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BACKGROUND: Tissue-based gene expression (genomic) tests provide estimates of prostate cancer aggressiveness and are increasingly used for patients considering or engaged in active surveillance. However, little is known about patient experiences with genomic testing and its role in their decision-making. METHODS: We performed a qualitative study consisting of in-depth, semi-structured interviews of patients with low- or favourable-intermediate-risk prostate cancer managed with active surveillance. We purposively sampled to include patients who received biopsy-based genomic testing as part of clinical care. The interview guide focused on experiences with genomic testing during patients decision-making for prostate cancer management and understanding of genomic test results. We continued interviews until thematic saturation was reached, iteratively created a code key and used conventional content analysis to analyse data. RESULTS: Participants (n = 20) mean age was 68 years (range 51-79). At initial biopsy, 17 (85%) had a Gleason grade group 1, and 3 (15%) had a grade group 2 prostate cancer. The decision to undergo genomic testing was driven by both participants and physicians recommendations; however, some participants were unaware that testing had occurred. Overall, participants understood the role of genomic testing in estimating their prostate cancer risk, and the test results increased their confidence in the decision for active surveillance. Participants had some misconceptions about the difference between tissue-based gene expression tests and germline genetic tests and commonly believed that tissue-based tests measured hereditary cancer risk. While some participants expressed satisfaction with their physicians explanations, others felt that communication was limited and lacked sufficient detail. CONCLUSION: Patients interact with and are influenced by the results of biopsy-based genomic testing during active surveillance for prostate cancer, despite gaps in understanding about test results. Our findings indicate areas for improvement in patient counselling in order to increase patient knowledge and comfort with genomic testing.

Introduction: Pre-exposure prophylaxis (PrEP) is an effective method for prevention of HIV transmission. Female sex workers (FSW) in Malaysia are at substantially increased risk of acquiring HIV compared to the general female population, yet little is known about this population's current HIV prevention practices or acceptance of PrEP. This study aims to inform the culturally relevant implementation of PrEP through the qualitative exploration of (1) the potential need for PrEP in this population and (2) the factors that determine FSW willingness to use oral PrEP. Methods: In-depth, semi-structured interviews (n = 30) were conducted with FSW in English, Malay, or Tamil. Transcribed and translated interviews were analyzed using a grounded theory approach. Results: FSW express positive interest in PrEP but prefer it as a supplement to condoms, not a replacement. Perceived challenges to PrEP use include cost, adherence, and side effects. Conclusion: The findings suggest that in combination with condom use, PrEP may be an acceptable method of HIV prevention. Effective PrEP rollout may also include condom promotion using a peer-driven model, cost subsidies, and sex work harm reduction and empowerment components. [ABSTRACT FROM AUTHOR]

Most Prostate Imaging Reporting and Data System (PI-RADS) 5 lesions on prostate MRI are found to harbor Gleason grade group ≥2 prostate cancer on initial biopsy. As a result, the optimal management of patients found to have Gleason grade group 1 (GG1) prostate cancer despite PI-RADS 5 lesions on prostate MRI remains unclear. To estimate risks of grade misclassification, we evaluated the occurrence of Gleason upgrade on subsequent active surveillance (AS) prostate biopsy or radical prostatectomy among patients diagnosed with GG1 prostate cancer with PI-RADS 5 lesions on MRI. We conducted a retrospective analysis at a single institution to identify patients diagnosed with GG1 prostate cancer whose MRI nearest to diagnosis demonstrated ≥1 lesion classified as PI-RADS 5. The primary study outcome was the presence of Gleason reclassification to GG≥2 prostate cancer on subsequent prostate biopsy or radical prostatectomy. The secondary outcomes included rates of grade reclassification on prostate biopsy, or conversion to active treatment among patients managed with initial active surveillance. We used multivariable logistic regression to identify factors associated with Gleason reclassification on subsequent biopsy or radical prostatectomy. Among 3,042 patients undergoing prostate biopsy between 01/2013-12/2022, we