Radical Prostatectomy versus Intensity Modulated Radiation Therapy in the Management of Localized Prostate Cancer

Purpose: To determine whether radical prostatectomy (RP) or intensity modulated radiation therapy (IMRT) to ≥72 Gy, plus hormonal therapy if indicated, results in improved biochemical disease free survival (BDFS) in localized prostate adenocarcinoma. Methods and Materials: Between 1997-2005, a consecutive sample of 556 patients who underwent RP (n=204) or IMRT (n=352) at two referral centers was analyzed. Patients were stratified into prognostic groups based on clinical stage, Gleason score, and pretreatment prostate specific antigen (PSA) level as outlined by schemes designed by Memorial Sloan Kettering (MSK) and the National Comprehensive Cancer Network (NCCN). The outcome used in this study was BDFS. Median follow up in the RP and IMRT cohorts was 46 months and 40 months, respectively. Results: IMRT patients had more advanced and aggressive disease at baseline (p\u3c.001). No difference was found in five-year BDFS rates between RP and IMRT in the favorable prognosis (92.8% vs. 85.3%, p=.20) or the MSK intermediate prognosis (86.7% vs. 82.2%, p=.46) subsets. A difference favoring IMRT was seen in the NCCN intermediate prognosis (70.7% vs. 83.3%, p=.03), MSK poor prognosis (38.4% vs. 62.2%, p\u3c.001), and NCCN poor prognosis (37.0% vs. 56.8%, p=.005) subsets. Within the entire cohort, after adjustment for confounding variables, Gleason score (p\u3c.001) and clinical stage (p\u3c.001) predicted BDFS, but treatment modality (p=.06) did not. Within the MSK poor prognosis subset, treatment modality (p=.006) was predictive of BDFS, favoring IMRT. Conclusion: Biochemical disease free survival is similar between RP and IMRT for patients with a good prognosis. Patients with a poor prognosis, and some with an intermediate prognosis, may benefit from IMRT to ≥72 Gy plus hormonal therapy

The association of very low PSA with increased cancer-specific death in men with high-grade prostate cancer

62 Background: It has been hypothesized that very low PSAs in men with high-grade prostate cancer could reflect dedifferentiation and a poorer prognosis, but clinical evidence to support this is limited. We sought to determine whether a very low-presenting PSA was associated with greater prostate cancer-specific mortality (PCSM) among men with Gleason score (GS) 8-10 disease. Methods: The Surveillance, Epidemiology and End Results Program was used to identify a national cohort of 328,904 men diagnosed with cT1-4N0M0 prostate cancer between 2004 and 2010. Multivariable Fine-Gray competing-risks regression analysis was used to determine PCSM as a function of PSA level (40ng/mL) and GS (8-10 vs. 40 was 3.19 (2.83-3.59; P<0.001), suggesting a U-shaped distribution. There was a significant interaction between PSA level and GS (Pinteraction<0.001) such that PSA <2.5 only significantly predicted for poorer PCSM among patients with high grade GS 8-10 disease. Conclusions: Among patients with high grade GS 8-10 disease, patients with PSA <2.5 and 2.6-4 appear to have a higher risk for cancer-specific death compared to patients with a 10.1-20 PSA level, supporting the notion that low PSA in GS 8-10 disease may be a sign of underlying aggressive and extremely poorly differentiated or anaplastic low PSA-producing tumors. Patients with low PSA GS 8-10 disease should be considered for clinical trials studying the use of chemotherapy and other novel agents in very-high risk prostate cancers

Rates and patterns of uninsured cancer survivors before and after implementation of the Affordable Care Act, 2000-2017

e18105 Background: Cancer survivors experience difficulties in maintaining healthcare coverage, however the reasons and risk factors for lack of insurance are poorly defined. We sought to assess self-reported reasons for not having insurance and to assess demographic and socioeconomic factors associated with non-insurance among cancer survivors, before and after implementation of the Affordable Care Act (ACA) in 2014. Methods: We used the National Health Interview Survey to identify adult participants (18-64 years) reporting a cancer diagnosis between 2000-2017. Multivariable logistic regression was used to define the association between demographic and socioeconomic variables and odds being uninsured. The prevalence of the most common self-reported reasons for not having insurance (unemployment, employment-related reason, family-related) were estimated, with AORs for each of the reasons defined by multivariable logistic regression. Results: Among 17,806 survey participants, 10.3% reported not having health insurance. Individuals surveyed in 2000-2013 had higher odds of not having insurance as compared to those surveyed in 2014-2017 (10.6% vs. 6.2%, AOR 1.75, 95% CI 1.49-2.08). Variables associated with higher odds of non-insurance throughout the entire study interval included younger age, annual family income below the poverty threshold, black race, Hispanic ethnicity, non-citizen status and current smoking (p < 0.001 for all). After implementation of the ACA, increasing interval from cancer diagnosis and black race were no longer associated with not having insurance. The most commonly cited reason for not having insurance were cost followed by unemployment, both of which decreased after ACA implementation (cost: 49.6% vs. 37.6%, AOR 0.62, 95% CI 0.46-0.85; unemployment: 37.1% vs. 28.5%, AOR 0.62, 95% CI 0.45-0.87). Conclusions: The proportion of uninsured cancer survivors decreased after implementation of the ACA, however certain subgroups remain at greater risk of being uninsured. Cost remains the primary barrier to obtaining insurance, although more than half of cancer survivors reported other barriers to coverage. Given the growing number of cancer survivors in conjunction with rising health costs, efforts addressing barriers to insurance coverage are needed for this population

Incidence and determinants of 1-month mortality after cancer-directed surgery.

282 Background: Death within 1 month of surgery is considered treatment related and serves as an important healthcare quality metric. We sought to identify the incidence of and factors associated with 1-month mortality after cancer-directed surgery. Methods: We used the Surveillance, Epidemiology and End Results Program to study a cohort of 1,110,236 patients diagnosed from 2004-2011 with cancers that are among the 10 most common or most fatal who received cancer-directed surgery. Multivariable logistic regression analyses were used to identify factors associated with 1-month mortality after cancer-directed surgery. Results: 53,498 patients (4.8%) died within 1 month of cancer-directed surgery. Patients who were married, insured, or who had a top 50th percentile income or educational status had lower odds of 1-month mortality from cancer-directed surgery ([adjusted odds ratio (AOR) 0.80; 95% CI 0.79 – 0.82; P<0.001], [AOR 0.88; (0.82 – 0.94); P<0.001], [AOR 0.95; (0.93 – 0.97); P<0.001], and [AOR 0.98; (0.96 – 0.99); P=0.043], respectively). Patients who were non-white minority, male, or older (per year increase), or who had advanced tumor stage 4 disease all had a higher risk of 1-month mortality after cancer-directed surgery, with AORs of 1.13 (1.11 – 1.15), P<0.001; 1.11 (1.08 – 1.13), P<0.001; 1.02 (1.02 – 1.03), P<0.001; and 1.89 (1.82 – 1.95), P<0.001 respectively. Conclusions: Unmarried, uninsured, non-white, male, older, less educated, and poorer patients were all at a significantly higher risk for death within 1 month of cancer-directed surgery. Efforts to reduce 1-month surgical mortality and eliminate sociodemographic disparities in this adverse outcome could significantly improve survival among patients with cancer