- Email: [email protected]
MP04-10 TRENDS AND REGIONAL VARIATION IN PROSTATE CANCER TREATMENT
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
0
ballpark0 . When using the nomogram only 23% (95% CI 17%-31%) of participants used it properly, but over half were in the 0 ballpark0 , (51%, 95% CI 43%-60%). CONCLUSIONS: Most adults significantly underestimated 15 year cancer specific survival for a prostate cancer patient using unrestricted internet searching. When using a validated online nomogram, most participants were unable to use the tool correctly, but estimates using the tool were closer to the true estimate. These findings suggest that even in a population more educated than the average U.S. citizen unrestricted internet searching often leads to poor estimates of survival, but nomograms can aid people in estimating survival rates. Clinicians should consider guiding patients to appropriate online health resources so that patients can obtain more accurate information and make informed decisions. Source of Funding: none
MP04-09 DOES A CLEAR UNDERSTANDING OF LIFE EXPECTANCY INCREASE DECISIONAL CONFLICT AND ANXIETY FOR MEN WITH NEWLY DIAGNOSED PROSTATE CANCER? Mazen Alsinnawi*, Seattle, WA; April E. Slee, John S. Banerji, seattle, WA; Kathryn L. Dahl, Seattle, WA; Sydney Akapame, seattle, WA; John D Massman III, Erika M. Wolff, John M. Corman, Seattle, WA INTRODUCTION AND OBJECTIVES: Prostate cancer (CaP) decision making is complicated by multiple treatment choices with implications for survival and quality of life. Although knowledge of the effect of co-morbidities on life expectancy helps clinicians to determine the range of treatment options available for their patients, patients are not usually, explicitly given this information. We utilized the Charlson Comorbidity Index (CCI) to predict life expectancy in men with newly diagnosed CaP. The objective of this study is to determine whether providing patients with their CCI score increases treatment decisional conflict and anxiety about death. METHODS: Patients with newly diagnosed CaP were randomized to receive standard multidisciplinary care versus the same counseling with the addition of the patient’s prospective understanding of his CCI score. Patients subsequently completed the Decisional Conflict Scale (DCS) and the Death Anxiety Scale (DAS). The primary objective was to determine whether telling patients their life expectancy complicated their treatment decisions and increased their anxiety levels. Five percent non inferiority margin was used for both instruments. Because the primary hypothesis was safety, patients were analyzed according to the intervention they received. RESULTS: A total of 228 patients returned surveys, 123 received standard counselling and 105 were prospectively informed of their CCI. Mean age was 65 years. 17% had high risk CaP and the median 10-year survival probability was 80.9%. There was no statistical significant difference in planned treatment choice (active surveillance vs active treatment).18.7 % of the standard counselling group reported significant decisional conflict (> 37.5 points) compared to 10.5 % in the CCI group (p¼0.08). Those who received CCI counseling had a mean decisional conflict score of 19.4, compared to 22.1 for the standard group. The difference between these was on average -2.7 points (95% CI -6.8, 1.3) which excludes the 5 % non-inferiority margin (range 0100). The difference for DAS was -0.24 (95% CI, -1.08, 0.60) which excludes the 5 % margin (range 0-15). CONCLUSIONS: Knowledge of CCI does not increase decisional conflict or anxiety about death, and may reduce the incidence of significant conflict. As we embrace the concept of shared decision making in urology, it is expected that the full disclosure of life expectancy will be standard of care. This study suggest that this disclosure can be made without contributing to patient stress and anxiety. Source of Funding: none
e31
MP04-10 TRENDS AND REGIONAL VARIATION IN PROSTATE CANCER TREATMENT Tudor Borza*, Samuel Kaufman, Vahakn B Shahinian, Ann Arbor, MI; Phyllis Yan, David C Miller, Ann Arbor, MI; Ted A Skolarus, Brent K Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Harms associated with diagnosis and treatment of prostate cancer have led to recommendations for reduced screening and less aggressive treatment. The extent to which practice patterns reflect these recommendations is unclear. We performed a national study to better understand recent trends and regional variation in the treatment of prostate cancer. METHODS: Using a 20% sample of national Medicare data we performed a retrospective cohort study of treatment patterns among men with newly diagnosed prostate cancer from 2007-2012. Our primary outcome was rate of curative treatment. Our secondary outcomes were treatment rates among men with a high 10-year risk of non-cancer mortality as a measure of treatment among those least likely to benefit and regional variation in treatment rates. Rates were adjusted for differences in age and race. Regions were defined by Health Referral Regions (HRRs) and HRRs with fewer than 20 treatments per year were excluded to prevent unstable estimates. RESULTS: We identified 67,023 incident cases of prostate cancer of which 48,464 underwent curative treatment during our study period. There was a small decrease in the annual rate of treatment in men diagnosed with prostate cancer (RR 0.99, [95% CI, 0.98-0.99]) (Figure 1A). A more profound change was observed in the rate of treatment in all eligible male beneficiaries (RR 0.92, [95% CI, 0.91-0.92]) (Figure 1B). Treatment rates did not change in men with the highest 10-year risk of non-cancer mortality (RR 1.00, [95% CI, 0.99-1.01]) (Figure 2). There was no decrease in the variation of treatment rates by HRR over the study period. CONCLUSIONS: Rates of curative treatment have declined slightly among men diagnosed with prostate cancer over the study period. This change is substantially less than the decline in rates for all eligible male beneficiaries, suggesting decreasing diagnosis as the main driver for the decline. Rates of treatment among those least likely to benefit remained unchanged. There was no observed decrease in the regional variation of treatment rate.
