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Thread: (F) Treatment Decisions Comparisons Trends

  1. #21
    [#16]
    Impact of Pathology Review for Decision Therapy in Localized Prostate Cancer
    [2017, Full Text]

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672998/

    Abstract

    Background:
    The Gleason score is an essential tool in the decision to treat localized prostate cancer. However, experienced pathologists can classify Gleason score differently than do low-volume pathologists, and this may affect the treatment decision. This study sought to assess the impact of pathology review of external biopsy specimens from 23 men with a recent diagnosis of localized prostate cancer.

    Methods:
    All external biopsy specimens were reviewed at our pathology department. Data were retrospectively collected from scanned charts.

    Results:
    The median patient age was 63 years (range: 46-74 years). All patients had a Karnofsky performance score of 90% to 100%. The median prostate-specific antigen level was 23.6 ng/dL (range: 1.04-13.6 ng/dL). Among the 23 reviews, the Gleason score changed for 8 (35%) patients: 7 upgraded and 1 downgraded. The new Gleason score affected the treatment decision in 5 of 8 cases (62.5%).

    Conclusions:
    This study demonstrates the need for pathology review in patients with localized prostate cancer before treatment because Gleason score can change in more than one-third of patients and can affect treatment decision in almost two-thirds of recategorized patients.
    From the Full Text:
    Discussion
    Our study shows the importance of pathology review by an expert pathologist in the diagnosis of localized prostate cancer. Gleason score can change in more than one-third of patients and can affect treatment decision in almost two-thirds of recategorized patients.

    The use of Gleason score in risk stratification for treatment of prostate adenocarcinoma is well established.15,16 The different ways of calculating the score are factors that may result in discordant analysis between pathologists from different services, according to the protocol of each institution.15

    Currently, the modified Gleason score (International Society of Urological Pathology) makes the standard definition of Gleason pattern 3 extremely rigorous and has led to a reduction in the frequency of Gleason 6 (3 + 3) prostate adenocarcinoma and an increase in the frequency of Gleason 7 (3 + 4).16,17

    In other words, a Gleason score of 6 has become a diagnosis of exclusion. Thus, the nonrecognition of new standards for defining criteria of Gleason patterns 3 and 4 (Figure 1) can lead to an “upgrade” at the time of histopathology review in reference centers. Another pathological factor contributing to the discrepancy in Gleason grading between primary centers and referral centers is the low frequency with which Gleason pattern 5 is recognized in prostate biopsy specimens (Figure 2).17.
    ...

    [Emphasis mine]

  2. #22
    [#17]
    MISINFORMATION ON THE INTERNET REGARDING ABLATIVE THERAPIES FOR PROSTATE CANCER
    [2018, Article, Full Text]

    https://www.sciencedirect.com/science/article/pii/S0022534718408889

    INTRODUCTION AND OBJECTIVES
    The Internet is a common source of information for patients contemplating ablation versus other treatments for localized prostate cancer. However, the accuracy of health information available on the Internet is variable. In this study, we evaluated the quality of web-based information on these therapies, with the hypothesis that there would be substantial misinformation.

    METHODS
    The two most common search engines (Google and Bing) were queried for the following terms: ″prostate cancer″ + ″HIFU″ and ″cryotherapy″, respectively. The top 50 websites for each were obtained. Websites were characterized and analyzed regarding their accuracy and completeness (e.g. oncological efficacy, side effect profile, morbidity, etc.) using criteria determined a priori. Search results that linked to academic papers were excluded.

    RESULTS
    Of ″HIFU″ search results, 17% were advertisements, 13% and 29% were academic and private practice websites, respectively, and 24% were patient support websites. Erroneous information on oncological efficacy was presented in 15% and 41% of academic and private practice websites, respectively. Selection criteria for treatment were mentioned in 31% and 66% of academic and private practice websites, respectively. Of ″cryotherapy″ search results, 18% were advertisements, 15% and 11% were academic and private practice websites, respectively, and 10% patient support websites. Erroneous information was presented in 73% of both academic and private practice websites. Criteria for treatment were mentioned in 27% and 18% of these sites, respectively. Most sites did mention general side effects, urinary morbidity, and erectile dysfunction risk (78% and 75%, 78% and 70%, and 77 and 74% for HIFU and cryotherapy, respectively). No sites mentioned that ablative therapies are not standard of care options for most patients (per American Urological Association guidelines).