identified 110 with GG1 prostate cancer and PI-RADS 5 lesions on;MRI who received a total of 216 biopsies. The median age was 69 years and median PSA at diagnosis was 6.4 ng/mL. There were 104 patients (94.6%) who elected initial AS and six (5.5%) were treated. Sixty-one patients managed with AS underwent ≥1 additional biopsy. Among this group, 43 (70.5%) experienced Gleason upgrade including 32 (74.4%) on second, 9 (20.9%) on third, and one (2.3%) each on fourth and fifth biopsy. A total of 44 (40%) patients received definitive treatment including prostatectomy in 15 (13.6%) and radiation in 25 (22.73%). Two patients (1.8%) developed metastatic disease, of whom one patient later demonstrated higher grade disease on biopsy, and one died of disease. In multivariable logistic regression, no clinical or pathological factors were significantly associated with odds of Gleason upgrade. The majority of patients diagnosed with GG1 prostate cancer in the setting of a PI-RADS 5 lesion will be found to have GG2 or higher disease in the short term during active surveillance or during treatment, suggesting substantial initial misclassification. These findings reinforce the need for confirmatory testing in these patients due to risks of disease under-sampling. [ABSTRACT FROM AUTHOR]

Background and Objective: Comparative studies among biopsy strategies have not been conducted evaluating pathologic concordance at radical prostatectomy(RP), especially with novel micro-ultrasound (micro-US) image-guided biopsy., Methods: A retrospective study among patients with PCa who underwent RP following TRUS, MRI-TRUS fusion, microUS, or MRI-microUS fusion biopsy in a multi-site single institution. We compared GG-upgrade from biopsy to RP based on highest GG in any biopsy core and examined clinical/pathologic factors associated with pathologic upgrading using descriptive statistics, and multivariable logistic-regression analysis., Results: 429 patients between 1/2021 and 6/2023 including 10 (25.6%) who underwent systematic TRUS, 237 (55.2%) MRI-TRUS, 67 (15.6%) MRI-microUS and 15 (3.5%) micoUS-alone biopsy prior to RP. 78 (18.2%) were upgraded on final pathology (TRUS 31 (28.2%), MRI-TRUS 31 (13.1%), MRI-microUS 10 (14.9%), microUS: 6 (40%)) and 99 downgraded. 14 (3.5%) experienced a major upgrade (≥2 GG increase). On multivariable-analysis both MRI-TRUS (odds ratio, OR: 0.31,95% CI:0.17-0.56, P < 0.001) and MRI-microUS (OR: 0.43,95%CI: 0.19-0.98, P = 0.044) were associated with lower odds pathological-upgrade compared with TRUS biopsy alone. No significant differences in the odds of upgrade between TRUS and microUS alone (P > 0.05), or between MRI-microUS and MRI-TRUS(P = 0.696) on pairwise comparisons. MRI-microUS was associated with lower upgrade compared with microUS (OR: 0.26,95% CI:0.08-0.90, P = 0.034). No difference among the biopsy strategies in pathologic downgrading or overall GG concordance. Limitations include retrospective analysis, inter-clinician experience and lesion selection in varying biopsy techniques., Conclusion: Both MRI-microUS and MRI-TRUS fusion were associated with similarly improved GG concordance compared with TRUS biopsy. No significant differences between microUS-alone and TRUS or between MRI-microUS and MRI-TRUS fusion approaches, may suggest similar accuracy performance for disease sampling., What Does the Study Add: To our knowledge, this is the first study to investigate GG concordance based on type of biopsy, especially microUS related GG upgrading after RP. In a moderately sized cohort this is the first to investigate pathologic concordance in MRI-microUS fusion compared to MRI-TRUS fusion biopsy. Our study may help urologists in counseling patients after biopsy and choosing the ideal image guided biopsy technique, however randomized controlled trials are needed to validate our results., Patient Summary: We performed a study to see if the type of prostate biopsy, including use of MRI assistance as well as a new image-guided biopsy using a more advanced ultrasound, was better able to identify the aggressiveness of prostate cancer patients had. We found that the new biopsy type when fused with MRI and the existing MRI-guided biopsy type were similar in predicting the type of prostate cancer found at prostate surgery. These were both more accurate than the conventional ultrasound only biopsy., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Globally, transgender women have been disproportionately affected by the HIV epidemic, including in Malaysia, where an estimated 11% of transgender women are living with HIV. Available interventions designed specifically to meet transgender women's needs for HIV prevention are limited. Mobile health, particularly smartphone mobile apps, is an innovative and