Introduction: Radical cystectomy is a complex surgery with better outcomes reported when performed at high-volume centers. This may lead to patients traveling farther for care. We examined the impact of travel distance on clinical outcomes. Methods: A total of 220 patients undergoing radical cystectomy from 2015-2021 were retrospectively reviewed. Distance traveled to the treatment center by patient zip codes was classified as <12.5 miles, 12.5-49.9 miles, and >= 50 miles. Multivariable logistic regression was used to assess complications, readmissions, 90-day mortality, and length of stay by distance traveled. Time to treatment based on distance traveled was compared. Results: A total of 220 patients underwent radical cystectomy with complete 90-day follow-up. Of the patients 38.6% (85/220) were readmitted; 62.5% (53/85) presented to the treatment center or were transferred. All patients readmitted to an outside hospital traveled >= 12.5 miles (P < .001). Patients with high-grade complications were likely to be transferred to the treatment center with only 23.7% (9/38) definitively managed by outside hospital. Patients traveling >12.5 miles with low-grade complications were more likely to be managed at an outside hospital (57.5%, P = .01). There was no difference in time to initiation of neoadjuvant chemotherapy (P = .99) or time to radical cystectomy following neoadjuvant chemotherapy (P = .23) by distance traveled. For 49 muscle-invasive bladder cancer patients proceeding directly to surgery without neoadjuvant chemotherapy, time from diagnosis to radical cystectomy was increased if traveling >12.5 miles (P = .04). Conclusions: Increased travel distance did not impact early postoperative outcomes. Distance traveled may impact access to care, such as time to surgery or location of readmission to the treatment center postoperatively.

Prostate cancer (PrCa) is one of the most genetically driven solid cancers with heritability estimates as high as 57%. African American men are at an increased risk of PrCa; however, current risk prediction models are based on European ancestry groups and may not be broadly applicable. In this study, we define an African ancestry group of 4,533 individuals to develop an African ancestry-specific PrCa polygenic risk score (PRState). We identified risk loci on chromosomes 3, 8, and 11 in the African ancestry group GWAS and constructed a polygenic risk score (PRS) from 10 African ancestry-specific PrCa risk SNPs, achieving an AUC of 0.61 [0.60-0.63] and 0.65 [0.64-0.67], when combined with age and family history. Performance dropped significantly when using ancestry-mismatched PRS models but remained comparable when using trans-ancestry models. Importantly, we validated the PRState score in the Million Veteran Program, demonstrating improved prediction of PrCa and metastatic PrCa in African American individuals. This study underscores the need for inclusion of individuals of African ancestry in gene variant discovery to optimize PRS.

Purpose: Medicaid expansion under the Patient Protection and Affordable Care Act occurred almost concurrently with 2012 U.S. Preventive Services Task Force recommendations against prostate specific antigen screening. Here the relative influence on prostate specific antigen screening rates by 2 concurrent and opposing system-level policy initiatives is investigated: improved access to care and change in clinical practice guidelines. Materials and Methods: Behavioral Risk Factor Surveillance System data from years 2012 to 2018 were analyzed for trends in self-reported prostate specific antigen screening and insurance coverage. Subanalyses included state Medicaid expansion status and respondent federal poverty level. Multivariable logistic regression was performed to evaluate factors associated with prostate specific antigen screening. Results: From 2012 to 2018 prostate specific antigen screening predominantly declined with a notable exception of an increase of 7.3% for men at <138% federal poverty level between 2011 and 2013 in early expansion states. Initial increases did not continue, and screening trends mirrored those of nonexpansion states by 2018. Notably, 2014 planned expansions states did not follow this trend with minimal change between 2015 and 2017 compared to declines in early expansion states and nonexpansion states (-0.4% vs -6.7% and -8.6%, respectively). Conclusions: Medicaid expansion was associated with increased rates of insured men at <138% federal poverty level from 2012 to 2018 in early expansion states. In this group, initial increases in prostate specific antigen screening were not durable and followed the trend of reduced screening seen across the United States. In planned expansions states the global drop in prostate specific antigen screening from 2016 to 2018 was offset in men at <138% federal poverty level by expanding access to care. Nonexpansion states showed a steady decline in prostate specific antigen screening rates. This suggests that policy such as U.S. Preventive Services Task Force recommendations against screening competes with and often outmatches access to care.