    CONCLUSIONS
    There is substantial inaccurate and incomplete information on the Internet regarding the efficacy of ablative treatments for prostate cancer, from both academic and private practice websites. Critically, selection criteria are uncommonly discussed, which risks giving patients false expectations that these therapies are appropriate. More attention to accuracy and completeness of information is needed to ensure patients are not misled about the data behind and their eligibility for these treatments.
    [Emphasis mine]
    Last edited by DjinTonic; 04-17-2018 at 12:59 PM.

  3. #23
    [#18]
    Perceptions about cancer clinical trials among prostate cancer survivors
    [2018, Full Text]

    http://ascopubs.org/doi/abs/10.1200/JCO.2018.36.6_suppl.42

    Abstract

    Background: Recruitment into cancer clinical trials (CCTs) remains challenging despite efforts to enhance patient understanding of and access to CCTs. We examined perceptions of CCTs among prostate cancer (PC) survivors. Methods: 86 PC survivors enrolled in Cancer Support Community’s Cancer Experience Registry online research platform, provided demographic and disease history, and rated their agreement (0 =strongly disagree; 4 =strongly agree) with 8 CCT statements. We examined bivariate associations between CCT counseling and individual factors via Spearman’s rank correlation and chi-square tests. Results: Participants were 95% White; mean (SD) age = 65 (7) years; time since diagnosis 4 (4) years. 24% had surgery, 34% underwent radiation, 20% both; 31% currently and 18% previously received hormone therapy. 32% were diagnosed 5+ years ago; 22% reported recurrence, 31% metastatic disease. 33% reported that their health care team spoke to them about participating in a CCT, with a non-significant trend for lower prevalence if all or part of care was received at a community hospital/cancer center (24%) vs. at an academic or comprehensive cancer center or private oncology practice (47%; χ2= 3.03, p = .082). 25% did not receive information about CCTs from the health care team prior to making a treatment decision. 21% reported there was a CCT available to them; 35% considered a CCT for treatment; 11% participated in a CCT. Regarding beliefs about CCTs (% agree or strongly agree): 64% felt uncomfortable with treatment random assignment; 52% feared receiving a placebo; 40% feared treatment side effects; 23% believed health insurance would not cover a CCT; 16% believed no clinical trials are available in their community; 16% felt mistrust and fear of being used as a “guinea pig” for research; 11% had concern about logistical barriers, e.g., transportation; 6% did not understand what CCTs are. Conclusions: Many prostate cancer survivors are uncomfortable with random assignment to treatment in a CCT and fear receiving a potentially ineffective placebo. Our findings underscore the need for comprehensive treatment decision counseling and patient education via health care providers and patient advocacy organizations.
    [Emphasis mine]

  4. #24
    [#19]
    Occurrence of pathologic stage T3 disease at radical prostatectomy with isup grade group 1 (Gleason 3+3=6) prostate cancer
    [2018, Full Text]

    Abstract

    Background: Treatment of ISUP Grade Group 1 (Gleason 3+3 = 6) disease continues to evolve in the modern era. We examined our surgical database to investigate patterns of behavior in this pathologic subset. Methods: We reviewed the results of 1127 consecutive radical prostatectomies performed by our surgeons from 2012−2015 at various community and academic medical centers in Chicagoland. Specifically, we examined the ISUP Grade Group 1 (Gleason 3+3 = 6) patients in our database, 314 patients overall. Results: A review of our database revealed that of ISUP Grade Group 1 (Gleason 3+3 = 6) patients (n = 314), only 3.82% had pT3 disease (11 patients stage pT3a and 1 stage pT3b). The only patient of these 12 to have lymphovascular invasion (LVI) was the singular pT3b patient. Overall, ISUP Grade Group 1 (Gleason 3+3 = 6) pT3 disease represents only 1.06% of all prostatectomies in our database. Conclusions: In our large prostatectomy cohort, ISUP Grade Group 1 (Gleason 3+3 = 6) prostate cancer was rarely associated with extra−prostatic extension (pT3) or lymphovascular invasion (LVI), suggesting that it has very low metastatic potential. These findings give further support to the trend of increased utilization of active surveillance for low risk prostate cancer.
    [Emphasis mine]

