Sydney. His principal clinical interest is urologic oncology.
Twitter @Ben_L_Jackson

 

Not So Watchful Waiting?

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SPCG-4 of Robotic Prostatectomy versus WW: April #urojc summary

This month’s twitter based international urology journal club, found by using #urojc, kicked off with the highly anticipated 20 year follow-up of the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4). This article had twitter buzzing in mid-March when it was published in the New England Journal of Medicine making it an ideal article for April’s journal club. This paper became an instant urology “classic.”

Bill-Axelson et al. published this 18 year follow up of a randomized control trial which separated individuals with early prostate cancer into two groups: watchful waiting or radical prostatectomy. Notable results of the study included a relative risk reduction of 44% from prostate cancer for those who underwent a radical prostatectomy compared to with watchful waiting with the NNT = 8, decreased use of androgen-deprivation therapy in this group, and the benefit of surgery being the most prominent in men <65 years with a 55% decrease in the relative risk of death due to prostate cancer.

Given that these results contradict the well known results of the Prostate Cancer Intervention versus Observation Trial (PIVOT), which started after the advent of PSA screening – the discussion of this article was particularly interesting. They are however, very different studies in terms of era and the populations studied.

During the 48 hour discussion period, key topics discussed were:

  • The applicability of these findings given the many advances in prostate cancer screening, diagnosis, and treatment since the 1990’s
  • The factors that influence the NNT
  • The impact of androgen deprivation therapy within both groups
  • How to weigh the impact of adverse effects including erectile dysfunction and urinary incontinence especially in the context of today’s treatment which includes radiation therapy, an option not addressed in this SPCG-4 study
  • The importance of this study should we face the possibility of shifting back to a pre-PSA era with the new USPSTF recommendations regarding PSA screening

As soon as the discussion opened, a question was posed if this was considered a contemporary cohort:

However, this thought was countered by:

The conversation continued to include the importance of time in NNT as pointed out Stacy Loeb. The point was later made, that the NNT might actually be lower with today’s advents of management in high-risk cancer patients.

There was a brief discussion on the statistic that 60% of the participants in the watchful waiting group underwent ADT treatment versus only 40% in the radical prostatectomy group.

Impact of adverse effects was also briefly discussed. The article stated that 84% of prostatectomy patients had ED versus 80% of the patients in WW.  However, incontinence was only present in 11% of the watchful waiting group versus 40% of the surgery group. These statistics are interesting to compare, when the third option of radiation therapy is introduced. With RT being a viable alternative today compared to the 1990’s when the initial enrollment for the SPCG-4 study was done, weighing the risk/benefits of treatment becomes much more complicated.

The importance of weighing QOL was not forgotten during this discussion.

Finally, there was some great conversation alluding to the relevance of this study in the future given the new guidelines of the USTPSF which recommend against using PSA to screen for prostate cancer in healthy men of all ages on the account that there is no realized benefit.

Overall the importance of this study can be easily summarized as follows:

We welcomed a new member!

A huge thank you to the American Urological Association who supported the Best Tweet prize of a video box set. The winner is Fardod O’Kelly for the following tweet:

Thank you to everyone who joined the discussion. We look forward to seeing you at the May #urojc! 

Meena Davuluri is a 3rd year medical student at Upstate Medical University in Syracuse, NY. She is interested in pursuing a career in Urology. Her interests include cost-effective decision analysis and health policy regarding healthcare delivery models. Follow her on Twitter @MeenaDavuluri.

 

To TVT or TVT-O, does it even matter?

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The March, 2014 edition of twitter-based international urology journal club discussion experienced a change of scenery as incontinence took center stage. The discussion focused on the five-year results of a randomised controlled trial (RCT) comparing retropubic versus transobturator midurethral slings for stress incontinence. The platinum priority article by Laurikainen et al. was made available open access thanks to European Urology. Special mention is also given to senior corresponding author Carl Nilsson, whose contributions were relayed via the #urojc guest account.