Introduction and objective: Research on the utility of meditative and mind-body (MB) practices has increased dramatically in the last two decades and both have been suggested as useful adjuncts in coping with stressors associated with cancer survivorship. There exists little data on use among genitourinary (GU) cancer survivors. This study seeks to describe meditative and MB utilization among GU cancer survivors. Methods: Analysis of data from the 2012 and 2017 National Health Interview Survey was conducted. Patients aged 40 and older reporting a history of any cancer diagnosis (including 3 GU cancers) were included in the analysis. We explored questions about meditative and MB practices in the past 12 months. Complex Samples Logistic regression was performed to compare the relationship between cancer status and use of these practices. Results: Self-reported meditative practices were more prevalent in 2017 (17%) than in 2012 (5%). Patients who self-reported a cancer diagnosis of any kind were significantly more likely to utilize meditative practices. Patients with kidney cancer were significantly more likely to meditate and trended towards higher MB utilization. In contrast, bladder cancer patients were less likely to meditate and use MB practices. Increases in meditation were greater than those seen for MB in all groups. Conclusions: Meditative and MB practices increased in prevalence between 2012 and 2017 with notable heterogeneity between cancer types. Given the potential benefit, more broad incorporation into survivorship programs may be warranted. Future work should explore the significance of this heterogeneity and the utility of these practices to patients with urologic malignancy. (C) 2020 Elsevier Inc. All rights reserved.

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety IV (MP58)1 Sep 2021MP58-16 RADICAL CYSTECTOMY WITH JUNIOR RESIDENTS: LONGER DAYS, EQUIVALENT OUTCOMES Joshua Linscott, Randie White, Stephen Ryan, Moritz Hansen, Jesse Sammon, and Matthew Hayn Joshua LinscottJoshua Linscott More articles by this author , Randie WhiteRandie White More articles by this author , Stephen RyanStephen Ryan More articles by this author , Moritz HansenMoritz Hansen More articles by this author , Jesse SammonJesse Sammon More articles by this author , and Matthew HaynMatthew Hayn More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002088.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) is known to be a highly morbid, complex, and technically challenging operation. At academic centers, the assistant is traditionally a chief or senior resident. Our institution has one urology resident per year and annually performs a total of 40-50 open or robotic radical cystectomies. This leads to junior residents (PGY2, PGY3) frequently participating as the primary assistant. Here we explore the impact of resident experience level on operative, hospital, and post-operative outcomes in RC. METHODS: A single institution, prospectively maintained database identified 159 consecutive patients who underwent open or robotic RC from 2015-2019. Resident involvement was recorded in 154 cases. Operative time, estimated blood loss (EBL), intraoperative transfusion, length of stay (LOS), in hospital complication, complications in 90d, readmission at 90d, and urinary diversion complications (eg uretero-ileal stricture) were compared between junior (PGY2 & PGY3) and senior (PGY4 & PGY5) residents. Patient demographics including age, sex, BMI, neoadjuvant chemotherapy, and ASA score were examined. Statistical analysis was performed with SPSS. RESULTS: Over a 5-year period, junior residents assisted in 53 of 154 cases (34%) where a resident was involved. The number of cases done by PGY2, PGY3, PGY4, & PGY5 residents was 6, 47, 44, and 57, respectively. The percentage of open versus robotic cases was similar. There were no differences in examined patient demographics between groups. Cases with junior residents took 29.1 min (CI 3.4-54.8, p=0.027) longer than when a senior resident was present. No other significant differences between the two groups were seen when comparing EBL, intraoperative transfusion, surgical margin status, LOS, in hospital complication, 90d complication, 90d readmission, or urinary diversion complication (Table 1). CONCLUSIONS: RC remains a challenging urologic operation demanding technical excellence. Our data suggests participation by junior residents increases the length of operation by ∼10% (29.1 min) but does not negatively impact patient outcomes. We propose this is explained by increased time required for teaching and oversight from the attending surgeon, which allows junior residents to participate in a complex surgery without increasing the risk to the patient. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e994-e994 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Linscott More articles by this author Randie White More articles by this author Stephen Ryan More articles by this author Moritz Hansen More articles by this author Jesse Sammon More articles by this author Matthew Hayn More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyProstate Cancer: Markers (MP60)1 Sep 2021MP60-06 PROSTATE: INCORPORATING GENETIC ANCESTRY IN PROSTATE CANCER RISK SCORES FOR MEN OF AFRICAN DESCENT Joshua Linscott, Meghana Pagadala, Hannah Carter, Matthew Hayn, Moritz Hansen, Jesse Sammon, Karim Kader, and Stephen Ryan Joshua LinscottJoshua Linscott More articles by this author , Meghana PagadalaMeghana Pagadala More articles by this author , Hannah CarterHannah Carter More articles by this author , Matthew HaynMatthew Hayn More articles by this author , Moritz HansenMoritz Hansen More articles by this author , Jesse SammonJesse Sammon More articles by this author , Karim KaderKarim Kader More articles by this author , and Stephen RyanStephen Ryan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002095.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostate cancer (PrCa) is the most heritable of the solid organ malignancies. In addition, incidence and aggressive phenotypes are higher in African American men. Prior research into genetic heritability has focused on ancestry as defined by the patient. We explored ancestral genetic backgrounds with forensic genetic tools to define and develop a polygenic risk score (PRS) in African Americans. METHODS: Single nucleotide polymorphisms (SNPs) were imputed from a PrCa case-control study of >99,000 men (ELLIPSE) using the Michigan Imputation Server, 1000 Genomes Project, Eaglev2.3. Ancestral likelihood ratios were calculated by Forensic Research Reference on Genetics (FROG)-kb based on a previously described 55-SNP panel and define genetically separate African and European cohorts. GWAS was performed to identify PrCa risk SNPs and PRSice 2.3.1 to develop a PRS. An 80:20 split training:testing groups was used with AUC and ROC analysis. RESULTS: FROG-kb identified 4,507 and 5,334 individuals of African and European ancestry, respectively (Figure 1). In the African group, 6 SNPs reached significance, 1 on chromosome 1, 4 on chromosome 8, and 1 on chromosome 11. Four SNPs unique to African ancestry, were used to create a PRS. Individually, family history (FH), age, and PRS achieved AUCs of 0.56, 0.54, and 0.60 respectively. Combined PRS, FH, and Age improved AUC to 0.64 (Figure 2). CONCLUSIONS: A 55-SNP panel identified genetic ancestral groups for GWAS analysis, which defined 4 PrCa associated SNPs specific to African genetic inheritance. The resulting PRS predicted PrCa better than FH and Age in African American men. A combined model performs similar to previously published studies in European cohorts. Here we have achieved comparable AUC using only 4 SNPs, in a group at higher risk for aggressive PrCa. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1043-e1043 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Linscott More articles by this author Meghana Pagadala More articles by this author Hannah Carter More articles by this author Matthew Hayn More articles by this author Moritz Hansen More articles by this author Jesse Sammon More articles by this author Karim Kader More articles by this author Stephen Ryan More articles by this author Expand All Advertisement Loading ...

