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Thread: Treatment Facility Volume and Survival in Patients with Advanced PCa

  1. #1

    Treatment Facility Volume and Survival in Patients with Advanced PCa

    Treatment Facility Volume and Survival in Patients with Advanced Prostate Cancer [2019, Full Text]

    https://euoncology.europeanurology.c...097-5/fulltext

    Abstract

    Background
    Despite improvements in medical management of advanced prostate cancer (aPC), it continues to be a leading cause of cancer death in men. Contemporary management of men with aPC is complex and requires resources to be more readily available at high-volume facilities.

    Objective
    To determine the relationship between facility volume and survival in men with aPC.

    Design, setting, and participants
    The National Cancer Database (NCDB) was queried from 2004 to 2013 for aPC, defined as T4, N+, or M+ disease, identifying 64 815 patients. Six predefined patient cohorts were evaluated. Cohort “A” included all patients with aPC. “B” cohorts included only M0 patients. “C” cohorts included only M1 patients. Facilities were divided into quartiles based on median treatment volume (patients/yr).

    Intervention
    Diagnosis and management of aPC at an NCDB-reporting facility.

    Outcome measurements and statistical analysis
    Overall survival (OS) was assessed as a function of facility volume. Multivariable Cox regression models were fitted. Cox regressions using natural cubic splines were used to test for nonlinear relationships between volume and OS.

    Results and limitations
    OS improved as facility volume increased (top quartile vs bottom quartile, hazard ratio 0.82, 95% confidence interval 0.77–0.88, p < 0.001) and was consistent across patient cohorts. Spline models demonstrate a continuous decrease in hazard of death as volume increases. Limitations include the retrospective analysis and a lack of precise treatment information.

    Conclusions
    In this retrospective analysis of nearly 65 000 men who presented with aPC, we demonstrate an association between higher facility volume and improvements in OS. This OS advantage persisted with similar magnitudes of effect after narrowing the cohorts by disease and treatment characteristics.

    Patient summary
    In this retrospective review of the National Cancer Database, we analyzed the association between treatment facility volume and survival in men who are diagnosed with advanced prostate cancer. We found that survival improved as volume increased, indicating a possible imbalance of resources and expertise that favors higher-volume facilities.
    From the Full Text:

    Patient characteristics
    This patient population was predominantly Caucasian (78%), with African-American men comprising 18% of the cohort. Of the men, 73% were >60 yr old and only 5% were <50 yr old. Many men received care using Medicare (48%) as their primary insurance, while 31% used private insurance or managed care plans. Notably, this cohort appeared to have good access to insurance coverage; only 5% of men used Medicaid and only 4% were uninsured. Table 1 details the patient characteristics pertinent to this study.
    In this retrospective analysis of nearly 65 000 men who presented with advanced PC, we demonstrate that management at a high-volume facility (top quartile, >5.6 patients/yr) confers a significant survival advantage when compared with management at a facility in the lowest quartile (<1.8 patients/yr)...In total, these findings imply that there may be differences in the management of advanced PC between lower- and higher-volume TFs, which affect survival. These findings are consistent with data demonstrating survival advantages following management at high-volume TFs in other systemic/advanced disease states, such as multiple myeloma [10] and metastatic renal cell carcinoma
    Conclusions
    In this NCDB review of nearly 65 000 men who presented with advanced PC, management at a high-volume TF was significantly associated with better OS, with the effect on OS increasing continuously as a function of TF volume. This association remained true even after narrowing the cohort to select for more homogeneous groups with regard to disease and treatment characteristics. Although the precise underlying mechanism for this association is not known, these findings may be used by both clinicians and researchers to optimize treatment strategies for men with advanced PC
    [TF = Treatment Facility]

    See the Full Text for details.

  2. #2
    Experienced User
    Join Date
    Apr 2019
    Posts
    68
    Fascinating, would love to see this same study done for each stage. I wonder if it holds true all the way down?
    Wife Posting, Husband D.O.B. 1975
    2/2018 - routine physical PSA 15
    3/2018 - PSA 13
    4/2018 - PSA down to 11.6, free PSA, 18%
    6/2018 - PSA 10, free PSA 20%
    7/2018 - mp- MRI done, prostate volume =22cc, "inflammation consistent with prostititis"
    11/2018 - PSA 14, free PSA 11%,
    3/2019 - PSA 12, free PSA 17%, 2nd opinion on MRI = PI RADs 3 lesion
    4/2019 - Cognitive Fusion Biopsy
    5/12 cores positive
    4 Gleason 3+3
    1 Gleason 3+4 5% (Where PIRADs 3 lesion IDd)
    Decipher Biopsy score: .07 very low risk

    Bone scan negative
    MRI 6/19 said PIRADS 4 lesion, no definite EPE

    RRP 7/19 Final Path: pT3a
    G6 - 75-90%
    G7 (3+4) - 11-25%
    24mm tumor, 30% of prostate
    EPE+, BNI+, SM + (at bladder neck), LVI-, SVI -, PNI-, Nodes -
    Decipher Post RP score: .78, high risk