The prospectively registered, independent RCT was conducted across several Finnish centers. The study reported that at five-year follow up there was no difference in cure rate between the two procedures and that patient satisfaction was high. Initial discussion comments focused on the impressive length of follow up. Furthermore, the study reported that 94.8% of women (254 of 268) returned for five-year follow up.

 

The question of whether or not urodynamics should form part of the pre-operative workup of urinary incontinence was also raised. The study reported that urodynamics to investigate urgency incontinence was not performed.

The study defined a negative 24hr pad test as being <8g leakage/day. An interesting point was raised as to how this compares with the definition used post radical prostatectomy.

A limitation in the study’s methodology was highlighted.

At this point it became obvious that the usual heavyweight #urojc contributors were missing. Even the ‘King of Twitter’ was unusually silent.

The thirst for knowledge was also evident amongst practicing urologists.

 

To further shed light on the differences in complications between the two procedures, we were directed to the study’s shorter-term results. While higher complication rate following transobturator sling was statistically significant, it was not regarded as clinically significant.

We were also directed to an excellent review of the surgical management of female stress urinary incontinence.

While the results of the study show no difference between retropubic versus transobturator midurethral slings, the generalisability of this data across various populations was questioned. The mean age and BMI of patients in the study was 53 and 26 respectively.

Surgeon expertise in vaginal/prolapse surgery was an important issue especially in light of litigation.

A few take home messages
 

While this month’s #urojc discussion did not have the usual level of participation it was nonetheless a valuable conversation concerning two common sling procedures for the management of stress incontinence. Best tweet prize was an iPad app subscription thanks to BJU International which goes to Helen Nicholson (@DrHLN) for above tweet. We look forward to the next installment of #urojc in April.

Isaac Thangasamy is a second year Urology Trainee currently working at the Royal Brisbane and Women’s Hospital, Brisbane, Australia. He is passionate about education and social media. Follow him on Twitter @iThangasamy

 

 

February #urojc summary: complications arising from radical treatment of prostate cancer

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February 2014 twitter-based international urology journal club #urojc continued with the theme of prostate cancer. This time the discussion was based around the complications arising from radical treatment, and the paper was available open access courtesy of Lancet Oncology. Nam et al [1]
reported on a population based retrospective cohort study of men who underwent surgery or radiotherapy alone for prostate cancer in Ontario, Canada between 2002 to 2009. Instead of the traditional outcomes that usually include urinary incontinence and erectile dysfunction, they evaluated five other treatment related complications, hospital admissions; urological, rectal or anal procedures, open surgical procedures and secondary malignancies.

First author of the manuscript Rob Nam joined the discussion using the urojcguest twitter account. The journal club kicked off on Sunday 2nd February at 8pm GMT time, quick off the mark was the ‘Queen of uro-twitter’.

There was quick agreement.

Patients who underwent surgery were more likely to undergo minimally invasive urological procedures, most commonly diagnostic cystoscopy, was this due to easy access to it for urologists?

However, there was comment from Canada where the study was performed that this may not necessarily be the case.

One of the limitations of the study was noted,

Stacy Loeb commented

and the lead author Robert Nam explained

The question was posed how much emphasis was placed on non ED, non urinary incontinence adverse events when counseling patients regarding prostate cancer treatment.

Ben Davies (the self-proclaimed King of uro-twitter) commented that bladder neck contracture was rare in the robotic prostatectomy era, which was the experience of others.

It was noted that the risk of secondary malignancy is probably underplayed due to the relatively short follow up in the study,

and secondary malignancies may sway the decision-making balance towards surgery

Stacy Loeb changed her avatar and commented that the study may not be generalizable to patients treated in the active surveillance era

The timing and severity of complications post treatment was discussed

It was commented that this is likely ‘real world’ data.

The side effects and their likely effects on quality of life were commented on, (from a surgical perspective).

In the same way that surgeons get different results for the same procedure, do radiation oncologists results differ.

A radiation oncologist joined in the discussion.

There was discussion regarding the mode of radiotherapy and variability in outcomes.

We were reminded that not all prostate cancer requires radical treatment.

Final thoughts in the last few minutes of the journal club came from Stacy Loeb.