INTRODUCTION AND OBJECTIVE: A proportion of the population utilise healthcare services at a higher rate compared to the general population, thereby costing a disproportionate amount of resources. We aimed to investigate urology patients frequently attending our hospital with a view to transform our services, thus improving their care and reducing attendances. METHODS: A locally approved prospective database was implemented to collate all emergency admissions presenting to our urology department over 15 years. Patients with fi ve or more atten-dances within eight years were included for analysis. Data on length of stay, reason for admission, co-morbidities and management were collected. RESULTS: During the 15-year period, 15611 patients were recorded in the database. Of these, 110 had recurrent attendances, contributing to 642 visits in total. The most common reasons for reattendance were catheter related issues (19.5%), haematuria (15.1%) and urinary tract stones (11.7%). Median length of stay was 1 (IQR 0-3), 3 (2-7) and 2 days (1-3.5) for catheter related issues, haematuria and urinary tract stones respectively. The biggest contributor for surgical management were urinary tract stones n [ 24 (19.4%). CONCLUSIONS: The key issues identi fi ed in this study informs the next stage of this quality improvement project. The view is to provide integrated multidisciplinary care to reduce reattendances by developing targeted pathways and services with community and allied healthcare professionals. If successfully implemented, these interventions may reduce admissions and improve the overall patient care and health economy.

INTRODUCTION AND OBJECTIVE: Multiparametric MRI (mpMRI) and fusion biopsy technology has allowed for more accurate diagnosis of clinically significant prostate cancer (PCa) while helping to limit the overdiagnosis of non-significant disease. Little data exists, however, about the feasibility and success of implementation outside of large academic centers. This study sought to evaluate fusion biopsy adoption at Maine Medical Center for improvement over time and to discover meaningful areas for improvement. METHODS: Starting in 2016 data was collected for patients undergoing mpMRI at Maine Medical Center and subsequent biopsy with the Phillips Uronav system. We also collected urology specific and general demographic information. We analyzed this data with special focus on the probability of cancer detection (PCD) of PI-RADS 3, 4, 5 lesions, as well as the percentage of patients who had negative targeted biopsies but PCa on 12-Core biopsy (our “false negative” rate). RESULTS: Data from 224 patients was analyzed (179 underwent both fusion and 12-core biopsy, 10%, 52%, 37% PI-RADS 3, 4, 5 respectively). 49% underwent MRI as part of active surveillance protocol. Our overall PCD increased yearly, from 39% in 2016 to 67% in 2019. Most importantly, the PCD of PI-RADS 5 lesions has increased, from 54% in 2016 to 100% in 2019. Our overall “false negative” rate was 50%, our “false negative” rate for clinically significant disease (≥ Gleason 3+4=7) was 24.6% (range 11%-35% annually). CONCLUSIONS: Our findings highlight the significant institutional learning curve associated with implementation of a fusion biopsy program at a large regional medical center. Our institution did not achieve desired outcomes immediately, but our results improved consistently over the study period. These outcomes highlight the importance of a rigorous iterative approach to quality improvement when implementing a fusion biopsy program.Source of Funding: None