e32
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
Source of Funding: Ted Skolarus is supported in part by a VA HSR&D Career Development Award - 2 (CDA 12-171) Brent Hollenbeck is supported in part by Research Scholar Grant RSGI-13-323-01-CPHPS from the American Cancer Society and by NIH/NCI grant R01 CA168691.
MP04-11 COMPARING QUALITY OF LIFE OUTCOMES IN MEN RECEIVING EARLY VERSUS LATE POST-PROSTATECTOMY RADIATION THERAPY Greg Murphy*, Peter Haddock, Ilene Staff, Joseph Tortora, Alison Champagne, Joseph Cusano, Joseph Wagner, Hartford, CT INTRODUCTION AND OBJECTIVES: Men with adverse pathologic features or biochemical recurrence after radical prostatectomy (RP) often receive subsequent radiation therapy (RT). The immediate post-operative deficits and slow recovery of urinary incontinence (UI) and sexual function (SF) over 2 years post-RP are well documented. Furthermore, RT may also significantly impact the recovery of UI and SF, particularly when combined with RP. As such, RT is often delayed until UI shows improvement. We sought to evaluate urinary and sexual quality of life (QOL) outcomes in RP patients to assess whether early RT administration was associated with worse outcomes. METHODS: We retrospectively identified patients who underwent RP and received subsequent RT during 2004 to 2013. The final cohort contained 113 men who completed 3 validated quality of life questionnaires: (i) pre-RP, (ii) post RP, pre-RT, and (iii) postRT. From 2004 to 2006 we used the UCLA PCI and switched to the UCLA PCI based EPIC-26 in 2007. Patients were stratified as having received (i) early RT (<1yr post-RP) and (ii) late RT (>1 year post-RP). EPIC-26 QOL outcomes for UI and SF were compared between groups. RESULTS: 44 (38.9%) and 69 (61.1%) of patients had early RT and late RT, respectively. Patient age, cancer stage, nerve sparing, and margin status were not significantly different between groups while Gleason score and D0 Amico risk groups tended to be worse in the early RT group. Median time to post-RP RT in the early and late groups was 8 and 28 months, respectively. Pre-RP UI and SF QOL scores were not significantly different between groups (p¼0.128; 0.199). There was no significant difference in change in UI between RT treatment groups (p¼0.166 see figure 1). Sexual function was worse in the early RT group after RP and showed no significant change after initiating RT. In the late RT group, there was improvement after RP and then a decline after RT (p¼0.043 see figure 1). CONCLUSIONS: Men receiving early versus late RT experienced significantly different SF QOL outcomes. RT appears to halt or worsen post-RP recovery of sexual function. Urinary incontinence was not significantly different between groups which may underscore the importance of our practice of waiting until continence has improved to initiate RT.
