- Email: [email protected]
MP2-12 LOWER SOCIOECONOMIC STATUS IS ASSOCIATED WITH MALIGNANCY IN PATIENTS WITH UNDESCENDED TESTIS
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Friday, May 16, 2014
not associated with kidney cancer death (p¼0.86). In multivariate analyses, individuals who reported “any physical activity” were 50% less likely [adjusted hazard ratio (HRadj) 0.50, 95% CI, 0.27 to 0.93, p-value ¼ 0.028] to die of kidney cancer than non-exercisers , while obese individuals (BMI 30 kg/m2) were nearly 3 times more likely (HRadj 2.84, 95% CI 1.30 to 6.23, p-value ¼ 0.009) compared to those of normal weight (BMI < 25 kg/m2). Compared to never smokers, former smokers were twice as likely to die of kidney cancer (HRadj 2.00, 95% CI 1.05 to 3.80, p-value ¼ 0.034). There was no significant association of current smoking with kidney cancer death (HRadj 1.75, 95% CI 0.76 to 4.10, p-value ¼ 0.19). CONCLUSIONS: Physical activity decreases and obesity increases the risk of kidney cancer mortality. Exercise and weight loss may potentially prevent kidney cancer death. Source of Funding: None
MP2-10 THE ASSOCIATION BETWEEN SOCIOECONOMIC STATUS AND RENAL CANCER PRESENTATION Matthew Danzig*, Aaron Weinberg, Rashed Ghandour, Srinath Kotamarti, James McKiernan, Ketan Badani, New York, NY INTRODUCTION AND OBJECTIVES: Most renal cancers in the United States are currently diagnosed incidentally on abdominal imaging. These tumors present relatively smaller and are localized compared to symptomatic tumors. Discrepancies in access to health care may lead to a lower likelihood of incidental detection in socioeconomically disadvantaged counties. We sought to determine if socioeconomic indicators predict the size and stage of renal cancers at presentation. METHODS: The National Cancer Institute’s Survival, Epidemiology, and End-Results (SEER) registry was queried for patients diagnosed with renal cancers between 2001 and 2010. Presentation, survival, and county-level socioeconomic data for these patients were obtained. Cancers with stage T0 or with histologic codes inconsistent with renal cell carcinoma were excluded. A socioeconomic index (SEI) was created based on median income, percentage of the population in poverty, and percentage of high school graduates. Outcome measures were tumor size and T stage on presentation, positive N or M stage at diagnosis, and overall survival. Linear, multinomial, and binary logistic regression analyses were used to assess the impact of a patient’s SEI score on these outcomes while controlling for age, gender, race, and tumor grade. RESULTS: 89,632 cases of renal cancer were identified. In regression modeling, lower SEI was a significant predictor of: larger tumor size (p<0.001), higher T stage (T2 vs. T1, p ¼ 0.008. T3 vs. T1, p ¼ 0.001. T4 vs. T1, p ¼ 0.002) and positive nodal status (p ¼ 0.045), but was not predictive of metastasis at diagnosis (p¼0.132). Lower SEI was predictive of shorter overall survival when controlling for: year of diagnosis, gender, race, grade, age, nodal status, and metastasis at diagnosis (p<0.001). CONCLUSIONS: This study suggests that lower socioeconomic status is correlated with larger, more locally advanced cancers at diagnosis, and poorer outcomes. Therefore, it can be inferred that improved access to health care is a form of screening that results in a greater likelihood of incidental detection of kidney cancer. Source of Funding: None
MP2-11 THE BURDEN OF GERIATRIC COMPLICATIONS FOLLOWING KIDNEY CANCER SURGERY Hung-Jui Tan*, Lorna Kwan, Mark S. Litwin, Los Angeles, CA INTRODUCTION AND OBJECTIVES: With the population aging and incidence rising, kidney cancer is increasingly becoming a
e29
