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ContextDespite established guidelines for the treatment of muscle-invasive bladder cancer, it has been reported that radical cystectomy (RC) is markedly underused, especially among patients of advanced age and those with higher comorbidity burden and lower access to care. Understanding the interactions between patient, provider, and hospital factors may inform targeted interventions to optimize RC utilization.ObjectiveTo systematically review the literature regarding factors associated with RC utilization.Evidence acquisitionA systematic search was conducted using Ovid and Medline according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2017 reporting on RC utilization. Prospective and retrospective studies were included.Evidence synthesisThere are no published randomized control trials on RC utilization. Variations in study quality and design precluded a formal statistical meta-analysis. RC receipt significantly depended on patient, provider, and hospital factors. Patient factors associated with lower RC use included advanced age, African American and Hispanic race/ethnicity, higher comorbidity burden, unmarried marital status, higher tumor stage and grade, and lower socioeconomic status. Provider factors associated with underutilization included lower surgeon volume and a metropolitan location. Finally, hospital factors associated with lower RC use included low hospital volume, nonacademic affiliation, and hospital location in the Midwest.ConclusionsRC is reportedly underutilized. We found that age, race, marital status, socioeconomic factors, cancer severity, comorbidity burden, surgeon volume, and facility type and location significantly determined RC receipt. Improved understanding of the varying contributions of the risk factors according to patient, provider, and hospital determinants may assist in developing targeted interventions to improve RC utilization.Patient summaryIn this review we explored the clinical evidence for factors predicting the utilization of radical cystectomy for muscle-invasive bladder cancer. Many factors related to the patient, provider, and hospital determine whether patients receive this guideline-recommended treatment. However, there remains a lack of understanding on characterization and targeted interventions according to these levels, which may improve use.

The purpose of this study was to examine temporal nationwide utilization patterns and predictors for use of positron emission tomography/computed tomography (PET/CT) in comparison with magnetic resonance imaging (MRI) and computed tomography (CT) among patients diagnosed with bladder cancer. A total of 36,855 patients aged 66 years or older diagnosed with clinical stage TI-IV, N0M0 bladder cancer from 2004 to 2011 were analyzed. We used multivariable logistic regression analyses to discern factors associated with receipt of imaging within 12 months from diagnosis. The Cochran-Armitage test for trend was used to determine changes in the proportion of patients receiving imaging after cancer diagnosis. Independent of clinical stage, there was marked increase in use of PET/CT throughout the study period (2011 vs. 2004: odds ratio, 17.55; 95% confidence interval, 10.14-30.38; P < .001). Although use of CT imaging remained stable during the study period, there was significantly decreased utilization of MRI (odds ratio, 0.60; 95% confidence interval, 0.49-0.75; P < .001) in 2011 versus 2004. The mean incremental cost of PET/CT versus CT and MRI was $1040 and $612 (in 2016 dollars), respectively. Extrapolating these findings to the patients with bladder cancer in the United States results in excess spending of $11.6 million for PET/CT imaging. We identified rapid adoption of PET/CT imaging independent of clinical stage, resulting in excess national spending of $11.6 million for this imaging modality alone. Further value-based research discerning the clinical versus economic benefits of advanced imaging among patients with bladder cancer are needed.

BackgroundThe objective of this study was to compare the overall survival of patients who undergo radical prostatectomy or radiotherapy versus noncancer controls to discern whether there is a survival advantage according to prostate cancer treatment and the impact of selection bias on these results.MethodsA matched cohort study was performed using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. In total, 34,473 patients ages 66 to 75 years were identified who were without significant comorbidity, were diagnosed with localized prostate cancer, and received treatment treated with surgery or radiotherapy between 2004 and 2011. These patients were matched to a noncancer control cohort. The rates of all-cause mortality that occurred within the study period were compared. Cox proportional hazards regression analysis was used to identify determinants associated with overall survival.ResultsOf 34,473 patients who were included in the analysis, 21,740 (63%) received radiation therapy, and 12,733 (37%) underwent surgery. There was improved survival in patients who underwent surgery (hazard ratio, 0.35; 95% confidence interval, 0.32-0.38) and in those who received radiotherapy (hazard ratio, 0.72; 95% confidence interval, 0.68-0.75) compared with noncancer controls. Overall survival improved significantly in both treatment groups, with the greatest benefit observed among patients who underwent surgery (log rank P