Thanks to all who participated, looking forward to next months #urojc. Best tweet prize was won by @VMisrai and is complimentary registration to #WCE14 courtesy of @EndourolSoc. His tweet provided a particularly useful link alerted us to an article published on line ahead of print in the ESTRO Green Journal within hours of his tweet. Special acknowledgement again to Rob Nam who contributed as an author and also to brave attendance by Matt Katz whose insightful tweets gave us urologists much to think about.

 

Kate. D. Linton is a consultant urological surgeon at Sheffield Teaching Hospitals/Barnsley Hospital, UK. Twitter @linton_kate

 

Reference

  1. Nam RK, Cheung P, Herschorn S, et al. Incidence of complications other than urinary incontinence or erectile dysfunction after radical prostatectomy or radiotherapy for prostate cancer: a population-based cohort study. Lancet Oncol 2014; 15: 223-31

 

Another new year, but evidently no new overall survivability for patients presenting with metastatic prostate cancer

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The first International Journal Club of 2014 pulled momentum from December’s discussion on treatment of metastatic prostate cancer. The study reported retrospective review of the California Cancer Registry (CCR) from 1988 to 2009 and found no significant improvement in overall or disease-specific survival in men presenting with metastatic prostate cancer. [1] Senior author Marc Dall’Era (@mdallera) led the Twitter #urojc chat.

 

 

 

 

Fresh into a new year, the crowd was giddy.

… and turned toward more important current events, like the U.S. Preventative Services Task Force’s prostate cancer screening recommendations from 2012.

Ultimately, Dall’Era reigned in the masses. His study sought to investigate whether improvement in patients with metastatic prostate cancer have contributed to the overall decline in prostate cancer mortality since the introduction prostate-specific antigen (PSA). The authors identified 19,336 men through the CCR who presented with de novo metastatic prostate cancer between 1988 and 2009. Over the entire study time period, median age of diagnosis decreased significantly from 73 years to 71 years.

The authors separated the men into chronologic cohorts:  1988-1992, 1993-1997, 1998-2003, and 2004-2009. Men in the recent era showed no significant overall survival (OS) or disease-specific survival (DSS) improvements versus earlier cohorts after 1988. Interestingly, on multivariate analysis controlling for baseline patient characteristics, OS was better for men in the 1988, 1993, and 1998 cohorts versus the 2004 cohort. DSS did improve with time when comparing the 2004 cohort with patients presenting in all earlier years.

If there have been no changes in overall survival in patients with de novo metastatic prostate cancer, might this support the effect of PSA screening?

Tweeters discussed prostate cancer screening selecting out a more biologically aggressive metastatic disease. Dall’Era explained the theory.

The overwhelming question chat participants asked is whether the lack of survival benefit over time is truly accurate, a false reflection of treatment advancements made in recent years, or an artifact created from limitations of the study.

Future studies should attempt to control for the different metastatic disease profiles, namely those patients diagnosed after clinical symptom workup versus those who are asymptomatic on presentation. Examining and comparing tumor biology is another future step.

Ultimately, it’s important not to lose sight of the two dramatic trends over the past decade: the decline in prostate cancer-specific mortality and incidence of metastatic disease. The next steps are solidifying which low-risk patients to treat and developing advanced methods to treat the most aggressive diseases.

The Best Tweet prize for January goes to Parth Modi from New Brunswick, NJ, which goes to show that even Urology residents are in with a chance to win.  The January prize has been kindly been donated by European Urology.

Thank you, Marc Dall’Era, for joining the chat. Your interaction made the January chat particularly lively and insightful. Thank you, European Urology for generously providing the Best Tweet prize.

Finally, here are the Symplur.com analytics for the chat.

[1] Wu JN, Fish KM, Evans CP, deVere White RW, Dall’Era MA. No improvement noted in overall or cause-specific survival for men presenting with metastatic prostate cancer over a 20-year period. Cancer 2013. In Press. doi: 10.1002/cncr.28485

Christopher Bayne is a PGY-3 urology resident at The George Washington University Hospital in Washington, DC and tweets @cbaynemd.

 

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