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making I (MP02)1 Apr 2020MP02-06 CAUSES FOR REFERRAL DELAY IN PATIENTS REQUIRING CYSTECTOMY AT A TERTIARY CARE CENTER Joshua Linscott*, William Daly, Tracy Robbins, Lisa Beaule, Matthew Hayn, Moritz Hansen, Jesse Sammon, and Stephen Ryan Joshua Linscott*Joshua Linscott* More articles by this author , William DalyWilliam Daly More articles by this author , Tracy RobbinsTracy Robbins More articles by this author , Lisa BeauleLisa Beaule More articles by this author , Matthew HaynMatthew Hayn More articles by this author , Moritz HansenMoritz Hansen More articles by this author , Jesse SammonJesse Sammon More articles by this author , and Stephen RyanStephen Ryan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000816.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Delays in treating bladder cancer are an unintentional consequence of regionally centralizing cystectomy care. Our prior work identified barriers to timely cystectomy and led to development of an independent nurse navigator system to mitigate delays. The aim was for all patients to receive treatment within 90 days of diagnosis. Here, we perform follow-up analysis to determine the impact of nurse navigation and identify target areas for further improvement. METHODS: Patients requiring cystectomy for bladder cancer at a tertiary care facility were identified by retrospective review. Dates were recorded for (1) procedure prompting cystectomy, (2) referral to cystectomy provider, (3) consultation, and (4) receipt of treatment (neoadjuvant chemotherapy or cystectomy). Nurse navigation was instituted at the time of consultation. Delay was defined as >90 days from procedure to treatment. Travel time was mapped as minutes in drive time from patient home to facility. Intervening milestones to care were analyzed based on first 10 records, power analysis was estimated (n=50). Wilcoxon analysis compared patient related (travel time) and provider related factors (days to referral). RESULTS: Of the 53 patients reviewed, 18/18 (100%) internal and 30/35 (86%) external regional referrals were treated within 90 days. Time from bladder procedure to cystectomy consultation was longer for external referrals compared to internal referrals [Median (Interquartile Range): 21 days (IQR 17-44) vs. 13 days (IQR 7 – 21), p=<0.001]. Time from procedure to referral order was longer in the external group (13 days, IQR 6-26) compared to the internal group (3 days, IQR 3-4). Interestingly, patients in the upper quartiles of referral delay had shorter travel times to the treatment facility [≥13 days: 40 mins (IQR 31-52)] compared to those referred earlier [<13days: 74 mins (IQR 51-99), p=<0.002]. CONCLUSIONS: Nurse navigation for cystectomy patients resulted in high levels of treatment within 90 days. Patients with external referrals were more likely to experience delays, and notably, delays were more likely to happen in patients living closer to the treatment facility. We suggest nurse navigation earlier in care to help address structural, political, and cultural causes of delays. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e13-e13 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Linscott* More articles by this author William Daly More articles by this author Tracy Robbins More articles by this author Lisa Beaule More articles by this author Matthew Hayn More articles by this author Moritz Hansen More articles by this author Jesse Sammon More articles by this author Stephen Ryan More articles by this author Expand All Advertisement PDF downloadLoading ...

