Evaluating the use of prostate-specific antigen as an instrument for early detection of prostate cancer beyond urologists: Results of a representative cross-sectional questionnaire study of general practitioners and internal specialists

OBJECTIVES The aim of this cross-sectional study was to evaluate the value of prostate-specific antigen (PSA) testing as a tool for early detection of prostate cancer (PCa) applied by general practitioners (GPs) and internal specialists (ISs) as well as to assess criteria leading to the application of PSA-based early PCa detection. METHODS Between May and December 2012, a questionnaire containing 16 items was sent to 600 GPs and ISs in the federal state Brandenburg and in Berlin (Germany). The independent influence of several criteria on the decision of GPs and ISs to apply PSA-based early PCa detection was assessed by multivariate logistic regression analysis (MLRA). RESULTS 392 evaluable questionnaires were collected (return rate 65%). 81% of the physicians declared that they apply PSA testing for early PCa detection; of these, 58 and 15% would screen patients until the age of 80 and 90 years, respectively. In case of a pathological PSA level, 77% would immediately refer the patient to a urologist, while 13% would re-assess elevated PSA levels after 3-12 months. Based on MLRA, the following criteria were independently associated with a positive attitude towards PSA-based early PCa detection: specialisation (application of early detection more frequent for GPs and hospital-based ISs) (OR 3.12; p < 0.001), physicians who use exclusively GP or IS education (OR 3.95; p = 0.002), and physicians who recommend yearly PSA assessment after the age of 50 (OR 6.85; p < 0.001). CONCLUSIONS GPs and ISs frequently apply PSA-based early PCa detection. In doing so, 13% would initiate specific referral to a urologist in case of pathological PSA values too late. Improvement of this situation could possibly result from specific educational activities for non-urological physicians active in fields of urological core capabilities, which should be guided by joint boards of the national associations of urology and general medicine

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

Awareness and perception of multidrug-resistant organisms and antimicrobial therapy among internists vs. surgeons of different specialties: Results from the German MR2 Survey

Background: Recently, antibiotic resistance rates have risen substantially and care for patients infected with multidrug-resistant organisms (MDRO) has become a common problem in most in &#8211; and outpatient settings. The objectives of the study were to compare the awareness, perception, and knowledge of MDRO and rational antibiotic use between physicians from different medical specialties in German hospitals. Methods: A 35-item questionnaire was sent to specialists in internal medicine (internists), gynecologists, urologists, and general surgeons (non-internists) in 18 German hospitals. Likert-scales were used to evaluate awareness and perception of personal performance regarding care for patients infected with MDRO and rational use of antibiotics. Additionally, two items assessing specific knowledge in antibiotic therapy were included. The impact of medical specialty on four predetermined endpoints was assessed by multivariate logistic regression. Results: 43.0 (456/1061) of recipients responded. Both internists and non-internists had low rates of training in antibiotic stewardship. 50.8 of internists and 58.6 of non-internists had attended special training in rational antibiotic use or care for patients infected with MDRO in the 12 months prior to the study. Internists deemed themselves more confidently to choose the indications for screening patients for colonization with methicillin-resistant Staphylococcus aureus (P=0.004) and to initiate adequate infection control measures (P=0.002) than other specialties. However, there was no significant difference between internists and other specialists regarding the two items assessing specific knowledge in antibiotic therapy and infection control. Conclusion: Among the study participants, a considerable need for advanced training in the study subjects was seen, regardless of the medical specialty

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

a retrospective study on determination of the prognostic significance of under- and overgrading