  5. #25
    [#20]
    Undertreatment of Elderly Men With High-Risk Prostate Cancer
    [2017, Full Text]

    http://www.redjournal.org/article/S0360-3016(17)32238-1/fulltext

    Purpose/Objective(s)
    Treatment of high risk prostate cancer (PCa) with androgen deprivation therapy (ADT) alone is inferior to radiation therapy (RT) plus ADT. Elderly men with high-risk PCa are often undertreated. To assess for an age-dependent bias, we examined patterns of care and compared overall survival (OS) between men treated with ADT or RT+ADT.

    Materials/Methods
    We queried the National Cancer Database between 2004-2013 and identified men ≥75 years of age with clinically localized high-risk PCa (Gleason 8-10, prostate specific antigen [PSA] >20 to 40 ng/ml, or T3a) treated with ADT alone or ADT+RT. Univariate (UVA), multivariate (MVA) and subset OS analyses were completed using chi-squared test, logistic regression, log-rank, Kaplan-Meier methods and cox-proportional hazards models. Propensity score matching was completed using significant variables from logistic regression.

    Results
    Among 17,636 patients treated with ADT, 14,254 (81%) were treated with RT and 3,382 (19%) with ADT alone. Median follow up was 71 months. Between 2004-2013, the proportion of men ≥75 treated with ADT alone remained unchanged (21% in 2004 and 20% in 2013). Factors independently associated with increased use of ADT alone were older age, African American race (vs. caucasian), uninsured and Medicaid insurance type (vs. Medicare), treatment in the South, Midwest and West (vs. Northeast), academic facility type (vs. non-academic), Charlson-Deyo comorbidity score (CCS) 1 and 2 (vs. 0), Gleason score 6 (vs. 7 and 8-10), and PSA of 10-20 and >20 (vs. <10). On UVA, ADT alone was associated with increased risk of death (hazard ratio [HR]: 2.5, 95% confidence interval [CI]: 2.4-2.7, p<0.001) when compared to RT+ADT. Five year OS for ADT alone and RT+ADT were 51% vs 78%, respectively (p<0.0001). On MVA, after controlling for age, race, insurance type, treatment location, facility type, CCS, PSA and clinical T-stage, ADT alone remained independently associated with increased risk of death (HR: 1.9, 95%CI: 1.7-2.0, p<0.001). Propensity score matching identified 4,216 patients and confirmed an increased risk of death associated with ADT alone (HR: 1.8, 95%CI: 1.7-2.0, p<0.001). On subset analysis, the increased risk of death associated with ADT alone persisted when stratified by CCS and age group (75-79, 80-84 and 85 years or greater) when compared to RT+ADT, except for those 85 years and older with CCS of 2 or greater.

    Conclusion
    Despite randomized evidence to support the use of RT+ADT for men with high-risk PCa, approximately 1 in 5 men who are 75 years and older are treated with ADT alone. This approach is associated with a 2-fold risk of death when compared to RT+ADT in most men. Careful consideration of life expectancy and comorbidity status should be given before omitting RT in the elderly.
    [Emphasis mine]

  6. #26
    [#21]
    Meta-analysis of studies comparing oncologic outcomes of radical prostatectomy and brachytherapy for localized prostate cancer
    [2017, Full Text]

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896855/

    Abstract

    Background:
    The aim of this study was to compare oncologic outcomes of radical prostatectomy (RP) with brachytherapy (BT).

    Methods:
    A literature review was conducted according to the ‘Preferred reporting items for systematic reviews and meta-analyses’ (PRISMA) statement. We included studies reporting comparative oncologic outcomes of RP versus BT for localized prostate cancer (PCa). From each comparative study, we extracted the study design, the number and features of the included patients, and the oncologic outcomes expressed as all-cause mortality (ACM), PCa-specific mortality (PCSM) or, when the former were unavailable, as biochemical recurrence (BCR). All of the data retrieved from the selected studies were recorded in an electronic database. Cumulative analysis was conducted using the Review Manager version 5.3 software, designed for composing Cochrane Reviews (Cochrane Collaboration, Oxford, UK). Statistical heterogeneity was tested using the Chi-square test.