PURPOSE:Implementation of survivorship care plans has been emphasized as a key component to improving care for cancer survivors. Our objective was to determine the prevalence of survivorship care plan receipt for survivors of genitourinary malignancy including kidney, prostate and bladder cancer, and evaluate whether receipt was associated with a measurable health benefit. MATERIALS AND METHODS:Data from the Behavioral Risk Factor Surveillance System Cancer Survivorship modules in 2012, 2014, 2016 and 2017 were analyzed. The proportion of patients with bladder, kidney or prostate cancer receiving a survivorship care plan was calculated. Complex samples multivariable logistic regressions were performed to determine the association of survivorship care plan receipt with sociodemographic variables, and assess the relationship between survivorship care plan receipt and self-reported health status (general, physical and mental). RESULTS:Survivorship care plan distribution increased from 27.5% in 2012 to 39.5% in 2017. Patients with low income, less formal education and extremes of age were less likely to receive a survivorship care plan. Those receiving a survivorship care plan were less likely to report poor physical health (OR 0.70, CI 0.52-0.96, p=0.026). Subanalysis showed a similar result for physical health of patients with prostate cancer (OR 0.68, CI 0.48-0.96, p=0.030) and general health of patients with kidney cancer (OR 0.37, CI 0.19-0.75, p=0.006). CONCLUSIONS:Distribution of survivorship care plans to genitourinary malignancy survivors has increased since 2012 in response to advocacy from national organizations. Nonetheless, utilization is low and there is heterogeneity in the populations likely to receive a survivorship care plan. There is a measurable association between survivorship care plans and improved health status but further study is needed to determine causality.

Background Current guidelines endorse shared decision making (SDM) for prostate‐specific antigen (PSA) screening. The relationship between a patient's health literacy (HL) and SDM remains unclear. In the current study, the authors sought to identify the impact of HL on the rates of PSA screening and on the relationship between HL and SDM following the 2012 US Preventive Services Task Force recommendations against PSA screening. Methods Using data from the 2016 Behavioral Risk Factor Surveillance System, the authors examined PSA screening in the 13 states that administered the optional “Health Literacy” module. Men aged ≥50 years were examined. Complex samples multivariable logistic regression models were computed to assess the odds of undergoing PSA screening. The interactions between HL and SDM were also examined. Results A weighted sample of 12.249 million men with a rate of PSA screening of 33.4% were identified. Approximately one‐third self‐identified as having optimal HL. Rates of PSA screening were found to be highest amongst the highest HL group (42.2%). Being in this group was a significant predictor of undergoing PSA screening (odds ratio, 1.214; 95% confidence interval, 1.051‐1.403). There was a significant interaction observed between HL and SDM ( P for interaction, <.001) such that higher HL was associated with a lower likelihood of undergoing PSA screening when SDM was present. Conclusions In the uncertain environment of multiple contradictory screening guidelines, men who reported higher levels of HL were found to have higher levels of screening. The authors demonstrated that increased HL may reduce the screening‐promoting effect of SDM. These findings highlight the dynamic interplay between HL and SDM that should inform the creation and promulgation of SDM guidelines, specifically when considering patients with low HL.

A prostate cancer (CaP) patient with nonmetastatic but clinical positive lymph nodes (cN+) represents a difficult clinical scenario. We compare overall survival (OS) between cN+ men that underwent radical prostatectomy (RP) and were found to have negative node status (pN) with those found to have positive nodal status (pN+), and assess predictors of discordant nodal status. We queried the National Cancer Data Base between 2004 and 2015 for patients that were cT1-3 cN+ cM0 CaP treated with RP. Patients with 0 nodes, cT4, or cM1 disease were excluded. We compared groups based on pathologic nodal status: Discordant (cN+ -> pN) & Concordant (cN+ -> pN+). Kaplan Meier estimations were used to compare OS. Logistic regression was used to determine possible predictors of nodal status. We find that of 6470 cN+ patients, 1,367 (21.1%) underwent RP, 866 (13.4%) had confirmed nodal status. Discordant status was found in 159 (18.4%) and concordant staging in 707 (81.6%). Differences exist in PSA at diagnosis (7.3 vs. 11.2), biopsy group, # of nodes examined (7 vs. 10), race, and Charlson index. Discordant staging had longer OS compared to Concordant staging (P = 0.007) and similar OS to a 3:1 matched cohort of high risk localized CaP patients used as reference (P = 0.46). Lower Gleason Score (GG1-3) was associated with an increased likelihood of discordant staging. Clinical nodal staging is associated with a substantial false positive rate. Discordant status had better OS than Concordant status and similar OS to matched patients with localized CaP. Clinical nodal staging may inappropriately lead to noncurative therapy in a substantial number of men with potentially curable disease.