Hintergrund: Aufgrund der schlechten Übereinstimmung des Gleasonscores in Biopsie und Prostatektomiepräparat von nur 45% erfolgte 2005 eine Modifikation des Gleasonscores (ISUP 2005), die zu einer Wegnahme der Gleasongrade 1 und 2 respektive der Gleasonscores 2-5 in der Biopsie führte. Fragestellung: Da der Gleasonscore der Biopsie ein entscheidendes tumoreigenes Kriterium für die Therapieplanung von Patienten mit Prostatakarzinom mit dominantem Einfluss auf Instrumente zur Risikostratifizierung ist, ergibt sich die Notwendigkeit, Häufigkeit und prognostische Signifikanz von Under- und Overgrading des konventionellen Gleasonscores (vor ISUP 2005) zu überprüfen. Material und Methode: In einem 10-Jahreszeitraum vor Modifikation des Gleasonscores erfolgte bei 856 Patienten (Studiengruppe, mittleres Alter 64,2 Jahre) eine radikale Prostatektomie. Von allen Patienten waren Gleasonscore und WHO- Grading in Biopsie und definitiver Histologie bekannt. Als Ausschlusskriterien galten weniger als 6 Biopsien, Diagnose von Gleasonscore 2 bis 4 ausschließlich in der Transitionalzone oder eine neoadjuvante Androgendeprivation. Die Übereinstimmung von Biopsie und definitiver Histologie bezüglich Gleasonscore und WHO-Grading wurde durch Kappa-Statistik (κ) berechnet (gesamt und in von 3 Zeiträumen). Es wurde der uni- und multivariate Einfluss verschiedener prätherapeutischer Variablen auf das rezidivfreie Überleben geprüft. Das mittlere follow-up der Studiengruppe betrug 39 (10-139) Monate. Ergebnisse: Das Overgrading wies im Untersuchungszeitraum keine prognostische Relevanz auf. Das Undergrading nahm für Gleasonscore und WHO-Grading innerhalb der drei Zeiträume kontinuierlich zugunsten einer exakteren Übereinstimmung zwischen Biopsie und definitiver Histologie ab. Trotzdem lag im gesamten Untersuchungszeitraum nur eine schlechte bis moderate Übereinstimmung vor (κ-Wert 0.354 für den Gleasonscore und 0.404 für das WHO-Grading). Eine bessere Übereinstimmung konnte durch Erhöhung der Biopsiezahl erreicht werden. Einen unabhängigen Beitrag zum rezidivfreien Überleben leisteten PSA-Wert, klinisches Tumorstadium, Anteil positiver Biopsien (dichotomisiert bei 34%) und Gleasonscore. Patienten mit Gleasonscore 2-4 in der Biopsie hatten unabhängig vom Gleasonscore in der definitiven Histologie eine signifikant bessere Prognose als Patienten mit höherem Gleasonscore. Schlussfolgerung: Die Ergebnisse beweisen erneut die unabhängige prognostische Signatur des Gleasonscores in der Biopsie. Die Übereinstimmung mit der definitiven Histologie ist jedoch unzureichend und kann durch Erhöhung der Biopsiezahl verbessert werden. Der aus pathologischer Sicht verständliche Verzicht auf die Gleasonscores 2-4 in der Biopsie führt zu einem relevanten Verlust an prognoserelevanter prätherapeutischer Information. Eine Objektivierung des Gleasongradings durch Entwicklung untersucherunabhängiger Bildverarbeitungs- und Analyseverfahren kann dazu beitragen, dieses Dilemma aufzulösen.Background: Due to the insufficient agreement of Gleason score in biopsy and prostatectomy specimens of only about 45%, in 2005 occurred a modification of the Gleason score (ISUP 2005), which led to a removal of the Gleason grades 1 and 2, respectively the Gleason scores 2-5 in the biopsy. Question: Since the Gleason score in the biopsy is one of the crucial tumor-specific criteria for treatment planning of patients with prostate cancer with a dominant influence on the common tools for risk stratification, the need arises, to evaluate the frequency and prognostic significance of under- and overgrading of conventional Gleason score (before ISUP 2005). Materials and methods: Within a 10-year period before modification of the Gleason score in 856 patients with prostate cancer (study group, mean age: 64.2 years) a radical prostatectomy was performed. In all patients were known Gleason score and WHO grading in biopsy and definitive histology. Exclusion criteria included: less than 6 biopsies, diagnosis of Gleason score 2-4 only in the transitional zone or neoadjuvant androgen deprivation. The degree of agreement between biopsy and definitive histology with respect to Gleason score and WHO grading was calculated by Kappa statistics (κ) (total and within 3 periods). The univariate and multivariate influence of different pre-treatment variables on relapse-free survival were investigated. Mean follow-up of the study group was 39 (10-139) months. Results: The overgrading in the entire study period had no prognostic relevance. The undergrading decreased for Gleason score and WHO grading within the three periods continuously in favor of a more exact match between biopsy and definitive histology. Nevertheless in the entire study period existed only a poor to moderate agreement (κ-value 0.354 for Gleason score and 0.404 for WHO grading). A better agreement for Gleason score and WHO-grading could be reached by an increased number of biopsy cores. An independent contribution to relapse-free survival showed PSA level, clinical tumor stage, percentage of positive biopsies (dichotomized at 34%) and Gleason score. Patients with Gleasonscore 2-4 in the biopsy had, regardless of their Gleason score in the final histology, a significantly better prognosis than patients with higher Gleason score. Conclusions: The results again demonstrate the independent prognostic signature of Gleason score in the biopsy. However, the agreement with the final histology is insufficient and can be improved by increasing the number of biopsy cores. The renouncement of diagnosis of Gleason score 2-4 in biopsy is comprehensible from pathological point of view, but results in a loss of relevant pretherapeutic forecasting information. An objectification of the Gleason grading by development of non-examiner dependent image processing and analysis methods can help to resolve this dilemma