    Results:
    Our cumulative analysis did not show any significant difference in terms of BCR, ACM or PCSM rates between the RP and BT cohorts. Only three studies reported risk-stratified outcomes of intermediate- and high-risk patients, which are the most prone to treatment failure.

    Conclusions:
    our analysis suggested that RP and BT may have similar oncologic outcomes. However, the analysis included a limited number of studies, and most of them were retrospective, making it impossible to derive any definitive conclusion, especially for intermediate- and high-risk patients. In this scenario, appropriate urologic counseling remains of utmost importance.

  7. #27
    [#22]
    Review of the comparative effectiveness of radical prostatectomy, radiation therapy, or expectant management of localized prostate cancer in registry data
    [2018]

    http://www.urologiconcology.org/article/S1078-1439(17)30530-6/abstract

    Highlights

    • Long-term outcomes in a diverse population following treatment for localized prostate cancer are difficult to evaluate in randomized controlled trials.
    • Administrative and registry data provide large pools of observational data that may be beneficial for elucidating long-term outcomes.
    • In this systematic review, administrative studies evaluating prostate-specific and overall mortality after definitive treatment of localized prostate cancer treatments found similar outcomes as recent randomized controlled trials.
    • Definitive therapy with prostatectomy and radiotherapy were associated with better survival than expectant management, watchful waiting/active surveillance, nondefinitive treatment or observation. Registry data regarding active surveillance is sparse.
    • As compared to radiotherapy, radical prostatectomy was associated with improved survival.

    Abstract

    Summary
    Evidence regarding the effectiveness of treatment for prostate cancer is primarily based on randomized controlled trials. Long-term outcomes are generally difficult to evaluate within experimental studies and may benefit from large pools of observational data. We conducted a systematic review of administrative and registry studies to evaluate the comparative effectiveness of treatment for clinically localized prostate cancer on overall and prostate-cancer specific mortality.

    Materials and Methods
    In accordance with the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P, 2015), we conducted a systematic search of Ovid Medline and Embase (1946–February 2017) and identified studies that evaluated the relationship between types of treatment for localized prostate cancer and mortality. Additional articles were identified through manual search. Randomized, prospective, and single institution studies were excluded. The risk of bias for each study was evaluated with the Newcastle Ottawa scale. Multivariable adjusted hazard ratios were reported to evaluate overall and cancer-specific mortality.

    Results
    We screened 4,721 studies and included for review, 19 that were published between 2001 and 2015. The pooled population included 228,444 patients. Countries of origin included the United States, Canada, China, Switzerland, the Netherlands, and Sweden, and the sources included administrative (n = 6) and cancer registry or prostate databases (n = 11). Overall and cancer-specific mortality were lowest among definitive treatment arms as compared to conservative therapy with no treatment, observation, or active surveillance. Radiotherapy was associated with worse overall and cancer-specific mortality than radical prostatectomy.

    Conclusion
    Although observational studies using large, population-based cohorts have the potential for bias, we found consistent evidence that high-quality observational studies may be used to evaluate the comparative effectiveness of prostate cancer treatment. Methodologic limitations of observational data should be considered

  8. #28
    [#23]
    Brachytherapy-Based Radiotherapy and Radical Prostatectomy Are Associated With Similar Survival in High-Risk Localized Prostate Cancer
    [2018]

    http://ascopubs.org/doi/abs/10.1200/jco.2017.75.9134

    Abstract

    Purpose
    There are no randomized trials to guide treatment decisions between radiotherapeutic and surgical options for patients with high-risk localized prostate cancer. Comparative studies have been limited by their ability to match patients on the basis of pretreatment prognostic variables and to adjust for the cancer-related, medical, and socioeconomic differences between patients who choose radiotherapeutic or surgical approaches.