disease of the elderly. Because these patients also face geriatric-specific health concerns (e.g., delirium, functional decline), we sought to better understand the burden of geriatric complications among older adults undergoing surgery for kidney cancer. METHODS: Using the Nationwide Inpatient Sample, we identified surgical admissions for kidney cancer among adults aged 55 and older in 2007e2011. For each admission, we ascertained demographic and clinical information (e.g., age, Charlson score, year, and surgical approach) and measured the occurrence of geriatric complications (i.e., delirium, fractures, falls, pressure ulcers, and failure to thrive). We further assessed for prolonged hospitalization, inpatient mortality, discharge disposition, and postoperative complications. We then fit multivariable logistic regression models to estimate the association between geriatric events and these secondary outcomes. RESULTS: Among a weighted sample of 125,516 surgical admissions for kidney cancer, geriatric complications occurred in 5.2% (95% confidence interval, 4.9-5.6%) of hospitalizations and were associated with older age, greater comorbidity, lower socioeconomic position, and open radical nephrectomy (all p<0.05). Model-adjusted probability for such events ranged from 3.1% among 55-64 year olds, 4.7% among 65-74 year olds, and 6.9% among patients 75 and older (p<0.001). Accounting for the above-listed factors, patients experiencing a geriatric event had substantially greater probability of prolonged hospitalization, discharge to a medical facility or home health care, and concurrent medical or surgical complications compared with those who did not have a geriatric complication (Figure). Although uncommon overall, these patients had a nearly 4-fold greater probability of death during the surgical admission (1.7% vs. 0.4%, p<0.001). CONCLUSIONS: Patients with a geriatric complication were more likely to experience greater operative morbidity and mortality, highlighting the substantial burden of these events. More deliberate risk stratification and thoughtful treatment selection may be particularly prudent among vulnerable elders.
Source of Funding: none
MP2-12 LOWER SOCIOECONOMIC STATUS IS ASSOCIATED WITH MALIGNANCY IN PATIENTS WITH UNDESCENDED TESTIS Zachary Klaassen*, Chris Ellington, Lael Reinstatler, Qiang Li, Rabii Madi, Martha K. Terris, Kelvin A. Moses, Augusta, GA INTRODUCTION AND OBJECTIVES: Males with cryptorchidism have a 2050x greater risk of malignancy compared to males with a normally descended testis. It is not known whether patients who present with an undescended testis malignancy (UTM) are of lower socioeconomic status (SES) compared to men with descended testis malignancy (DTM), which may contribute to less optimal outcomes.
THE JOURNAL OF UROLOGYâ
e30
Thus, the objective of this study was to analyze the socioeconomic demographics of patients with UTM and DTM. METHODS: All 17 registries comprising the Surveillance Epidemiology and End Results (SEER) database were analyzed from 19882008. Patients with descended or undescended testis and a diagnosis of nonseminomatous or seminomatous germ cell tumor were identified. Patients classified as testisnot otherwise specified were grouped with DTM. Variables of interest included census county data for % foreign born, educational attainment (less than 9th grade vs less than high school), poverty level, median family income, % unemployed, ethnic or racial minority and rural/urban (populations rural < 2500; urban 250019,999; urban >20,000; metropolitan <250,000; metropolitan 250,0001,000,000; metropolitan >1,000,000; unknown/missing/Alaska). Multivariate analysis was used to assess the above variables according to their quartile range and risk of UTM. RESULTS: There were 27,831 (98.3%) men with DTM and 496 (1.7%) men with UTM who comprised the study cohort. Compared to patients with DTM, patients with UTM were more commonly from counties with higher % foreign born (19.9% vs. 17.1%, p<0.0001), less likely to have a 9th grade education (8.1% vs. 9.0%, p<0.0001), less likely to have a high school education (18.9% vs. 20.1%, p¼0.0002), more commonly living in poverty (9.2% vs. 8.7%, p¼0.02), more commonly minority (41.8% vs. 37.7%, p<0.0001), and more commonly living in rural (<2500 people) or metropolitan (>1 million people) communities (p¼0.02). On multivariate analysis, residing in a county with greater foreignborn inhabitants was associated with greater odds of UTM (highest quartile vs. lowest quartile e OR 1.33, 95% CI 1.0041.759). CONCLUSIONS: Patients with UTM are more commonly from regions with a greater proportion of foreign born and minority inhabitants, poorer and less educated. These results suggest that indicators of lower SES are associated with UTM and outcomes may be linked to access to adequate healthcare. Source of Funding: None
