Does the Identification of a Minimum Number of Cases Correlate With Better Adherence to International Guidelines Regarding the Treatment of Penile Cancer? Survey Results of the European PROspective Penile Cancer Study (E-PROPS)

Background: Penile cancer represents a rare malignant disease, whereby a small caseload is associated with the risk of inadequate treatment expertise. Thus, we hypothesized that strict guideline adherence might be considered a potential surrogate for treatment quality. This study investigated the influence of the annual hospital caseload on guideline adherence regarding treatment recommendations for penile cancer. Methods: In a 2018 survey study, 681 urologists from 45 hospitals in four European countries were queried about six hypothetical case scenarios (CS): local treatment of the primary tumor pTis (CS1) and pT1b (CS2); lymph node surgery inguinal (CS3) and pelvic (CS4); and chemotherapy neoadjuvant (CS5) and adjuvant (CS6). Only the responses from 206 head and senior physicians, as decision makers, were evaluated. The answers were assessed based on the applicable European Association of Urology (EAU) guidelines regarding their correctness. The real hospital caseload was analyzed based on multivariate logistic regression models regarding its effect on guideline adherence. Results: The median annual hospital caseload was 6 (interquartile range (IQR) 3–9). Recommendations for CS1–6 were correct in 79%, 66%, 39%, 27%, 28%, and 28%, respectively. The probability of a guideline-adherent recommendation increased with each patient treated per year in a clinic for CS1, CS2, CS3, and CS6 by 16%, 7.8%, 7.2%, and 9.5%, respectively (each p < 0.05); CS4 and CS5 were not influenced by caseload. A caseload threshold with a higher guideline adherence for all endpoints could not be perceived. The type of hospital care (academic vs. non-academic) did not affect guideline adherence in any scenario. Conclusions: Guideline adherence for most treatment recommendations increases with growing annual penile cancer caseload. Thus, the results of our study call for a stronger centralization of diagnosis and treatment strategies regarding penile cancer

Does the Identification of a Minimum Number of Cases Correlate With Better Adherence to International Guidelines Regarding the Treatment of Penile Cancer? Survey Results of the European PROspective Penile Cancer Study (E-PROPS)

Background: Penile cancer represents a rare malignant disease, whereby a small caseload is associated with the risk of inadequate treatment expertise. Thus, we hypothesized that strict guideline adherence might be considered a potential surrogate for treatment quality. This study investigated the influence of the annual hospital caseload on guideline adherence regarding treatment recommendations for penile cancer. Methods: In a 2018 survey study, 681 urologists from 45 hospitals in four European countries were queried about six hypothetical case scenarios (CS): local treatment of the primary tumor pTis (CS1) and pT1b (CS2); lymph node surgery inguinal (CS3) and pelvic (CS4); and chemotherapy neoadjuvant (CS5) and adjuvant (CS6). Only the responses from 206 head and senior physicians, as decision makers, were evaluated. The answers were assessed based on the applicable European Association of Urology (EAU) guidelines regarding their correctness. The real hospital caseload was analyzed based on multivariate logistic regression models regarding its effect on guideline adherence. Results: The median annual hospital caseload was 6 (interquartile range (IQR) 3–9). Recommendations for CS1–6 were correct in 79%, 66%, 39%, 27%, 28%, and 28%, respectively. The probability of a guideline-adherent recommendation increased with each patient treated per year in a clinic for CS1, CS2, CS3, and CS6 by 16%, 7.8%, 7.2%, and 9.5%, respectively (each p < 0.05); CS4 and CS5 were not influenced by caseload. A caseload threshold with a higher guideline adherence for all endpoints could not be perceived. The type of hospital care (academic vs. non-academic) did not affect guideline adherence in any scenario. Conclusions: Guideline adherence for most treatment recommendations increases with growing annual penile cancer caseload. Thus, the results of our study call for a stronger centralization of diagnosis and treatment strategies regarding penile cancer

The Phase 3 COU-AA-302 Study of Abiraterone Acetate Plus Prednisone in Men with Chemotherapy-naive Metastatic Castration-resistant Prostate Cancer: Stratified Analysis Based on Pain, Prostate-specific Antigen, and Gleason Score