ContextMultimodal treatment for men with locally advanced prostate cancer (PCa) using neoadjuvant/adjuvant systemic therapy, surgery, and radiation therapy is being increasingly explored. There is also interest in the oncologic benefit of treating the primary tumor in the setting of metastatic PCa (mPCa).ObjectiveTo perform a review of the literature regarding the treatment of the primary tumor in the setting of mPCa.Evidence acquisitionMedline, PubMed, and Scopus electronic databases were queried for English language articles from January 1990 to September 2014. Prospective and retrospective studies were included.Evidence synthesisThere is no published randomized controlled trial (RCT) comparing local therapy and systemic therapy to systemic therapy alone in the treatment of mPCa. Prospective studies of men with locally advanced PCa and retrospective studies of occult node-positive PCa have consistently shown the addition of local therapy to a multimodal treatment regimen improves outcomes. Molecular and genomic evidence further suggests the primary tumor may have an active role in mPCa.ConclusionsTreatment of the primary tumor in mPCa is being increasingly explored. While preclinical, translational, and retrospective evidence supports local therapy in advanced disease, further prospective studies are under way to evaluate this multimodal approach and identify the patients most likely to benefit from the inclusion of local therapy in the setting of metastatic disease.Patient summaryIn this review we explored preclinical and clinical evidence for treatment of the primary tumor in metastatic prostate cancer (mPCa). We found evidence to support clinical trials investigating mPCa therapy that includes local treatment of the primary tumor. Currently, treating the primary tumor in mPCa is controversial and lacks high-level evidence sufficient for routine recommendation.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer Early Detection provide recommendations for prostate cancer screening in healthy men who have elected to participate in an early detection program. The NCCN Guidelines focus on minimizing unnecessary procedures and limiting the detection of indolent disease. These NCCN Guidelines Insights summarize the NCCN Prostate Cancer Early Detection Panel's most significant discussions for the 2016 guideline update, which included issues surrounding screening in high-risk populations (ie, African Americans, BRCA1/2 mutation carriers), approaches to refine patient selection for initial and repeat biopsies, and approaches to improve biopsy specificity.

Objective: To determine whether a simple point‐of‐care measurement system estimating renal parenchymal volume using tools ubiquitously available could be used to replace nuclear medicine renal scintigraphy (NMRS) in current clinical practice to predict estimated glomerular filtration rate (eGFR) after nephrectomy by estimating preoperative split renal function. Patients and Methods: We performed a retrospective review of patients who underwent abdominal cross‐sectional imaging (computed tomography/magnetic resonance imaging) and mercaptoacetyltriglycine (MAG3) NMRS prior to total nephrectomy at a single institution. We developed the real‐time estimation of nephron activity with a linear measurement system (RENAL‐MS) method of estimating postoperative renal function via the following technique: renal parenchymal volume of the removed kidney relative to the remaining kidney was estimated as the product of renal length and the average of six renal parenchymal thickness measurements. The utility of this value was compared to the utility of the split renal function measured by MAG3 for prediction of eGFR and new onset Stage 3 chronic kidney disease (CKD) at ≥90 days after nephrectomy using uni‐ and multivariate linear and logistic regression. Results: A total of 57 patients met the study criteria. The median (interquartile range [IQR]) age was 69 (61–80) years. The median (IQR) pre‐ and postoperative eGFR was 74 (IQR 58–90) and 46 (35–62) mL/min/1.73 m2, respectively. [Correction added on 29 December 2023, after first online publication: The data numbers in the preceding sentence have been corrected.] Correlations between actual and predicted postoperative eGFR were similar whether the RENAL‐MS or NMRS methods were used, with correlation using RENAL‐MS being slightly numerically but not statistically superior (R = 0.82 and 0.76; P = 0.138). Receiver operating characteristic curve analysis using logistic regression estimates incorporating age, sex, and preoperative creatinine to predict postoperative Stage 3 CKD were similar between RENAL‐MS and NMRS (area under the curve 0.93 vs. 0.97). [Correction added on 29 December 2023, after first online publication: The data numbers in the preceding sentence have been corrected.] Conclusion: A point‐of‐care tool to estimate renal parenchymal volume (RENAL‐MS) performed equally as well as NMRS to predict postoperative eGFR and de novo Stage 3 CKD after nephrectomy in our population, suggesting NMRS may not be necessary in this setting. [ABSTRACT FROM AUTHOR]

One of the most common ways researchers compare cancer survival outcomes across treatments from observational data is using Cox regression. This model depends on its underlying assumption of proportional hazards, but in some real‐world cases, such as when comparing different classes of cancer therapies, substantial violations may occur. In this situation, researchers have several alternative methods to choose from, including Cox models with time‐varying hazard ratios; parametric accelerated failure time models; Kaplan–Meier curves; and pseudo‐observations. It is unclear which of these models are likely to perform best in practice. To fill this gap in the literature, we perform a neutral comparison study of candidate approaches. We examine clinically meaningful outcome measures that can be computed and directly compared across each method, namely, survival probability at time T, median survival, and restricted mean survival. To adjust for differences between treatment groups, we use inverse probability of treatment weighting based on the propensity score. We conduct simulation studies under a range of scenarios, and determine the biases, coverages, and standard errors of the average treatment effects for each method. We then demonstrate the use of these approaches using two published observational studies of survival after cancer treatment. The first examines chemotherapy in sarcoma, which has a late treatment effect (i.e., similar survival initially, but after 2 years the chemotherapy group shows a benefit). The other study is a comparison of surgical techniques for kidney cancer, where survival differences are attenuated over time. [ABSTRACT FROM AUTHOR]