Source of Funding: none
MP04-12 COMORBIDITY STATUS AS A PREDICTOR OF HIGH-GRADE DISEASE IN MEN WITH PROSTATE CANCER Timothy Daskivich*, Los Angeles, CA; Douglas Skarecky, Thomas Ahlering, Irvine, CA; Stephen Freedland, Los Angeles, CA INTRODUCTION AND OBJECTIVES: While it has long been known that advanced age is associated with higher tumor grade, it is unknown if comorbid disease burden has a similar, independent association. We sought to evaluate the impact of comorbid disease burden on risk of tumor aggressiveness as indicated by biopsy Gleason score. METHODS: We conducted an observational cohort study of 1,482 men with non-metastatic prostate cancer consecutively diagnosed from 1998 to 2004 at two Southern California Veterans Affairs Medical Centers. We determined age, race, Charlson comorbidity index scores, clinical tumor stage, PSA at diagnosis, mobility status (use of walker, wheelchair, or cane), smoking history, and biopsy Gleason score from review of the electronic medical record. We categorized Charlson scores into categories of 0, 1, 2, and 3+ and Gleason scores into categories of 6, 7, and 8-10. We used multivariable ordinal and multinomial logistic regression to evaluate the associations between Charlson score and Gleason score after correcting for the covariates mentioned above. RESULTS: Our final analytic sample comprised 1,260 men. In a multivariable ordinal logistic regression model predicting higher tumor grade, men with Charlson scores of 2 (OR 1.8, p <0.001) and 3+ (OR 1.8, p <0.001) had significantly greater odds of higher Gleason scores, compared with men with Charlson scores of 0. Other factors associated with higher tumor grade were clinical stage T2b and T2c or higher (vs. T2a or lower), higher PSA, site, and older age at diagnosis. In a multinomial logistic regression model predicting Gleason 7 vs. 6, only men with Charlson scores of 2 (OR 1.6, p¼0.01) had greater odds of having a Gleason 7 tumor, compared with those with Charlson scores of 0. In a multinomial logistic regression model predicting Gleason 8-10 vs. 6, those with Charlson scores of 1 (OR 1.6, p¼0.047), 2 (OR 2.8, p¼0.01) and 3+ (OR 2.9, p¼0.001) had higher odds of having a Gleason 8-10 tumor (Table). CONCLUSIONS: Moderate-to-heavy comorbid disease burden at diagnosis is associated with higher biopsy Gleason score, independent of the impact of age. Comorbidity burden appears to be a stronger predictor of Gleason 8-10 than Gleason 7 disease. Abandoning PSA
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
0
ballpark0 . When using the nomogram only 23% (95% CI 17%-31%) of participants used it properly, but over half were in the 0 ballpark0 , (51%, 95% CI 43%-60%). CONCLUSIONS: Most adults significantly underestimated 15 year cancer specific survival for a prostate cancer patient using unrestricted internet searching. When using a validated online nomogram, most participants were unable to use the tool correctly, but estimates using the tool were closer to the true estimate. These findings suggest that even in a population more educated than the average U.S. citizen unrestricted internet searching often leads to poor estimates of survival, but nomograms can aid people in estimating survival rates. Clinicians should consider guiding patients to appropriate online health resources so that patients can obtain more accurate information and make informed decisions. Source of Funding: none
MP04-09 DOES A CLEAR UNDERSTANDING OF LIFE EXPECTANCY INCREASE DECISIONAL CONFLICT AND ANXIETY FOR MEN WITH NEWLY DIAGNOSED PROSTATE CANCER? Mazen Alsinnawi*, Seattle, WA; April E. Slee, John S. Banerji, seattle, WA; Kathryn L. Dahl, Seattle, WA; Sydney Akapame, seattle, WA; John D Massman III, Erika M. Wolff, John M. Corman, Seattle, WA INTRODUCTION AND OBJECTIVES: Prostate cancer (CaP) decision making is complicated by multiple treatment choices with implications for survival and quality of life. Although knowledge of the effect of co-morbidities on life expectancy helps clinicians to determine the range of treatment options available for their patients, patients are not usually, explicitly given this information. We utilized the Charlson Comorbidity Index (CCI) to predict life expectancy in men with newly diagnosed CaP. The objective of this study is to determine whether providing patients with their CCI score increases treatment decisional conflict and anxiety about death. METHODS: Patients with newly diagnosed CaP were randomized to receive standard