BACKGROUND: In the COU-AA-302 study (NCT00887198), abiraterone acetate plus prednisone (AAP) significantly improved outcomes in patients with metastatic castration-resistant prostate cancer (mCRPC) versus prednisone alone. Baseline clinical parameters predicting that treatment response could help inform clinical decisions were explored. OBJECTIVE: To identify patients who derive the greatest clinical benefit from AAP treatment. DESIGN, SETTING, AND PARTICIPANTS: A total of 1088 mCRPC patients treated with either AAP or prednisone in the first-line setting in COU-AA-302 were included in this post hoc analysis. INTERVENTION: Abiraterone acetate1000mg daily versus placebo, both plus prednisone 10mg daily. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Univariate and multivariable Cox regression analyses were performed, including clinical and pathological parameters for the primary end points overall survival (OS) and radiographic progression-free survival (rPFS), and secondary study end points. Tumor-associated baseline parameters independently impacting OS were applied to stratify patients according to possible treatment effects. RESULTS AND LIMITATIONS: Baseline prostate-specific antigen (PSA), tumor-related pain as assessed by the Brief Pain Inventory-Short Form (BPI-SF), and Gleason score (GS) at primary diagnosis were identified as tumor-associated variables that independently impacted OS. AAP significantly improved outcomes versus prednisone in both group 1 (BPI-SF 0-1 and PSA <80 ng/ml and GS <8; p=0.006; hazard ratio [HR]: 0.61) and group 2 (BPI-SF 2-3 and/or PSA ≥80 ng/ml and/or GS ≥8; p=0.03; HR: 0.84). The differences observed for treatment effects between groups 1 and 2 for OS (HR: 0.61 vs 0.84), rPFS (HR: 0.41 vs 0.59), and time to chemotherapy (HR: 0.64 vs 0.71) were not statistically significant. CONCLUSIONS: AAP significantly improved outcomes in mCRPC patients compared with prednisone alone regardless of baseline pain and PSA level, and GS at primary diagnosis with no significant differences between observed treatment effects in groups 1 and 2. PATIENT SUMMARY: Treatment with abiraterone acetate and prednisone (compared with treatment with prednisone only) for metastatic castration-resistant prostate cancer increased survival in all patients in the study regardless of pain, prostate-specific antigen levels at the start of treatment, and Gleason score at primary diagnosis.status: publishe

BioScore (B7-H1, survivin, and Ki-67) does not predict cancer-specific mortality in surgically treated patients with renal cell carcinoma: An external validation study

BACKGROUND To externally validate' BioScore', a biomarker-based scoring system using immunohistochemical tumor expression levels of B7-H1, survivin, and Ki-67, in a single-center cohort of renal cell carcinoma (RCC) patients. Additionally, we investigated the potential benefit of BioScore as compared to the Mayo Clinic stage, size, grade, and necrosis (SSIGN) score. MATERIALS AND METHODS The validation cohort comprised 393 nonmetastatic RCC patients treated with radical nephrectomy or nephron-sparing surgery from 1999 to 2004. Kaplan-Meier estimators, the log-rank test, uni- and multivariable Cox regression models, and measures of discrimination were used to quantify the prognostic performance of BioScore regarding cancer-specific mortality (CSM). RESULTS During a median follow-up of 7.8 years, 69/132 (52%) deaths were adjudicated to progressive disease. BioScore was weakly associated with CSM in univariable analysis (hazard ratio per 1 point increase = 1.12, 95% confidence interval = 1.02-1.23, P = 0.023). However, this association did not prevail after adjusting for other adverse prognostic factors as represented by the SSIGN score. The discriminative performance of BioScore was very modest (Harrell's C-Index = 0.60) and did not improve the SSIGN score (P = 0.341), which already showed an excellent discrimination, as evidenced by Harrell's C-Index of 0.81. In a sensitivity analysis regarding clear cell RCC patients only, B7-H1 positivity did not emerge as a statistically significant predictor of CSM. CONCLUSION Although a higher BioScore was significantly associated with a higher CSM, the magnitude of this association was weak and not independent from other prognosticators. Moreover, BioScore did not improve the prognostic accuracy of the SSIGN score

Improved prediction of nephron-sparing surgery versus radical nephrectomy by the optimized R.E.N.A.L. Score in patients undergoing surgery for renal masses