INTRODUCTION AND OBJECTIVE: Multiparametric MRI (mpMRI) and fusion biopsy technology has allowed for more accurate diagnosis of clinically significant prostate cancer (PCa) while helping to limit the overdiagnosis of non-significant disease. Little data exists, however, about the feasibility and success of implementation outside of large academic centers. This study sought to evaluate fusion biopsy adoption at Maine Medical Center for improvement over time and to discover meaningful areas for improvement. METHODS: Starting in 2016 data was collected for patients undergoing mpMRI at Maine Medical Center and subsequent biopsy with the Phillips Uronav system. We also collected urology specific and general demographic information. We analyzed this data with special focus on the probability of cancer detection (PCD) of PI-RADS 3, 4, 5 lesions, as well as the percentage of patients who had negative targeted biopsies but PCa on 12-Core biopsy (our “false negative” rate). RESULTS: Data from 224 patients was analyzed (179 underwent both fusion and 12-core biopsy, 10%, 52%, 37% PI-RADS 3, 4, 5 respectively). 49% underwent MRI as part of active surveillance protocol. Our overall PCD increased yearly, from 39% in 2016 to 67% in 2019. Most importantly, the PCD of PI-RADS 5 lesions has increased, from 54% in 2016 to 100% in 2019. Our overall “false negative” rate was 50%, our “false negative” rate for clinically significant disease (≥ Gleason 3+4=7) was 24.6% (range 11%-35% annually). CONCLUSIONS: Our findings highlight the significant institutional learning curve associated with implementation of a fusion biopsy program at a large regional medical center. Our institution did not achieve desired outcomes immediately, but our results improved consistently over the study period. These outcomes highlight the importance of a rigorous iterative approach to quality improvement when implementing a fusion biopsy program.Source of Funding: None

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III (MP54)1 Apr 2019MP54-09 PROSTATECTOMY IN MEN WITH CLINICALLY POSITIVE LYMPH NODES: COMPARING SURVIVAL IN HIGH RISK CN-, PATHOLOGICALY NEGATIVE NODES, AND PATHOLOGICALLY POSITIVE NODAL DISEASE Stephen Ryan*, Fady Ghali, Moritz Hansen, Matthew Hayn, Jesse Sammon, Reith Sarkar, James Don Murphy, A. Karim Kader, and Brent Rose Stephen Ryan*Stephen Ryan* More articles by this author , Fady GhaliFady Ghali More articles by this author , Moritz HansenMoritz Hansen More articles by this author , Matthew HaynMatthew Hayn More articles by this author , Jesse SammonJesse Sammon More articles by this author , Reith SarkarReith Sarkar More articles by this author , James Don MurphyJames Don Murphy More articles by this author , A. Karim KaderA. Karim Kader More articles by this author , and Brent RoseBrent Rose More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000556686.46954.87AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: A prostate cancer (PCa) patient with non-metastatic but clinical positive lymph nodes (cN+) represents a difficult clinical scenario. Advocates for radical prostatectomy (RP) cite the high false positive rate of imaging (pN-) and overall survival (OS) benefit in men with a ≤2 positive lymph nodes (pN+). While others consider cN+ an omen of metastatic disease and advocate for systemic treatment without curative intent therapy. We compared OS after RP in cN- (High Risk), cN+/pN- (Discordant), and cN+/pN+ (Concordant). METHODS: The National Cancer Database was queried for all PCa patients from 2004-2013. Inclusion criteria were known age and PSA at diagnosis, biopsy Gleason score, TNM staging (cT1-3B, cN0/1, M0/X), margin, nodal status and primary treatment modality. cN+ was separated into two cohorts: pN- (Discordant) and pN+ (Concordant). RPs for High Risk PCa (cT3a/b or GS 8 or PSA >20) with cN- was used as a comparison. OS was analyzed with Kaplan Meier (KMA) and Cox proportional hazard model combing demographic, clinical, and pathological factors. RESULTS: 4944 cN+ men were identified (21.7% RP, 27.5% systemic therapy only). 794 RPs had completed records. Discordant and Concordant represented 18.8% and 81.2% with median follow-up 48 and 48.9 months, and 13 and 97 deaths, respectively. KMA pairwise OS of High Risk (n=35,502) verses Discordant was not significant (p=0.28) but was significant verses Concordant (p<0.001). There was no difference in OS on KMA between Discordant and Concordant (p=0.11). OS on Cox proportional hazard model, High Risk and Discordant had no observable difference (p=1.22). Concordant pathology had much worsened OS (HR 1.829, p<0.001), as well as Medicaid/Medicare patients (HR 1.344, p<0.001), biopsy Gleason score ≥8 (HR 1.350, p=0.0019), pathologic T stage (pT3a HR 1.567, pT3b 2.396, p<0.001), and positive surgical margin (HR 1.257, p<0.001). CONCLUSIONS: In a large cohort of nonmetastatic PCa patients with cN+ disease, >27% were treated with systemic therapy based on clinical staging, but 18.8% of cN+ RPs were incorrectly staged. There was no difference in OS between cN- High Risk patients and pathologic Discordant (cN+/pN-) men, and the much worse OS in men with pN+. Study is needed for a more accurate clinical staging tool to identify the pathologically discordant population. Source of Funding: None San Diego, CA; Portland, ME; San Diego, CA© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e787-e788 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stephen Ryan* More articles by this author Fady Ghali More articles by this author Moritz Hansen More articles by this author Matthew Hayn More articles by this author Jesse Sammon More articles by this author Reith Sarkar More articles by this author James Don Murphy More articles by this author A. Karim Kader More articles by this author Brent Rose More articles by this author Expand All Advertisement PDF downloadLoading ...

