Search

Purpose: External-beam radiation therapy (EBRT) may predispose to secondary malignancies that include bladder cancer (BCa), rectal cancer (RCa), and lung cancer (LCa). We tested this hypothesis in a large French Canadian population-based cohort of prostate cancer patients., Methods and Materials: Overall, 8,455 radical prostatectomy (RP) and 9,390 EBRT patients treated between 1983 and 2003 were assessed with Kaplan-Meier and Cox regression analyses. Three endpoints were examined: (1) diagnosis of secondary BCa, (2) LCa, or (3) RCa. Covariates included age, Charlson comorbidity index, and year of treatment., Results: In multivariable analyses that relied on incident cases diagnosed 60 months or later after RP or EBRT, the rates of BCa (hazard ratio [HR], 1.4; p = 0.02), LCa (HR, 2.0; p = 0.004), and RCa (HR 2.1; p <0.001) were significantly higher in the EBRT group. When incident cases diagnosed 120 months or later after RP or EBRT were considered, only the rates of RCa (hazard ratio 2.2; p = 0.003) were significantly higher in the EBRT group. In both analyses, the absolute differences in incident rates ranged from 0.7 to 5.2% and the number needed to harm (where harm equaled secondary malignancies) ranged from 111 to 19, if EBRT was used instead of RP., Conclusions: EBRT may predispose to clinically meaningfully higher rates of secondary BCa, LCa and RCa. These rates should be included in informed consent consideration., (Crown Copyright 2010. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Seven percent of patients with prostate cancer (PCa) who are exposed to androgen deprivation therapy (ADT) may need transurethral resection of the prostate (TURP). Our objective was to examine the rate and the predictors of 30-day mortality (30dM) after TURP in patients who were exposed to ADT in a large, contemporary Canadian cohort., Patients and Methods: We assessed the 30dM rate after TURP in 853 men with the diagnosis of PCa who were treated with primary ADT or radiation therapy followed by ADT. The effect of age, comorbidity (coded according to the Charlson Comorbidity Index [CCI]), number of previous TURP procedures, history of radiation therapy, exposure to antiandrogens, and the type and the duration of ADT before TURP were all tested in univariable and multivariable logistic regression models that predicted 30dM after TURP., Results: During the initial 30 days after TURP, 38 deaths occurred (4.5%, 95% confidence interval: 3.2%-6.2%). Of all variables, the CCI was the only statistically significant (P = 0.001) predictor of 30dM after TURP. The accuracy of CCI in predicting 30dM after TURP in individual patients was 65.1%. Lack of consideration of clinical variables that could predict the 30dM rate after TURP, such as prostate size or prostate-specific antigen level, represents a limitation of this study., Conclusions: A substantial risk of 30dM is associated with TURP that is performed in patients who are exposed to ADT. Unfortunately, the predictors used in this analysis could not define the individual risk of 30dM with sufficient accuracy. Nonetheless, the average 4.5% risk should be considered at the time of informed consent.

Introduction: Elevated body mass index (BMI) may predispose to several pelvic pathologies., Aims: We tested the association between BMI and five end points, namely, (i) erectile dysfunction (ED); (ii) lower urinary tract symptoms (LUTS); (iii) chronic prostatitis-associated pain (CPP); and ejaculatory dysfunction that is subdivided between (iv) pain/discomfort on ejaculation; and (v) subjectively decreased ejaculate volume., Methods: Age, height, and weight were prospectively recorded in a cohort of 590 consecutive healthy men undergoing prostate cancer screening. Continuously coded and categorized BMI (World Health Organization classification) were studied., Main Outcome Measures: Age-adjusted analyses relied on logistic and linear regression models, according to data type., Results: The average age was 54.1 years (range 30-83). Of all, 296 were overweight (50.2%, BMI 25-29.9 kg/m(2)) and 85 were obese (14.4%, BMI > or = 30 kg/m(2)). After age adjustment, elevated continuously coded BMI (P < 0.001) and elevated categorized BMI (P = 0.01) were associated with worse erectile function. Conversely, after age adjustment, elevated continuously coded BMI (P = 0.02) and elevated categorized BMI (P = 0.05) were associated with a lower rate of subjectively decreased ejaculate volume. Finally, after age adjustment, elevated categorically coded BMI was related to lower rates of CPP (P < 0.001) and to a lower rate of pain/discomfort on ejaculation (P = 0.03)., Conclusions: In men undergoing prostate cancer screening, the effect of BMI on the five end points is not invariably detrimental. Elevated BMI may predispose to ED, but may also decrease the rate of pain/discomfort on ejaculation and may lower the reported rate of subjectively decreased ejaculate volume. Finally, it appeared to have no effect on LUTS.

Objective: To assess the relationship between surgical volume (SV), defined as the number of radical prostatectomies (RPs) within a calendar year, and the time to secondary therapy (ST) after RP, as this might represent an important determinant of cancer control., Patients and Methods: The study included 7937 men treated with RP by 130 urologists between 1989 and 2000. Radiotherapy or any form of hormonal manipulation represented ST. Univariable and multivariable Cox regression analyses was used to evaluate the time to ST after RP., Results: SV was an independent (P = 0.02) predictor of ST-free survival after RP, and the multivariable rate of ST sharply decreased with increasing SV., Conclusions: The use of ST is inversely proportional to SV of up to 24 RPs per year. A higher annual SV might be indicative of less restrictive use of RP in high-risk patients who eventually require combined treatments.

