Oncologic outcomes in men with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institution international study

BackgroundThe presence of lymph nodes (LN) within the prostatic anterior fat pad (PAFP) has been reported in several recent reports. These PAFP LNs rarely harbor metastatic disease, and the characteristics of patients with PAFP LN metastasis are not well-described in the literature. Our previous study suggested that metastatic disease to the PAFP LN was associated with less severe oncologic outcomes than those that involve the pelvic lymph node (PLN). Therefore, the objective of this study is to assess the oncologic outcome of prostate cancer (PCa) patients with PAFP LN metastasis in a larger patient population.MethodsData were analyzed on 8800 patients from eleven international centers in three countries. Eighty-eight patients were found to have metastatic disease to the PAFP LNs (PAFP+) and 206 men had isolated metastasis to the pelvic LNs (PLN+). Clinicopathologic features were compared using ANOVA and Chi square tests. The Kaplan-Meier method was used to calculate the time to biochemical recurrence (BCR).ResultsOf the eighty-eight patients with PAFP LN metastasis, sixty-three (71.6%) were up-staged based on the pathologic analysis of PAFP and eight (9.1%) had a low-risk disease. Patients with LNs present in the PAFP had a higher incidence of biopsy Gleason score (GS) 8-10, pathologic N1 disease, and positive surgical margin in prostatectomy specimens than those with no LNs detected in the PAFP. Men who were PAFP+ with or without PLN involvement had more aggressive pathologic features than those with PLN disease only. However, there was no significant difference in BCR-free survival regardless of adjuvant therapy. In 300 patients who underwent PAFP LN mapping, 65 LNs were detected. It was also found that 44 out of 65 (67.7%) nodes were located in the middle portion of the PAFP.ConclusionsThere was no significant difference in the rate of BCR between the PAFP LN+ and PLN+ groups. The PAFP likely represents a landing zone that is different from the PLNs for PCa metastasis. Therefore, the removal and pathologic analysis of PAFP should be adopted as a standard procedure in all patients undergoing radical prostatectomy

Evaluation of Industry Payments to US Advanced Practice Clinicians in 2021

Importance: Advanced practice clinicians (APCs) are a growing part of the US health care system, and their financial relationships with pharmaceutical and medical device companies have not been well studied. Objectives: To examine the value, frequency, and types of payments made to APCs and the association of state scope-of-practice laws with these payments. Design, setting, and participants: This cross-sectional study used 2021 Open Payments Program data to analyze payments from pharmaceutical or medical device companies to physicians or APCs between January 1 and December 31, 2021. Doctors of medicine and osteopathy were categorized as physicians, and nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, and anesthesiologist assistants as APCs. Main outcomes and measures: The total value and total number of payments were calculated in aggregate and per clinician for each type of APC, all APCs, and physicians. These calculations were repeated by submitting manufacturer, form of payment, nature of payment, and state scope-of-practice law for nurse practitioners, physician assistants, and physicians. Results: A total of 412 000 physicians and 232 000 APCs collectively received 1.99 billion dollars in payments from industry in 2021, of which APCs received 121 million dollars (6.1%). The median total value of payments per clinician for physicians was 167 dollars (IQR, 45-712 dollars) and for APCs was 117 dollars (IQR, 33-357 dollars). The median total number of payments per clinician was equal for physicians and APCs (n = 4). The most common payments to APCs included food and beverage (69 million dollars [57.6%]), compensation for services other than consulting (32 million dollars [26.4%]), and consulting fees (8 million dollars [6.6%]). Advanced practice clinicians in states with the most restrictive scope-of-practice laws received 15.9% lower total value of payments than those in the least restrictive states (P = .002). Physician assistants received 7.6% (P = .005) higher value and 18.1% (P Conclusions and relevance: In this cross-sectional study, 232 000 APCs collectively received $121 million in industry payments in 2021. The frequency of industry interactions with APCs was similar to that for physicians, but the average value was lower. The greater value of payments to APCs who practice in states with the least restrictive scope-of-practice laws suggests that industry payments may be related to clinician autonomy.</p