BACKGROUND: One major objective of currently available morphometric scores (MS) for renal masses, i.e., R.E.N.A.L., PADUA classification, Centrality-Index, is the prediction of type of surgery (nephron-sparin surgery [NSS] or radical nephrectomy [RN]). METHODS: Based on a prospective study protocol, various MS were assigned and calculated for 108 patients undergoing surgical treatment for renal masses at a single academic center. MS calculation was based on preoperative computed-tomography or magnet-resonance-imaging and performed by two independent readers blinded for surgical approach and outcome. Multivariable logistic-regression- and ROC-analyses were performed to assess the predictive value of various MS for surgical approach and the correlation of clinical parameters with nephrectomy type. Furthermore, the association with perioperative outcome parameters was evaluated. RESULTS: None of the tested MS was significantly superior to tumor size alone (area under the curve [AUC]=0.82) in predicting RN, with Centrality-Index showing the best association (AUC-0.88). Based on these findings, a simplified and optimized R.E.N.A.L. Score (optR.E.N.A.L.) was developed with different weightings of included parameters, which did not only show a significantly enhanced association with surgery type (AUC=0.93) than tumor size, but also outperformed all 1st and 2nd generation MS tested in the study cohort. Besides a modest correlation with postoperative change in renal function, no association with perioperative outcome variables was found for all MS including optR.E.N.A.L.. CONCLUSIONS: optR.E.N.A.L. represents a promising improvement of the preexisting R.E.N.A.L. Score with higher predictive ability for nephrectomy type than established MS and may serve as a benchmarking tool for nephrectomy assessment and comparison of surgical strategies

Impact of the medical specialty on knowledge regarding multidrug-resistant organisms and strategies toward antimicrobial stewardship

Evidence is scarce on subject-specific knowledge of multidrug-resistant organisms and rational use of antibiotics. We aimed at evaluating attitude, perception, and knowledge about multidrug-resistant organisms (MDRO) and antibiotic prescribing among urologists versus other medical specialties. Within the MR2-study (Multiinstitutional Reconnaissance of practice with MultiResistant bacteria), a questionnaire was conducted targeting general surgeons, internists, gynecologists, and urologists in 18 German hospitals. The influence of medical specialty on predetermined endpoints was assessed by multivariable logistic regression models. With 456 evaluable questionnaires, the response rate was 43% (456/1061). Within seven workdays prior to survey, urologists prescribed antibiotics to > 5 patients more often than non-urologists (50.7 vs. 24.3%; p < 0.001). Urologists were more confident regarding dosage, frequency, and duration of antibiotic treatment (p = 0.038) as well as in interpreting antibiograms (p < 0.001). Both urologists and non-urologists had poor knowledge about antibiotic stewardship. Urologists were more confident regarding local resistance patterns (p < 0.001). However, local rates of ciprofloxacin-resistant E. coli strains were correctly categorized by only 36.3 and 31.2% of urologists and non-urologists, respectively (p = 0.168). Compared to non-urologists, urologists more often acknowledged the use of broad-spectrum antibiotic agents as a problem, potentially resulting in increased resistance pattern (p = 0.036). Conversely, 31.5 and 30.7% of urologists and non-urologists (p = 0.424), respectively, would prescribe broad-spectrum antibiotics to a female patient with an uncomplicated urinary tract infection. Urologists did not attend more training courses regarding multidrug-resistance or antibiotic prescribing and did not perceive a better quality of discharge letters regarding MDRO. There is substantial need for advanced training regarding MDRO and antibiotic stewardship, regardless of medical specialty

Population-based study of disease trajectory after radical treatment for high-risk prostate cancer

Objectives: To investigate long-term disease trajectories among men with high-risk localized or locally advanced prostate cancer (HRLPC) treated with radical radiotherapy (RT) or radical prostatectomy (RP). Material and Methods: Men diagnosed with HRLPC in 2006–2020, who received primary RT or RP, were identified from the Prostate Cancer data Base Sweden (PCBaSe) 5.0. Follow-up ended on 30 June 2021. Treatment trajectories and risk of death from prostate cancer (PCa) or other causes were assessed by competing risk analyses using cumulative incidence for each event. Results: In total, 8317 men received RT and 4923 men underwent RP. The median (interquartile range) follow-up was 6.2 (3.6–9.5) years. After RT, the 10-year risk of PCa-related death was 0.13 (95% confidence interval [CI] 0.12–0.14) and the risk of death from all causes was 0.32 (95% CI 0.31–0.34). After RP, the 10-year risk of PCa-related death was 0.09 (95% CI 0.08–0.10) and the risk of death from all causes was 0.19 (95% CI 0.18–0.21). The 10-year risks of androgen deprivation therapy (ADT) as secondary treatment were 0.42 (95% CI 0.41–0.44) and 0.21 (95% CI 0.20–0.23) after RT and RP, respectively. Among men who received ADT as secondary treatment, the risk of PCa-related death at 10 years after initiation of ADT was 0.33 (95% CI 030–0.36) after RT and 0.27 (95% CI 0.24–0.30) after RP. Conclusion: Approximately one in 10 men with HRLPC who received primary RT or RP had died from PCa 10 years after diagnosis. Approximately one in three men who received secondary ADT, an indication of PCa progression, died from PCa 10 years after the start of ADT. Early identification and aggressive treatment of men with high risk of progression after radical treatment are warranted