cost-effective strategy for reaching transgender women and delivering interventions to reduce HIV vulnerability., Objective: This study aims to adapt a theory-based mobile health HIV prevention smartphone app, HealthMindr, to meet the unique needs of transgender women in Malaysia. We conducted theater testing of the HealthMindr app with transgender women and key stakeholders and explored barriers to transgender women's uptake of HIV pre-exposure prophylaxis (PrEP)., Methods: From February to April 2022, a total of 6 focus group (FG) sessions were conducted with 29 participants: 4 FG sessions with transgender women (n=18, 62%) and 2 FG sessions with stakeholders (n=11, 38%) providing HIV prevention services to transgender women in Malaysia. Barriers to PrEP uptake and gender-affirming care services among transgender women in Malaysia were explored. Participants were then introduced to the HealthMindr app and provided a comprehensive tour of the app's features and functions. Participants provided feedback on the app and on how existing features should be adapted to meet the needs of transgender women, as well as any features that should be removed or added. Each FG was digitally recorded and transcribed. Transcripts were coded inductively using Dedoose software (version 9.0.54; SocioCultural Research Consultants, LLC) and analyzed to identify and interpret emerging themes., Results: Six subthemes related to PrEP barriers were found: stigma and discrimination, limited PrEP knowledge, high PrEP cost, accessibility concerns, alternative prevention methods, and perceived adverse effects. Participants suggested several recommendations regarding the attributes and app features that would be the most useful for transgender women in Malaysia. Adaptation and refinement of the app were related to the attributes of the app (user interface, security, customizable colors, themes, and avatars), feedback, and requests for additional mobile app functional (appointment booking, e-consultation, e-pharmacy, medicine tracker, mood tracker, resources, and service site locator) and communication (peer support group, live chat, and discussion forum) features., Conclusions: The results reveal that multifaceted barriers hinder PrEP uptake and use among transgender women in Malaysia. The findings also provide detailed recommendations for successfully adapting the HealthMindr app to the context of Malaysian transgender women, with a potential solution for delivering tailored HIV prevention, including PrEP, and increasing accessibility to gender-affirming care services., (©Kamal Gautam, Roman Shrestha, Sihlelelwe Dlamini, Belle Razali, Kiran Paudel, Iskandar Azwa, Rumana Saifi, YuHang Toh, Hazriq Justin Lim, Ryan Sutherland, Arjee Restar, Nittaya Phanuphak, Jeffrey A Wickersham. Originally published in JMIR Formative Research (https://formative.jmir.org), 13.08.2024.)

The need for improved clinical education surrounding the way difficult news is delivered and how to initiate end-of-life (EOL) discussions with seriously ill patients and their families is essential. Physicians and medical students often report feeling unprepared or uncomfortable with broaching the topic of death with their patients and families [1]. Early and honest conversations with patients concerning diagnoses and advance directives help patients and their families make well-informed decisions regarding future medical care, minimize pain and fears, and allow patients to experience a "peaceful death [1]." Moreover, end-of-life conversations frequently focus on resuscitation plans (advance directives), but should be broadened to include patients' psychosocial, physical, and economic concerns. Transparent, realistic, and sensitive end-of-life conversations can help patients maintain autonomy and dignity in the dying process and increase their quality of life as they near death. Additionally, initiating these conversations can alleviate emotional stress and physical symptoms, prevent invasive, costly, unnecessary, and unwanted care, aid grieving families through the bereavement process, and increase patients' satisfaction with end-of-life care provisions [2]. Overall, more attention and training must be delivered to physicians so that they are better prepared to initiate end-of-life discussions in a patient-centered way, focusing on patients' values and priorities. Requiring a more in depth, developmentally appropriate, and standardized training in EOL and palliative care for physicians-in-training in all disciplines in medical education is necessary. Redesigning medical school EOL curriculum will ensure physicians are better prepared to discuss death and dying and to ensure that seriously ill patients are dying well-informed., (Copyright ©2019, Yale Journal of Biology and Medicine.)