multidisciplinary care versus the same counseling with the addition of the patient’s prospective understanding of his CCI score. Patients subsequently completed the Decisional Conflict Scale (DCS) and the Death Anxiety Scale (DAS). The primary objective was to determine whether telling patients their life expectancy complicated their treatment decisions and increased their anxiety levels. Five percent non inferiority margin was used for both instruments. Because the primary hypothesis was safety, patients were analyzed according to the intervention they received. RESULTS: A total of 228 patients returned surveys, 123 received standard counselling and 105 were prospectively informed of their CCI. Mean age was 65 years. 17% had high risk CaP and the median 10-year survival probability was 80.9%. There was no statistical significant difference in planned treatment choice (active surveillance vs active treatment).18.7 % of the standard counselling group reported significant decisional conflict (> 37.5 points) compared to 10.5 % in the CCI group (p¼0.08). Those who received CCI counseling had a mean decisional conflict score of 19.4, compared to 22.1 for the standard group. The difference between these was on average -2.7 points (95% CI -6.8, 1.3) which excludes the 5 % non-inferiority margin (range 0100). The difference for DAS was -0.24 (95% CI, -1.08, 0.60) which excludes the 5 % margin (range 0-15). CONCLUSIONS: Knowledge of CCI does not increase decisional conflict or anxiety about death, and may reduce the incidence of significant conflict. As we embrace the concept of shared decision making in urology, it is expected that the full disclosure of life expectancy will be standard of care. This study suggest that this disclosure can be made without contributing to patient stress and anxiety. Source of Funding: none
e31
MP04-10 TRENDS AND REGIONAL VARIATION IN PROSTATE CANCER TREATMENT Tudor Borza*, Samuel Kaufman, Vahakn B Shahinian, Ann Arbor, MI; Phyllis Yan, David C Miller, Ann Arbor, MI; Ted A Skolarus, Brent K Hollenbeck, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Harms associated with diagnosis and treatment of prostate cancer have led to recommendations for reduced screening and less aggressive treatment. The extent to which practice patterns reflect these recommendations is unclear. We performed a national study to better understand recent trends and regional variation in the treatment of prostate cancer. METHODS: Using a 20% sample of national Medicare data we performed a retrospective cohort study of treatment patterns among men with newly diagnosed prostate cancer from 2007-2012. Our primary outcome was rate of curative treatment. Our secondary outcomes were treatment rates among men with a high 10-year risk of non-cancer mortality as a measure of treatment among those least likely to benefit and regional variation in treatment rates. Rates were adjusted for differences in age and race. Regions were defined by Health Referral Regions (HRRs) and HRRs with fewer than 20 treatments per year were excluded to prevent unstable estimates. RESULTS: We identified 67,023 incident cases of prostate cancer of which 48,464 underwent curative treatment during our study period. There was a small decrease in the annual rate of treatment in men diagnosed with prostate cancer (RR 0.99, [95% CI, 0.98-0.99]) (Figure 1A). A more profound change was observed in the rate of treatment in all eligible male beneficiaries (RR 0.92, [95% CI, 0.91-0.92]) (Figure 1B). Treatment rates did not change in men with the highest 10-year risk of non-cancer mortality (RR 1.00, [95% CI, 0.99-1.01]) (Figure 2). There was no decrease in the variation of treatment rates by HRR over the study period. CONCLUSIONS: Rates of curative treatment have declined slightly among men diagnosed with prostate cancer over the study period. This change is substantially less than the decline in rates for all eligible male beneficiaries, suggesting decreasing diagnosis as the main driver for the decline. Rates of treatment among those least likely to benefit remained unchanged. There was no observed decrease in the regional variation of treatment rate.
e32
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
Source of Funding: Ted Skolarus is supported in part by a VA HSR&D Career Development Award - 2 (CDA 12-171) Brent Hollenbeck is supported in part by Research Scholar Grant RSGI-13-323-01-CPHPS from the American Cancer Society and by NIH/NCI grant R01 CA168691.