MP2-13 INCIDENCE OF THROMBOEMBOLIC EVENTS AFTER MAJOR ONCOLOGIC UROLOGIC SURGERY IS UNDERESTIMATED IN THE PERIOPERATIVE PERIOD: ANALYSIS OF A NATIONAL DATABASE Blake Alberts*, Aaron Weinberg, Matthew Danzig, Solomon Woldu, Ketan Badani, New York, NY INTRODUCTION AND OBJECTIVES: Patients undergoing radical nephrectomy (RN), partial nephrectomy (PN), nephroureterectomy (NU), radical prostatectomy (RP), and radical cystectomy (RC) have a significant risk of venous thromboembolism (VTE) in the postoperative period. Most studies on VTE incidence are limited by lack of follow up after discharge. We analyzed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to identify risk factors for VTE and incidence of VTE both pre- and post-discharge in patients undergoing the above named procedures. METHODS: ACS-NSQIP is a national multicenter quality improvement initiative which prospectively gathers data on select complications including VTE in the 30 day postoperative period. Current Procedural Terminology identified patients who underwent RN, PN, NU, RP, and RC in the 2005-2012 NSQIP dataset. Primary outcome was occurrence of any VTE event within 30 days of surgery. Logistic regression analysis was used to investigate relationships between perioperative variables and the occurrence of VTE events. RESULTS: A total of 32,692 patients were identified in the NSQIP dataset from 2005-2012. Incidence of 30-day VTE across all procedures was 1.4%. Incidence was highest in RC (5.3%) and lowest
Vol. 191, No. 4S, Supplement, Friday, May 16, 2014
in minimally-invasive RN (0.6%). Fig 1 details incidence for individual procedures. Across all procedures, independent predictors of VTE occurrence within 30 days of surgery were age 80 (p<0.01), metastatic disease (p<0.01), morbid obesity (p<0.01), and prolonged operative time (p<0.01). CONCLUSIONS: The incidence of post-discharge VTE is likely higher than previously reported, occurring in greater than 80% of prostatectomies. The incidence of VTE in the inpatient versus postdischarge setting differs between the described procedures.
Source of Funding: None. The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
MP2-14 EFFICACY AND SAFETY OF A CLINICAL PROTOCOL FOR PREVENTING VENOUS THROMBOEMBOLISM AFTER SURGERY FOR UROLOGIC CANCER WITH IN HOSPITAL AND EXTENDED LOW MOLECULAR WEIGHT HEPARIN PROPHYLAXIS Janet Baack Kukreja*, Emelian Scosyrev, Helen R. Levey, Maureen Kiernan, Claudia Berrondo, Divya Kumar, Guan Wu, Jean Joseph, Ahmed Ghazi, Hani Rashid, Edward M. Messing, Rochester, NY INTRODUCTION AND OBJECTIVES: Venous thromboembolism (VTE) remains an important preventable adverse event in urologic oncology surgery (UOS). Impacts include increased healthcare costs, morbidity, and mortality. Based on level 1 evidence, the American Academy of Chest Physicians recommends high-risk patients undergoing abdominal or pelvic surgery for cancer have extended duration prophylaxis (EDP) using low molecular weight heparin (LMWH) for 28 days. In this study, we aim to evaluate safety and efficacy of LMWH EDP for VTE reduction in UOS patients. METHODS: After IRB approval, a VTE prevention protocol was implemented. Adherence to protocol, complications, and VTEs occurring within 365 days from surgery were tracked by medical record review and patient phone interviews. Perioperative VTE risk was evaluated using the validated Caprini risk assessment score (CRS). The cohort included 200 patients from Sept. 2011 to Sept. 2013. The VTE prophylaxis protocol included: preoperative low dose unfractionated heparin (LDUH), postoperative LMWH or LDUH within eight hours, no in hospital interruptions of prophylaxis, and EDP. For VTE incidence analysis, patients were grouped as follows: 1. per protocol with EDP, N¼50, 2. per protocol without EDP, N¼24, 3. not per protocol with EDP, N¼61, 4. not per protocol without EDP, N¼65. The risk of VTE was compared between the four groups using the Cox model, with adjustment for baseline risk factors.