Objectives: The relationship between provider volume and cancer control has not been studied in the setting of definitive radiotherapy. We examined the effect of annual and cumulative provider volume on the rate of use of secondary therapies after definitive external-beam radiotherapy (EBRT) for localized prostate cancer., Methods: The cohort consisted of 3907 patients treated with definitive radiotherapy without neoadjuvant or adjuvant hormonal therapy (delivered within 12 mo of EBRT) between 1989 and 2000. Overall median follow-up was 6.2 yr versus 3.8 yr in event-free patients. All were treated by 72 radiation oncologists, with an average annual provider volume of 14 cases (median: 10.4; range: 1-39) and an average cumulative volume of 138 (median: 105; mean: 138). Secondary treatment was defined as hormonal therapy after definitive EBRT. Age and comorbidities represented covariates in Cox regression analyses., Results: Of all patients, 731 (18.7%) received secondary therapy. The median failure-free survival was not reached (mean: 11.2 yr). At 5 and 10 yr, secondary therapy-free survival rates were 79.5% and 61.3%, respectively. Annual (p=0.007) and cumulative (p=0.003) provider volumes were independent predictors of failure-free survival. After adjustment for covariates, cubic splines demonstrated lower rates of secondary therapy for annual provider volume > 10 cases and for cumulative provider volume > 200 cases., Conclusions: Our data suggest that to minimize the rates of secondary therapy, EBRT should ideally be delivered by high-volume providers with an annual or cumulative volume in excess of, respectively, 10 or 200 cases.

Objectives: To examine the effect of surgical volume (SV) on 30-day mortality after radical prostatectomy (RP; reportedly 0.1-0.6% and influenced by age and comorbidities) and to explore the most informative SV, age and comorbidity thresholds to distinguish between high- and low-risk men., Patients and Methods: Between 1989 and 2000, 9208 consecutive patients were treated with RP. The effects on 30-day mortality of (either continuously coded or categorized) patient age, comorbidities (Charlson Comorbidity Index, CCI) and SV were tested in multivariable logistic regression models. The models were corrected for overfit bias using 200 bootstrap re-samples and were displayed graphically as nomograms., Results: The overall 30-day mortality was 0.52%; being younger (<69 years, 0.3% vs 1.0% 30-day mortality otherwise, P < 0.001), lower CCI (0, 0.2% vs 0.8% otherwise, P < 0.001) and higher SV (>27 RPs, 0.07 vs 0.6% otherwise, P = 0.049) had a protective effect and represented independent predictors of 30-day mortality. After correction for overfit bias, their combined input was 72.3% accurate in predicting 30-day mortality, vs 67.1% (P < 0.001) when the same variables were used in continuously coded (uncategorized) format. A model-derived probability threshold of 27 RPs) can accurately identify patients at negligible risk of 30-day mortality.

Introduction: Different treatments for localized prostate cancer (PCa) may be associated with similar overall survival but may demonstrate important differences in health-related quality of life (HRQOL). Therefore, valid interpretation of cancer control outcomes requires adjustment for HRQOL., Aim: To assess the effect of comorbidity and socioeconomic status (SES) on sexual and urinary function as well as general HRQOL in men treated with radical prostatectomy (RP) for PCa., Methods: We sent a self-addressed mail survey, composed of the research and development short form 36-item health survey, the PCa-specific University of California at Los Angeles (UCLA) Prostate Cancer Index (PCI), as well as a battery of items addressing SES and lifetime prevalence of comorbidity, to 4,546 men treated with RP in Quebec between 1988 and 1996., Main Outcome Measures: The association between comorbidity, SES, and HRQOL was tested and quantified using univariable and multivariable linear regression models., Results: Survey responses from 2,415 participants demonstrated that comorbidity and SES are strongly related to sexual, urinary, and general HRQOL in univariable and multivariable analyses. In multivariable models, the presence of comorbid conditions was associated with significantly worse HRQOL, as evidenced by lower scale scores by as much as 17/100 points in general domains, and by as much as 10/100 points in PCa-specific domains. Favorable SES characteristics were related to higher general (up to 9/100 points) and higher PCa-specific (up to 8/100 points) HRQOL scale scores., Conclusions: Comorbidity and SES are strongly associated with sexual, urinary and general HRQOL.

Purpose: To test the accuracy of life tables (LTs) in predicting survival in men treated with radiotherapy for localized prostate cancer., Methods and Materials: We selected the records of 3,176 patients treated with radiotherapy and who had no clinical evidence of disease relapse. Life table-derived life expectancy (LE) was defined for every individual using a population-specific LT. Age, Charlson Comorbidity Index (CCI), and LT-derived LE were then used as predictors of overall mortality in Cox regression models. Predictive accuracy (PA) was estimated with the Harrell's concordance index and was internally validated with 200 bootstrap resamples., Results: The actuarial median survival was 4.7 years (mean, 6.4 years). At radiotherapy, median age was 70.6 years, median CCI was 2, and median LT-derived LE was 12 years. All variables were statistically significant predictors of overall mortality (all p values <0.001). Age (PA, 60.2%), CCI (PA, 60.1%), and LT-derived LE (PA, 60.2%) were equally accurate. Finally, when age and CCI were combined (PA, 63.2%), both variables provided more accurate mortality predictions than either variable alone (all p values = 0.01)., Conclusions: Life tables have a limited ability to predict LE in patients treated with radiotherapy for prostate cancer. We, therefore, recommend the use of multivariate prognostic models that integrate several variables, such as at least age and comorbidities, to estimate LE. This might help to improve LE estimation during prostate cancer treatment decision making.