Commentary: Kappen S, Jürgens V, Freitag MH, Winter A. Attitudes Toward and Use of Prostate-Specific Antigen Testing Among Urologists and General Practitioners in Germany: A Survey

A Commentary on: Attitudes Toward and Use of Prostate-Specific Antigen Testing Among Urologists and General Practitioners in Germany: A Survey By Kappen S, Jürgens V, Freitag MH, Winter A. (2021) Front Oncol. 11:691197. doi: 10.3389/fonc.2021.69119

Diagnostic relevance of metastatic renal cell carcinoma in the head and neck: An evaluation of 22 cases in 671 patients

ABSTRACT Purpose Renal cell carcinoma (RCC) is a malignant tumor that metastasizes early, and patients often present with metastatic disease at the time of diagnosis. The aim of our evaluation was to assess the diagnostic and differential diagnostic relevance of metastatic renal cell carcinoma (RCC) with particular emphasis on head and neck manifestations in a large patient series. Patients and methods We retrospectively evaluated 671 consecutive patients with RCC who were treated in our urology practice between 2000 and 2013. Results Twenty-four months after diagnosis, 200/671 (30%) of RCC had metastasized. Distant metastases were found in 172 cases, with 22 metastases (3.3%) in the head and neck. Cervical and cranial metastases were located in the lymph nodes (n=13) and in the parotid and the thyroid gland, tongue, the forehead skin, skull, and paranasal sinuses (n=9). All head and neck metastases were treated by surgical excision, with 14 patients receiving adjuvant radiotherapy and 9 patients receiving chemotherapy or targeted therapy at some point during the course of the disease. Five patients (23%) survived. The mean time of survival from diagnosis of a head and neck metastasis was 38 months, the shortest period of observation being 12 months and the longest 83 months. Discussion and conclusion Our findings show that while RCC metastases are rarely found in the neck, their proportion among distantly metastasized RCC amounts to 13%. Therefore, the neck should be included in staging investigations for RCC with distant metastases, and surgical management of neck disease considered in case of resectable metastatic disease. Similarly, in patients presenting with a neck mass with no corresponding tumor of the head and neck, a primary tumor below the clavicle should be considered and the appropriate staging investigations initiated

Fühlen sich Chirurgen gerüstet für die komplexen Fragestellungen im Umgang mit multiresistenten Erregern? – Ergebnisse der Fragebogenstudie MR2

Background At the present time, there is no evidence available as to the knowledge of general surgeons regarding multi-resistant pathogens (MRP) and the rational use of antibiotic medication (antibiotic stewardship/ABS) compared with physicians from other disciplines. Methods As part of the MR2 survey (Multiinstitutional Reconnaissance of practice with MultiResistant bacteria - a survey focussing on German hospitals), a questionnaire comprising 4 + 35 items was distributed to urologists, internists, gynaecologists and general surgeons in 18 hospitals. Multivariate regression models were applied to assess the impact of each discipline affiliation on predefined endpoints. Results 456 evaluable surveys were analysed. The response rate of surgeons (156/330; 47%) and physicians from other disciplines (300/731; 41%) did not differ significantly. Based on their self-assessment, surgeons indicated a significantly lower certainty regarding the correct choice of dose, frequency and duration of antibiotic treatment (p = 0.005), the decision between intravenous or oral application (p = 0.005), as well as the accurate interpretation of microbiological reports (p = 0.023). Both surgeons and doctors from other disciplines rated their knowledge of ABS as limited. An insignificant difference was found between surgeons and non-surgeons regarding the knowledge of E. coli resistance against Ciprofloxacin in their own hospital 27.6 vs. 35.3% estimated the correct category; p = 0.114), with 64% of surgeons underestimating the local resistance rates. Both physician groups assumed that the frequent use of broad-spectrum antibiotics is substantially responsible for the increase in MRP. However, in the given case study of a highly symptomatic female patient with uncomplicated urinary tract infection, both physician groups were almost equally likely to propose treatment with a broad-spectrum antibiotic (34.0 vs. 29.3%; p = 0.331). Based on the results of the multivariate models, there were no significant differences between surgeons and non-surgeons with regard to both the attendance of training courses related to MRP/ABS over the past 12months and the quality of discharge summaries in their hospitals regarding the correct listing of MRP. Conclusion In due consideration of the results of the MR2 survey, mandatory ABS programs should be implemented in hospitals, including regular training of physicians regardless of their discipline