Vol. 191, No. 4S, Supplement, Friday, May 16, 2014
not associated with kidney cancer death (p¼0.86). In multivariate analyses, individuals who reported “any physical activity” were 50% less likely [adjusted hazard ratio (HRadj) 0.50, 95% CI, 0.27 to 0.93, p-value ¼ 0.028] to die of kidney cancer than non-exercisers , while obese individuals (BMI 30 kg/m2) were nearly 3 times more likely (HRadj 2.84, 95% CI 1.30 to 6.23, p-value ¼ 0.009) compared to those of normal weight (BMI < 25 kg/m2). Compared to never smokers, former smokers were twice as likely to die of kidney cancer (HRadj 2.00, 95% CI 1.05 to 3.80, p-value ¼ 0.034). There was no significant association of current smoking with kidney cancer death (HRadj 1.75, 95% CI 0.76 to 4.10, p-value ¼ 0.19). CONCLUSIONS: Physical activity decreases and obesity increases the risk of kidney cancer mortality. Exercise and weight loss may potentially prevent kidney cancer death. Source of Funding: None
MP2-10 THE ASSOCIATION BETWEEN SOCIOECONOMIC STATUS AND RENAL CANCER PRESENTATION Matthew Danzig*, Aaron Weinberg, Rashed Ghandour, Srinath Kotamarti, James McKiernan, Ketan Badani, New York, NY INTRODUCTION AND OBJECTIVES: Most renal cancers in the United States are currently diagnosed incidentally on abdominal imaging. These tumors present relatively smaller and are localized compared to symptomatic tumors. Discrepancies in access to health care may lead to a lower likelihood of incidental detection in socioeconomically disadvantaged counties. We sought to determine if socioeconomic indicators predict the size and stage of renal cancers at presentation. METHODS: The National Cancer Institute’s Survival, Epidemiology, and End-Results (SEER) registry was queried for patients diagnosed with renal cancers between 2001 and 2010. Presentation, survival, and county-level socioeconomic data for these patients were obtained. Cancers with stage T0 or with histologic codes inconsistent with renal cell carcinoma were excluded. A socioeconomic index (SEI) was created based on median income, percentage of the population in poverty, and percentage of high school graduates. Outcome measures were tumor size and T stage on presentation, positive N or M stage at diagnosis, and overall survival. Linear, multinomial, and binary logistic regression analyses were used to assess the impact of a patient’s SEI score on these outcomes while controlling for age, gender, race, and tumor grade. RESULTS: 89,632 cases of renal cancer were identified. In regression modeling, lower SEI was a significant predictor of: larger tumor size (p<0.001), higher T stage (T2 vs. T1, p ¼ 0.008. T3 vs. T1, p ¼ 0.001. T4 vs. T1, p ¼ 0.002) and positive nodal status (p ¼ 0.045), but was not predictive of metastasis at diagnosis (p¼0.132). Lower SEI was predictive of shorter overall survival when controlling for: year of diagnosis, gender, race, grade, age, nodal status, and metastasis at diagnosis (p<0.001). CONCLUSIONS: This study suggests that lower socioeconomic status is correlated with larger, more locally advanced cancers at diagnosis, and poorer outcomes. Therefore, it can be inferred that improved access to health care is a form of screening that results in a greater likelihood of incidental detection of kidney cancer. Source of Funding: None
MP2-11 THE BURDEN OF GERIATRIC COMPLICATIONS FOLLOWING KIDNEY CANCER SURGERY Hung-Jui Tan*, Lorna Kwan, Mark S. Litwin, Los Angeles, CA INTRODUCTION AND OBJECTIVES: With the population aging and incidence rising, kidney cancer is increasingly becoming a
e29