MP04-11 COMPARING QUALITY OF LIFE OUTCOMES IN MEN RECEIVING EARLY VERSUS LATE POST-PROSTATECTOMY RADIATION THERAPY Greg Murphy*, Peter Haddock, Ilene Staff, Joseph Tortora, Alison Champagne, Joseph Cusano, Joseph Wagner, Hartford, CT INTRODUCTION AND OBJECTIVES: Men with adverse pathologic features or biochemical recurrence after radical prostatectomy (RP) often receive subsequent radiation therapy (RT). The immediate post-operative deficits and slow recovery of urinary incontinence (UI) and sexual function (SF) over 2 years post-RP are well documented. Furthermore, RT may also significantly impact the recovery of UI and SF, particularly when combined with RP. As such, RT is often delayed until UI shows improvement. We sought to evaluate urinary and sexual quality of life (QOL) outcomes in RP patients to assess whether early RT administration was associated with worse outcomes. METHODS: We retrospectively identified patients who underwent RP and received subsequent RT during 2004 to 2013. The final cohort contained 113 men who completed 3 validated quality of life questionnaires: (i) pre-RP, (ii) post RP, pre-RT, and (iii) postRT. From 2004 to 2006 we used the UCLA PCI and switched to the UCLA PCI based EPIC-26 in 2007. Patients were stratified as having received (i) early RT (<1yr post-RP) and (ii) late RT (>1 year post-RP). EPIC-26 QOL outcomes for UI and SF were compared between groups. RESULTS: 44 (38.9%) and 69 (61.1%) of patients had early RT and late RT, respectively. Patient age, cancer stage, nerve sparing, and margin status were not significantly different between groups while Gleason score and D0 Amico risk groups tended to be worse in the early RT group. Median time to post-RP RT in the early and late groups was 8 and 28 months, respectively. Pre-RP UI and SF QOL scores were not significantly different between groups (p¼0.128; 0.199). There was no significant difference in change in UI between RT treatment groups (p¼0.166 see figure 1). Sexual function was worse in the early RT group after RP and showed no significant change after initiating RT. In the late RT group, there was improvement after RP and then a decline after RT (p¼0.043 see figure 1). CONCLUSIONS: Men receiving early versus late RT experienced significantly different SF QOL outcomes. RT appears to halt or worsen post-RP recovery of sexual function. Urinary incontinence was not significantly different between groups which may underscore the importance of our practice of waiting until continence has improved to initiate RT.
Source of Funding: none
MP04-12 COMORBIDITY STATUS AS A PREDICTOR OF HIGH-GRADE DISEASE IN MEN WITH PROSTATE CANCER Timothy Daskivich*, Los Angeles, CA; Douglas Skarecky, Thomas Ahlering, Irvine, CA; Stephen Freedland, Los Angeles, CA INTRODUCTION AND OBJECTIVES: While it has long been known that advanced age is associated with higher tumor grade, it is unknown if comorbid disease burden has a similar, independent association. We sought to evaluate the impact of comorbid disease burden on risk of tumor aggressiveness as indicated by biopsy Gleason score. METHODS: We conducted an observational cohort study of 1,482 men with non-metastatic prostate cancer consecutively diagnosed from 1998 to 2004 at two Southern California Veterans Affairs Medical Centers. We determined age, race, Charlson comorbidity index scores, clinical tumor stage, PSA at diagnosis, mobility status (use of walker, wheelchair, or cane), smoking history, and biopsy Gleason score from review of the electronic medical record. We categorized Charlson scores into categories of 0, 1, 2, and 3+ and Gleason scores into categories of 6, 7, and 8-10. We used multivariable ordinal and multinomial logistic regression to evaluate the associations between Charlson score and Gleason score after correcting for the covariates mentioned above. RESULTS: Our final analytic sample comprised 1,260 men. In a multivariable ordinal logistic regression model predicting higher tumor grade, men with Charlson scores of 2 (OR 1.8, p <0.001) and 3+ (OR 1.8, p <0.001) had significantly greater odds of higher Gleason scores, compared with men with Charlson scores of 0. Other factors associated with higher tumor grade were clinical stage T2b and T2c or higher (vs. T2a or lower), higher PSA, site, and older age at diagnosis. In a multinomial logistic regression model predicting Gleason 7 vs. 6, only men with Charlson scores of 2 (OR 1.6, p¼0.01) had greater odds of having a Gleason 7 tumor, compared with those with Charlson scores of 0. In a multinomial logistic regression model predicting Gleason 8-10 vs. 6, those with Charlson scores of 1 (OR 1.6, p¼0.047), 2 (OR 2.8, p¼0.01) and 3+ (OR 2.9, p¼0.001) had higher odds of having a Gleason 8-10 tumor (Table). CONCLUSIONS: Moderate-to-heavy comorbid disease burden at diagnosis is associated with higher biopsy Gleason score, independent of the impact of age. Comorbidity burden appears to be a stronger predictor of Gleason 8-10 than Gleason 7 disease. Abandoning PSA