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making III (MP44)1 Apr 2019MP44-13 “I DON’T KNOW WHAT A NOMOGRAM IS”: A MIXED METHODS APPROACH TO THE CREATION OF A PATIENT DECISION AID FOR MEN WITH HIGH-RISK FEATURES POST PROSTATECTOMY Jesse Sammon*, Christina Gentile, Michael Kohut, Christopher Stockdale, Moritz Hansen, and Paul Han Jesse Sammon*Jesse Sammon* More articles by this author , Christina GentileChristina Gentile More articles by this author , Michael KohutMichael Kohut More articles by this author , Christopher StockdaleChristopher Stockdale More articles by this author , Moritz HansenMoritz Hansen More articles by this author , and Paul HanPaul Han More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000556256.95011.bdAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Three large multi-institution RCTs have demonstrated that for men with extracapsular extension, seminal vesicle involvement, and/or positive surgical margins, after radical prostatectomy, adjuvant radiotherapy (ART) may have a favorable impact on biochemical and local recurrence rates. However there is conflicting evidence concerning the effect of ART on cancer specific and overall survival. Given limitations of existing data, and the risk of treatment related side effects, the decision to pursue ART is patient preference-sensitive. METHODS: A multidisciplinary work-group (Urologists, Radiation Oncologists, Medical Oncologists, Physician Assistants, Nurse practitioners, Oncology nurses) created an evidence-based decision aid (DA), based on a review of available literature and guided by International Patient Decision Aid Society criteria, to inform patients of the risks, benefits, and uncertainties of ART vs. early salvage RT for men with high-risk features following RP. Alpha testing included readability, plain language assessment and 3 iterative waves of qualitative usability interviews with prostate cancer patients recruited from a large metropolitan Urology group practice (n=12). Three members of the study team conducted software-assisted coding and thematic analysis of transcribed interviews, focusing on participants’ reactions to the DA, points of confusion, and recommendations for improvement. Usability of the DA was measured using the NASA-TLX and system usability score. RESULTS: Prostate cancer patients reported favorable perceptions of the value of the prototype DA, but also identified several areas for improvement, including confusing terms and jargon. Patient feedback was used to iteratively revise the DA to maximize its understandability and usability. Patients also provided valuable input on their informational and emotional needs in dealing with prostate cancer. Quantitative measures suggested that the prototype DA had an acceptable level of usability. CONCLUSIONS: A new decision aid for men with high-risk features following RP for PCa, iteratively designed with patient input, shows promising evidence of understandability and usability. Further research will assess the effectiveness of the DA in improving shared decision making for this subset of prostate cancer patients. Source of Funding: MMC Institutional Mentored Research Grant Portland , ME© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e634-e634 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jesse Sammon* More articles by this author Christina Gentile More articles by this author Michael Kohut More articles by this author Christopher Stockdale More articles by this author Moritz Hansen More articles by this author Paul Han More articles by this author Expand All Advertisement PDF downloadLoading ...