disease of the elderly. Because these patients also face geriatric-specific health concerns (e.g., delirium, functional decline), we sought to better understand the burden of geriatric complications among older adults undergoing surgery for kidney cancer. METHODS: Using the Nationwide Inpatient Sample, we identified surgical admissions for kidney cancer among adults aged 55 and older in 2007e2011. For each admission, we ascertained demographic and clinical information (e.g., age, Charlson score, year, and surgical approach) and measured the occurrence of geriatric complications (i.e., delirium, fractures, falls, pressure ulcers, and failure to thrive). We further assessed for prolonged hospitalization, inpatient mortality, discharge disposition, and postoperative complications. We then fit multivariable logistic regression models to estimate the association between geriatric events and these secondary outcomes. RESULTS: Among a weighted sample of 125,516 surgical admissions for kidney cancer, geriatric complications occurred in 5.2% (95% confidence interval, 4.9-5.6%) of hospitalizations and were associated with older age, greater comorbidity, lower socioeconomic position, and open radical nephrectomy (all p<0.05). Model-adjusted probability for such events ranged from 3.1% among 55-64 year olds, 4.7% among 65-74 year olds, and 6.9% among patients 75 and older (p<0.001). Accounting for the above-listed factors, patients experiencing a geriatric event had substantially greater probability of prolonged hospitalization, discharge to a medical facility or home health care, and concurrent medical or surgical complications compared with those who did not have a geriatric complication (Figure). Although uncommon overall, these patients had a nearly 4-fold greater probability of death during the surgical admission (1.7% vs. 0.4%, p<0.001). CONCLUSIONS: Patients with a geriatric complication were more likely to experience greater operative morbidity and mortality, highlighting the substantial burden of these events. More deliberate risk stratification and thoughtful treatment selection may be particularly prudent among vulnerable elders.
Source of Funding: none
MP2-12 LOWER SOCIOECONOMIC STATUS IS ASSOCIATED WITH MALIGNANCY IN PATIENTS WITH UNDESCENDED TESTIS Zachary Klaassen*, Chris Ellington, Lael Reinstatler, Qiang Li, Rabii Madi, Martha K. Terris, Kelvin A. Moses, Augusta, GA INTRODUCTION AND OBJECTIVES: Males with cryptorchidism have a 2050x greater risk of malignancy compared to males with a normally descended testis. It is not known whether patients who present with an undescended testis malignancy (UTM) are of lower socioeconomic status (SES) compared to men with descended testis malignancy (DTM), which may contribute to less optimal outcomes.
THE JOURNAL OF UROLOGYâ
e30
Thus, the objective of this study was to analyze the socioeconomic demographics of patients with UTM and DTM. METHODS: All 17 registries comprising the Surveillance Epidemiology and End Results (SEER) database were analyzed from 19882008. Patients with descended or undescended testis and a diagnosis of nonseminomatous or seminomatous germ cell tumor were identified. Patients classified as testisnot otherwise specified were grouped with DTM. Variables of interest included census county data for % foreign born, educational attainment (less than 9th grade vs less than high school), poverty level, median family income, % unemployed, ethnic or racial minority and rural/urban (populations rural < 2500; urban 250019,999; urban >20,000; metropolitan <250,000; metropolitan 250,0001,000,000; metropolitan >1,000,000; unknown/missing/Alaska). Multivariate analysis was used to assess the above variables according to their quartile range and risk of UTM. RESULTS: There were 27,831 (98.3%) men with DTM and 496 (1.7%) men with UTM who comprised the study cohort. Compared to patients with DTM, patients with UTM were more commonly from counties with higher % foreign born (19.9% vs. 17.1%, p<0.0001), less likely to have a 9th grade education (8.1% vs. 9.0%, p<0.0001), less likely to have a high school education (18.9% vs. 20.1%, p¼0.0002), more commonly living in poverty (9.2% vs. 8.7%, p¼0.02), more commonly minority (41.8% vs. 37.7%, p<0.0001), and more commonly living in rural (<2500 people) or metropolitan (>1 million people) communities (p¼0.02). On multivariate analysis, residing in a county with greater foreignborn inhabitants was associated with greater odds of UTM (highest quartile vs. lowest quartile e OR 1.33, 95% CI 1.0041.759). CONCLUSIONS: Patients with UTM are more commonly from regions with a greater proportion of foreign born and minority inhabitants, poorer and less educated. These results suggest that indicators of lower SES are associated with UTM and outcomes may be linked to access to adequate healthcare. Source of Funding: None