Cost-Effectiveness of Immune Checkpoint Inhibitors in Urothelial Carcinoma&mdash;A Review

Over the last decade, an increasing number of immune checkpoint inhibitors (ICIs) have been assessed for therapeutic efficacy in urothelial carcinoma (UC). The high cost has prompted multiple cost-effectiveness analyses for the various disease stages, with no established consensus. We reviewed the literature to assess the available cost-effectiveness studies and summarize their findings. Studies were filtered for a calculated incremental cost-effectiveness ratio (ICER) to standardize comparison. Over 2600 articles were narrowed to eight primary investigations: one for BCG-refractory non-muscle invasive (NMI), one for neoadjuvant therapy in muscle-invasive (MI), and six for advanced disease. Cost-effectiveness was not achieved for NMI disease. Atezolizumab met the willingness-to-pay (WTP) threshold as neoadjuvant therapy for MI disease compared to chemotherapy, but with multiple limitations on the interpretation. Of the six studies on advanced disease, the results were mixed. This was at least partially attributable to varied methodologies including extrapolated time horizons, inconsistent cost inputs, and different WTP thresholds. Overall, the aggregate results were not compelling enough to establish ICIs as cost-effective compared to conventional chemotherapy. Value may improve with continued investigation into long-term outcomes, refined patient selection, and pricing discounts

Aortic valve replacement among patients with Alzheimer’s disease and related dementias

BackgroundTranscatheter aortic valve replacement (TAVR) has made palliation from aortic stenosis more broadly available to populations previously thought to be too high risk for surgery, such as those with Alzheimer’s disease and related dementias (ADRD); however, its safety and effectiveness in this context are uncertain.MethodsWe performed a retrospective cohort study of national Medicare beneficiaries, aged 66 and older with Parts A and B, between 2010 and 2016. Patients undergoing AVR were identified, and follow‐up was available through 2017. Multivariable regression was used to measure the independent association between having a diagnosis of ADRD at the time of AVR, stratified by TAVR and surgery, and outcomes (mortality and Medicare institutional days at 1 year after AVR).ResultsThe average rate of increase in AVR per year was 17.5 cases per 100,000 ADRD and 8.4 per 100,000 non‐ADRD beneficiaries, largely driven by more rapid adoption of TAVR. Adjusted mortality following AVR declined significantly between those treated in 2010 and 2016, from 13.5% (95% CI 10.2%–17.7%) to 6.3% (95% CI 5.2%–7.6%) and from 13.7% (95% CI 12.7%–14.7%) to 6.3% (95% CI 5.8%–6.9%) in those with and without ADRD, respectively. The sharpest decline was noted for patients undergoing TAVR between 2011 and 2016, with adjusted mortality declining from 19.9% (95% CI 11.2%–32.8%) to 5.2% (95% CI 4.1%–6.5%) and from 12.2% (95% CI 9.3%–15.8%) to 5.0% (95% CI 4.4%–5.6%) in patients with and without ADRD, respectively. Similar declines were evident for Medicare institutional days in the year after AVR in both patient groups.ConclusionsRates of AVR in those with ADRD increased during the past decade largely driven by the diffusion of TAVR. The use of TAVR in this vulnerable population did not come at the expense of increasing Medicare institutional days or mortality at 1‐year.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/171180/1/jgs17432-sup-0001-supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/171180/2/jgs17432_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/171180/3/jgs17432.pd

Industry Payments for Vibegron and Prescribing Patterns Among Urologic Clinicians

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Abrogation of survival disparity between Black and White individuals after the USPSTF′s 2012 prostate‐specific antigen–based prostate cancer screening recommendation

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163646/2/cncr33179.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163646/1/cncr33179_am.pd

Adherence and out‐of‐pocket costs among Medicare beneficiaries who are prescribed oral targeted therapies for advanced prostate cancer

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163634/3/cncr33176.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163634/2/cncr33176-sup-0001-FigS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163634/1/cncr33176_am.pd

Variation in prostate cancer treatment and spending among Medicare shared savings program accountable care organizations

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/145563/1/cncr31573.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/145563/2/cncr31573_am.pd