  3. #3
    Looks like the facilities with the highest volume of patients might get an even higher volume of advanced PCa patients when this report gets out.
    History: age 53 It took 3 biopsies (34 cores) to find 2 cores 4+4 Gleason 8
    Lap RP at MSKCC Apr 2004, age 54 All neg margins, nodes & structures. (T2a).
    Post RP PSA: <.1 until Feb, 08 (46 mos) PSA 0.1 - I then got sensitive tests -> 2008: Feb 0.06,
    May-08 0.09 - Jun-08 0.10, - Aug-08 0.10, - Nov-08 0.15
    SRT Dec-2008 ---Post SRT PSA 2009, Feb-09 0.10, May-09 0.09, Aug-09 0.06, Dec-09 .04, - 2010 Mar-09 0.04, 2011 .02, 2012 .02,
    STARTED UP Feb 2014-0.06, Jul-2015 0.10, Oct-2015 0.10, Feb-2016 0.15, Jun-2016 0.17, Dec-2016 0.25, Jan-2019 0.74, Jun -2019 0.72
    Aug 2018 Auximin scan - nothing
    Had an inflatable penile implant 2018 for ED. Best decision ever https://www.peyroniesforum.net/index...oard,56.0.html

  4. #4
    It seems logical that with advanced PCa, you want a team with diverse subspecialties, who confer, have up-to-date knowledge of recent and ongoing trials (e.g. interim reports), have experience with patients with your specific cancers type, presentation, genomics, etc. and know the outcomes at their institution with treatment A vs treatment B...

    Djin
    Last edited by DjinTonic; 07-23-2019 at 03:04 AM.

  5. #5
    I currently live about 4 hours from Memorial Sloan-Kettering Cancer Center and just a little closer to Johns Hopkin. I have had an Axumin scan right in the town I live in since our local hospital system and my urologist group is associated with the University Pittsburgh Medical Center. It is just a case that UPMC just bought out our distant site but it has seemed to elevate some of the services they provide.

    It makes me wonder about the value of driving 4 hours one direction or the other. While I like my urologist because he spends a lot of time with his patients, I have always gotten vibes from that practice that they don't like people getting second opinions, etc. I got a very cold reception when I went to MSKCC for my surgery 15 years ago. The problem is they are the only urological group in the county. The next closest one is about25 miles away. I know nothing about them and it is uncertain if they are even taking new patients.
    History: age 53 It took 3 biopsies (34 cores) to find 2 cores 4+4 Gleason 8
    Lap RP at MSKCC Apr 2004, age 54 All neg margins, nodes & structures. (T2a).
    Post RP PSA: <.1 until Feb, 08 (46 mos) PSA 0.1 - I then got sensitive tests -> 2008: Feb 0.06,
    May-08 0.09 - Jun-08 0.10, - Aug-08 0.10, - Nov-08 0.15
    SRT Dec-2008 ---Post SRT PSA 2009, Feb-09 0.10, May-09 0.09, Aug-09 0.06, Dec-09 .04, - 2010 Mar-09 0.04, 2011 .02, 2012 .02,
    STARTED UP Feb 2014-0.06, Jul-2015 0.10, Oct-2015 0.10, Feb-2016 0.15, Jun-2016 0.17, Dec-2016 0.25, Jan-2019 0.74, Jun -2019 0.72
    Aug 2018 Auximin scan - nothing
    Had an inflatable penile implant 2018 for ED. Best decision ever https://www.peyroniesforum.net/index...oard,56.0.html

  6. #6
    Top User
    Join Date
    Aug 2016
    Posts
    1,709
    I've practised solo and in a larger group of diverse peers with supportive and complimentary talents. The larger group is more challenging, educational, competitive, enjoyable, and is producing my best work. I am mentoring and being mentored. The larger multi service team attracts more challenging work and demanding clients.

    I'm certain it has its own issues, but all things being equal it is an inherently more inspiring model.
    Last edited by Another; 07-23-2019 at 01:38 AM.

  7. #7
    Quote Originally Posted by Another View Post
    I've practised solo and in a larger group of diverse peers with supportive and complimentary talents. The larger group is more challenging, educational, competitive, enjoyable, and is producing my best work. I am mentoring and being mentored. The larger multi service team attracts more challenging work and demanding clients.

    I'm certain it has its own issues, but all things being equal it is an inherently more inspiring model.
    Great points and well said!
    History: age 53 It took 3 biopsies (34 cores) to find 2 cores 4+4 Gleason 8
    Lap RP at MSKCC Apr 2004, age 54 All neg margins, nodes & structures. (T2a).
    Post RP PSA: <.1 until Feb, 08 (46 mos) PSA 0.1 - I then got sensitive tests -> 2008: Feb 0.06,
    May-08 0.09 - Jun-08 0.10, - Aug-08 0.10, - Nov-08 0.15
    SRT Dec-2008 ---Post SRT PSA 2009, Feb-09 0.10, May-09 0.09, Aug-09 0.06, Dec-09 .04, - 2010 Mar-09 0.04, 2011 .02, 2012 .02,
    STARTED UP Feb 2014-0.06, Jul-2015 0.10, Oct-2015 0.10, Feb-2016 0.15, Jun-2016 0.17, Dec-2016 0.25, Jan-2019 0.74, Jun -2019 0.72
    Aug 2018 Auximin scan - nothing
    Had an inflatable penile implant 2018 for ED. Best decision ever https://www.peyroniesforum.net/index...oard,56.0.html

 

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