    Methods
    We analyzed the outcome of all patients in the National Cancer Database with high-risk, clinically localized prostate cancer with complete prognostic data who were treated with either radical prostatectomy (RP), external beam radiotherapy (EBRT) combined with androgen deprivation (AD), or EBRT plus brachytherapy with or without AD. Inverse probability of treatment weighting was used to adjust for covariable imbalance among treatment groups. The weighted time-dependent Cox proportional hazards model was then used to estimate the effects of treatment groups on survival, accounting for differential treatment initiation times. A predictive model of pathologic nodal (pLN) status was built using prostate-specific antigen level, Gleason score, and clinical T stage; predicted pLN status was used to repeat the inverse probability of treatment weighting and time-dependent Cox proportional hazards model.

    Results
    A total of 42,765 patients were analyzed. There was no statistically significant difference in survival between RP and EBRT plus brachytherapy with or without AD (hazard ratio [HR], 1.17; 95% CI, 0.88 to 1.55). However, EBRT plus AD was associated with higher mortality than RP (HR, 1.53; 95% CI, 1.22 to 1.92). Adjustment for predicted pLN status did not yield statistically different results. A sensitivity analysis showed that EBRT plus AD ≥ 7920 cGy narrowed the difference, but a significantly higher mortality remained (HR, 1.33; 95% CI, 1.05 to 1.68 ).

    Conclusion
    After comprehensively adjusting for imbalances in prostate cancer prognostic factors, other medical conditions, and socioeconomic factors, this analysis showed no statistical difference in survival between patients treated with RP versus EBRT plus brachytherapy with or without AD. EBRT plus AD was associated with lower survival.
    [Emphasis mine]

    Meta-analysis of studies comparing oncologic outcomes of radical prostatectomy and brachytherapy for localized prostate cancer [2017, Full Text]

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896855/

    Abstract

    Background:
    The aim of this study was to compare oncologic outcomes of radical prostatectomy (RP) with brachytherapy (BT).

    Methods:
    A literature review was conducted according to the ‘Preferred reporting items for systematic reviews and meta-analyses’ (PRISMA) statement. We included studies reporting comparative oncologic outcomes of RP versus BT for localized prostate cancer (PCa). From each comparative study, we extracted the study design, the number and features of the included patients, and the oncologic outcomes expressed as all-cause mortality (ACM), PCa-specific mortality (PCSM) or, when the former were unavailable, as biochemical recurrence (BCR). All of the data retrieved from the selected studies were recorded in an electronic database. Cumulative analysis was conducted using the Review Manager version 5.3 software, designed for composing Cochrane Reviews (Cochrane Collaboration, Oxford, UK). Statistical heterogeneity was tested using the Chi-square test.

    Results:
    Our cumulative analysis did not show any significant difference in terms of BCR, ACM or PCSM rates between the RP and BT cohorts. Only three studies reported risk-stratified outcomes of intermediate- and high-risk patients, which are the most prone to treatment failure.

    Conclusions:
    our analysis suggested that RP and BT may have similar oncologic outcomes. However, the analysis included a limited number of studies, and most of them were retrospective, making it impossible to derive any definitive conclusion, especially for intermediate- and high-risk patients. In this scenario, appropriate urologic counseling remains of utmost importance.
    [Emphasis mine]
    Last edited by DjinTonic; 04-20-2018 at 02:28 PM.

  9. #29
    [#24]
    Association Between Primary Local Treatment and Non–prostate Cancer Mortality in Men With Nonmetastatic Prostate Cancer
    [2018]

    https://www.sciencedirect.com/science/article/pii/S0090429517313304

    Objective
    To assess the association between local treatment modality, surgery or radiotherapy, and non–prostate cancer and cardiovascular mortality in patients treated for nonmetastatic prostate cancer, given the high competing risk of mortality in this population.

    Methods
    We performed a population-based, retrospective cohort study of men treated for nonmetastatic prostate cancer in Ontario, Canada, from 2002 to 2009. Patients treated with surgery and radiotherapy were matched on demographics, comorbidity, and cardiovascular risk factors. The primary outcome was non–prostate cancer mortality. Outcomes were compared using the Fine and Gray subdistribution method with generalized estimating equations. We used a previously published technique to quantify the prevalence and strength of residual confounding necessary to account for observed results.