327 Background: A prostate cancer (PCa) patient with non-metastatic but clinical positive lymph nodes (cN+) represents a difficult clinical scenario. We compared OS after RP in cN- (High Risk), cN+/pN- (Discordant), and cN+/pN+ (Concordant). Methods: The National Cancer Database was queried for all PCa patients from 2004-2013. Inclusion criteria were known age and PSA at diagnosis, biopsy Gleason score, TNM staging (cT1-3B, cN0/1, M0/X), margin, nodal status and primary treatment modality. cN+ was separated into two cohorts: pN- (Discordant) and pN+ (Concordant). RPs for High Risk PCa (cT3a/b or GS ≥ 8 or PSA > 20) with cN- was used as a comparison. OS was analyzed with Kaplan Meier (KMA) and Cox proportional hazard model combing demographic, clinical, and pathological factors. Results: 4944 cN+ men were identified (21.7% RP, 27.5% systemic therapy only). 794 RPs had completed records. Discordant and Concordant represented 18.8% and 81.2% with median follow-up 48 and 48.9 months, and 13 and 97 deaths, respectively. KMA pairwise OS of High Risk (n=35, 502) verses Discordant was not significant (p=0.28) but was significant verses Concordant (p < 0.001). There was no difference in OS on KMA between Discordant and Concordant (p=0.11). OS on Cox proportional hazard model, High Risk and Discordant had no observable difference (p=1.22). Concordant pathology had much worsened OS (HR 1.829, p < 0.001), as well as Medicaid/Medicare patients (HR 1.344, p < 0.001), biopsy Gleason score ≥ 8 (HR 1.350, p=0.0019), pathologic T stage (pT3a HR 1.567, pT3b 2.396, p < 0.001), and positive surgical margin (HR 1.257, p < 0.001). Conclusions: In a large cohort of nonmetastatic PCa patients with cN+ disease, > 27% were treated with systemic therapy based on clinical staging, but 18.8% of cN+ RPs were incorrectly staged. There was no difference in OS between cN- High Risk patients and pathologic Discordant (cN+/pN-) men, and the much worse OS in men with pN+. Study is needed for more accurate clinical staging tools to identify the pathologically discordant population.

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance I1 Apr 2018MP12-08 PATIENT NAVIGATION AND ITS ASSOCIATION WITH TREATMENT SELECTION FOR LOW-RISK PROSTATE CANCER Emily C. Serrell, Moritz Hansen, Andrew Perry, Melanie Feinberg, Tracy Robbins, Scot Remick, Lisa Beaule, Tom Kinkead, Paul K.J. Han, and Jesse D. Sammon Emily C. SerrellEmily C. Serrell More articles by this author , Moritz HansenMoritz Hansen More articles by this author , Andrew PerryAndrew Perry More articles by this author , Melanie FeinbergMelanie Feinberg More articles by this author , Tracy RobbinsTracy Robbins More articles by this author , Scot RemickScot Remick More articles by this author , Lisa BeauleLisa Beaule More articles by this author , Tom KinkeadTom Kinkead More articles by this author , Paul K.J. HanPaul K.J. Han More articles by this author , and Jesse D. SammonJesse D. Sammon More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.395AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Patient navigation has many theoretical and reported benefits in cancer care. In 2008 our multi-institution health system developed a navigation program to promote shared decision-making for treatment of prostate cancer. This was facilitated by an oncology nurse who educated patients and practiced independent of but in coordination with urology and radiation oncology. We hypothesized that navigation would increase utilization of active surveillance in men with low-risk disease. METHODS Data from 2009-2015 were collected from our multi-institutional tumor registry. Patients with unknown staging were excluded. A subset of patients with National Comprehensive Cancer Network (NCCN) very-low/ low-risk disease were extracted. Multivariable logistic regression analyses were performed to determine factors associated with initial treatment type, controlling for disease and patient characteristics. RESULTS Data from 1,533 patients with prostate cancer in 2009-2015 were reviewed, and 454 men had very-low or low-risk disease. In this group active surveillance increased from 20% in 2009 to 68% in 2015 (Figure). Following adjustment, patients were significantly more likely to choose active surveillance if they were navigated, treated later, treated by a low-volume surgeon, or never married (Table). Navigation was independently associated with active surveillance (Odds Ratio=8.0, 95% Confidence Interval 3.2-19.7). CONCLUSIONS Active surveillance as initial treatment for men with low-risk prostate cancer increased over the study period. Patient navigation was significantly associated with active surveillance. This may reflect increased decision support provided by the clinical patient navigator, who acts as an independent entity to facilitate consults between multiple disciplines, educate patients based on NCCN guidelines, and focus on shared decision making in treatment discussions. With this support, navigation may help to increase active surveillance for low-risk disease. More research is necessary to evaluate other outcomes. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e138 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Emily C. Serrell More articles by this author Moritz Hansen More articles by this author Andrew Perry More articles by this author Melanie Feinberg More articles by this author Tracy Robbins More articles by this author Scot Remick More articles by this author Lisa Beaule More articles by this author Tom Kinkead More articles by this author Paul K.J. Han More articles by this author Jesse D. Sammon More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

To evaluate factors associated with use of patient navigation in a prostate cancer population and identify whether navigation is associated with prolonged time to care. Cancer patient navigation has been shown to improve access to cancer screening, diagnosis, and treatment, but little is known about patient navigation in prostate cancer care.