MP2-13 INCIDENCE OF THROMBOEMBOLIC EVENTS AFTER MAJOR ONCOLOGIC UROLOGIC SURGERY IS UNDERESTIMATED IN THE PERIOPERATIVE PERIOD: ANALYSIS OF A NATIONAL DATABASE Blake Alberts*, Aaron Weinberg, Matthew Danzig, Solomon Woldu, Ketan Badani, New York, NY INTRODUCTION AND OBJECTIVES: Patients undergoing radical nephrectomy (RN), partial nephrectomy (PN), nephroureterectomy (NU), radical prostatectomy (RP), and radical cystectomy (RC) have a significant risk of venous thromboembolism (VTE) in the postoperative period. Most studies on VTE incidence are limited by lack of follow up after discharge. We analyzed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to identify risk factors for VTE and incidence of VTE both pre- and post-discharge in patients undergoing the above named procedures. METHODS: ACS-NSQIP is a national multicenter quality improvement initiative which prospectively gathers data on select complications including VTE in the 30 day postoperative period. Current Procedural Terminology identified patients who underwent RN, PN, NU, RP, and RC in the 2005-2012 NSQIP dataset. Primary outcome was occurrence of any VTE event within 30 days of surgery. Logistic regression analysis was used to investigate relationships between perioperative variables and the occurrence of VTE events. RESULTS: A total of 32,692 patients were identified in the NSQIP dataset from 2005-2012. Incidence of 30-day VTE across all procedures was 1.4%. Incidence was highest in RC (5.3%) and lowest
Vol. 191, No. 4S, Supplement, Friday, May 16, 2014
in minimally-invasive RN (0.6%). Fig 1 details incidence for individual procedures. Across all procedures, independent predictors of VTE occurrence within 30 days of surgery were age 80 (p<0.01), metastatic disease (p<0.01), morbid obesity (p<0.01), and prolonged operative time (p<0.01). CONCLUSIONS: The incidence of post-discharge VTE is likely higher than previously reported, occurring in greater than 80% of prostatectomies. The incidence of VTE in the inpatient versus postdischarge setting differs between the described procedures.
Source of Funding: None. The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
MP2-14 EFFICACY AND SAFETY OF A CLINICAL PROTOCOL FOR PREVENTING VENOUS THROMBOEMBOLISM AFTER SURGERY FOR UROLOGIC CANCER WITH IN HOSPITAL AND EXTENDED LOW MOLECULAR WEIGHT HEPARIN PROPHYLAXIS Janet Baack Kukreja*, Emelian Scosyrev, Helen R. Levey, Maureen Kiernan, Claudia Berrondo, Divya Kumar, Guan Wu, Jean Joseph, Ahmed Ghazi, Hani Rashid, Edward M. Messing, Rochester, NY INTRODUCTION AND OBJECTIVES: Venous thromboembolism (VTE) remains an important preventable adverse event in urologic oncology surgery (UOS). Impacts include increased healthcare costs, morbidity, and mortality. Based on level 1 evidence, the American Academy of Chest Physicians recommends high-risk patients undergoing abdominal or pelvic surgery for cancer have extended duration prophylaxis (EDP) using low molecular weight heparin (LMWH) for 28 days. In this study, we aim to evaluate safety and efficacy of LMWH EDP for VTE reduction in UOS patients. METHODS: After IRB approval, a VTE prevention protocol was implemented. Adherence to protocol, complications, and VTEs occurring within 365 days from surgery were tracked by medical record review and patient phone interviews. Perioperative VTE risk was evaluated using the validated Caprini risk assessment score (CRS). The cohort included 200 patients from Sept. 2011 to Sept. 2013. The VTE prophylaxis protocol included: preoperative low dose unfractionated heparin (LDUH), postoperative LMWH or LDUH within eight hours, no in hospital interruptions of prophylaxis, and EDP. For VTE incidence analysis, patients were grouped as follows: 1. per protocol with EDP, N¼50, 2. per protocol without EDP, N¼24, 3. not per protocol with EDP, N¼61, 4. not per protocol without EDP, N¼65. The risk of VTE was compared between the four groups using the Cox model, with adjustment for baseline risk factors.