    Results
    We examined 5393 pairs of matched men. The 10-year cumulative incidence of non–prostate cancer mortality was higher among patients who underwent radiotherapy (12%) than surgery (8%; adjusted subdistribution hazard ratio [HR] 1.57, 95% confidence interval 1.35-1.83). Patients treated with radiotherapy also had an increased risk of cardiovascular mortality (adjusted HR 1.74, 95% confidence interval 1.27-2.37). Hypothetical residual confounders would have to be both strongly associated with non–prostate cancer mortality (HRs > 2.5) and have highly differential prevalence to nullify the observed effect.

    Conclusion
    Among patients carefully matched on cardiovascular risk factors, those treated with radiotherapy had an increased risk of non–prostate cancer mortality and cardiovascular disease. Because of the observational nature of the data, the potential for confounding remains. The magnitude and prevalence of potential residual confounders required to account for differences in treatment effects for prostate cancer was quantified.
    [Emphasis mine]

  10. #30
    [#25]
    Association Between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life Among Men With Localized Prostate Cancer
    [2017, Full Text]

    https://jamanetwork.com/journals/jama/fullarticle/2612617?utm_source=Silverchair_Information_Systems &utm_campaign=FTM_03162017&utm_content=news_releas es&cmp=1&utm_medium=email

    Abstract

    Importance Patients diagnosed with localized prostate cancer have to decide among treatment strategies that may differ in their likelihood of adverse effects.

    Objective To compare quality of life (QOL) after radical prostatectomy, external beam radiotherapy, and brachytherapy vs active surveillance.

    Design, Setting, and Participants Population-based prospective cohort of 1141 men (57% participation among eligible men) with newly diagnosed prostate cancer were enrolled from January 2011 through June 2013 in collaboration with the North Carolina Central Cancer Registry. Median time from diagnosis to enrollment was 5 weeks, and all men were enrolled with written informed consent prior to treatment. Final follow-up date for current analysis was September 9, 2015.

    Exposures Treatment with radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance.

    Main Outcomes and Measures Quality of life using the validated instrument Prostate Cancer Symptom Indices was assessed at baseline (pretreatment) and 3, 12, and 24 months after treatment. The instrument contains 4 domains—sexual dysfunction, urinary obstruction and irritation, urinary incontinence, and bowel problems—each scored from 0 (no dysfunction) to 100 (maximum dysfunction). Propensity-weighted mean domain scores were compared between each treatment group vs active surveillance at each time point.

    Results Of 1141 enrolled men, 314 pursued active surveillance (27.5%), 469 radical prostatectomy (41.1%), 249 external beam radiotherapy (21.8%), and 109 brachytherapy (9.6%). After propensity weighting, median age was 66 to 67 years across groups, and 77% to 80% of participants were white. Across groups, propensity-weighted mean baseline scores were 41.8 to 46.4 for sexual dysfunction, 20.8 to 22.8 for urinary obstruction and irritation, 9.7 to 10.5 for urinary incontinence, and 5.7 to 6.1 for bowel problems. Compared with active surveillance, mean sexual dysfunction scores worsened by 3 months for patients who received radical prostatectomy (36.2 [95% CI, 30.4-42.0]), external beam radiotherapy (13.9 [95% CI, 6.7-21.2]), and brachytherapy (17.1 [95% CI, 7.8-26.6]). Compared with active surveillance at 3 months, worsened urinary incontinence was associated with radical prostatectomy (33.6 [95% CI, 27.8-39.2]); acute worsening of urinary obstruction and irritation with external beam radiotherapy (11.7 [95% CI, 8.7-14.8]) and brachytherapy (20.5 [95% CI, 15.1-25.9]); and worsened bowel symptoms with external beam radiotherapy (4.9 [95% CI, 2.4-7.4]). By 24 months, mean scores between treatment groups vs active surveillance were not significantly different in most domains.

    Conclusions and Relevance In this cohort of men with localized prostate cancer, each treatment strategy was associated with distinct patterns of adverse effects over 2 years. These findings can be used to promote treatment decisions that incorporate individual preferences.

 

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