PURPOSE:We sought to evaluate the real-world utility of adding the Cxbladder Triage test to microhematuria diagnostic workflow in an integrated health care system. METHODS:We conducted a retrospective matched cohort study of patients with microhematuria tested with Cxbladder Triage, a urine-based biomarker of mRNA targets and clinical factors to assess urothelial cancer risk. We matched untested controls based on age, encounter date, and Hematuria Risk Index score. The cohort was stratified by Cxbladder Triage result: low probability (<4.00, cystoscopy could be deferred) vs physician-directed protocol (≥4.00, cystoscopy recommended). We evaluated the use of cystoscopy, CT urograms, and new diagnoses of bladder cancer. RESULTS:We matched 3353 patients tested with Cxbladder Triage with 3353 controls according to AUA risk (15.7% AUA low risk for cases and controls, P = .362). Among 3353 tested patients, 2670 (79.6%) had low probability of cancer and were less likely to undergo cystoscopy (3.8% vs 46.5% controls, P < .001). Tested patients with elevated risk for cancer (n = 683) were more likely to undergo cystoscopy (73.4% vs 45.7% controls, P < .001). Similar patterns were seen for the CT urogram (7.5% vs 11.7% low probability; 19.5% vs 13.3% physician-directed protocol, both P < .001). Cancer detection was similar between both groups (0.3% tested vs 0.6% controls, P = .105) and between tested patients with elevated risk vs untested controls (1.5% physician-directed protocol vs 0.6% controls, P = .107). CONCLUSIONS:Cxbladder Triage testing decreases burden of cystoscopy and CT urogram use among patients with microhematuria. This test maintains similar cancer detection overall and among patients with microhematuria at greater risk for underlying malignancy.

INTRODUCTION:Kidney stone recurrence can be reduced by implementing AUA medical management guidelines. We assessed whether machine learning (ML) could identify patients at risk for symptomatic kidney stone recurrence events. METHODS:We retrospectively reviewed electronic health records with kidney stone diagnosis over a 16-year period (January 2008 to December 2023). Using historical data from a large integrated health system, we applied supervised ML to build a model that identifies patients at risk for symptomatic recurrence events within 12 months after an initial stone encounter with a urologist. The model used 952 candidate features drawn from both a clinician-curated set of kidney stone-specific factors and a general set of common diagnoses, laboratory results, medications, procedures, and utilization records were used as inputs to the model. RESULTS:Our model was tested and trained on data collected for 154,876 patients older than 16 years with urinary stone; 1,439,671 unique kidney stone encounters were attributable to this population. The algorithm was trained on 123,900 (80%) and tested on 30,976 (20%) patients. In the test set, the model predicted 1-year risk of symptomatic recurrence with an area under the receiver operating characteristic curve of 0.727. CONCLUSIONS:ML models can effectively discriminate between high and low risk of urinary stone recurrence events.

You have accessJournal of UrologyHealth Services Research: Value of Care: Cost and Outcomes I (PD08)1 May 2024PD08-04 COST EFFECTIVENESS OF SHARING CAPITAL MEDICAL EQUIPMENT IN UROLOGY Ronald K. Loo and Eugene Y. Rhee Ronald K. LooRonald K. Loo and Eugene Y. RheeEugene Y. Rhee View All Author Informationhttps://doi.org/10.1097/01.JU.0001008576.33217.96.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Advances in medical equipment continually improve health outcomes. However, investing in this technology can be expensive for healthcare organizations. We evaluated whether sharing capital medical equipment between facilities in a large healthcare network could optimize utilization while reducing costs and improving value. METHODS: The sharing network was comprised of 14 hospitals and 11 medical offices within the same health system in Southern California. We focused on 19 common types of urology equipment with prices >$40,000 and tracked the number of moves between lenders and borrowers, unique equipment moving, and associated case volumes by CPT code. We tabulated the cost savings from 2016-2022. Cost savings were defined in three categories 1) capital expenses 2) associated operational expenses and 3) rental expenses. Capital expense savings were reductions in purchases realized through improved utilization of new and existing equipment with sharing. Associated operational expenses were decreased storage, security, and maintenance costs as a direct result of reduced capital inventory. Rental expenses were calculated by tracking real reductions in historical rental volume. Lastly, expenses incurred through shared equipment were carefully tracked as offsets to cost savings. These expenses included logistics, transport, and wear and tear on equipment. Facilities participated in the sharing program in multiple ways. The first was through the capital request process. Facilities had the opportunity to fulfill their capital requests on an expedited timeline by combining their purchase with one or more facilities and sharing. In addition, cumulative ongoing rental expenses were used to target capital investment. The second was through emergent equipment needs. If there was broken equipment, add-on cases, or the need to run multiple rooms, facilities could request shared equipment through a hotline. Lastly, if a facility no longer needed equipment, those assets were made available to the network for permanent reallocation. RESULTS: From 2016-2022, sharing urology equipment achieved $10 million in savings, supporting more than 3,000 urology cases across 25 sites. We observed a 24% reduction in capital expenses and a 25% reduction in associated operational expenses during this time period. CONCLUSIONS: This study was the first to longitudinally assess financial outcomes from sharing capital medical equipment. As the pace of technological innovation accelerates and demand increases, process innovation can improve the value of care. Sharing capital medical equipment offers a framework for other healthcare organizations. Source of Funding: The program is funded by Kaiser Permanente in Southern California © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e174 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Ronald K. Loo More articles by this author Eugene Y. Rhee More articles by this author Expand All Advertisement PDF downloadLoading ...

SCOPE:Dietary isothiocyanate (ITC) exposure from cruciferous vegetable (CV) intake may improve non-muscle invasive bladder cancer (NMIBC) prognosis. This study aims to investigate whether genetic variations in key ITC-metabolizing/functioning genes modify the associations between dietary ITC exposure and NMIBC prognosis outcomes. METHODS AND RESULTS:In the Bladder Cancer Epidemiology, Wellness, and Lifestyle Study (Be-Well Study), a prospective cohort of 1472 incident NMIBC patients, dietary ITC exposure is assessed by self-reported CV intake and measured in plasma ITC-albumin adducts. Using Cox proportional hazards regression models, stratified by single nucleotide polymorphisms (SNPs) in nine key ITC-metabolizing/functioning genes, it is calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for recurrence and progression. The rs15561 in N-acetyltransferase 1 (NAT1) is alter the association between CV intake and progression risk. Multiple SNPs in nuclear factor E2-related factor 2 (NRF2) and nuclear factor kappa B (NFκB) are modify the associations between plasma ITC-albumin adduct level and progression risk (pint < 0.05). No significant association is observed with recurrence risk. Overall, >80% study participants are present with at least one protective genotype per gene, showing an average 65% reduction in progression risk with high dietary ITC exposure. CONCLUSION:Despite that genetic variations in ITC-metabolizing/functioning genes may modify the effect of dietary ITCs on NMIBC prognosis, dietary recommendation of CV consumption may help improve NMIBC survivorship.

PURPOSE:Nonmuscle-invasive bladder cancer (NMIBC) has high recurrence rates and is often treated with mitomycin C (MMC) and bacillus Calmette-Guérin (BCG). Their efficacy relies on phase 2 enzyme metabolism and immune response activation, respectively. Dietary isothiocyanates, phytochemicals in cruciferous vegetables, are phase 2 enzyme inducers and immunomodulators, and may impact treatment outcomes. We investigated the modifying effects of cruciferous vegetable and isothiocyanate intake on recurrence risk following MMC or BCG treatment. MATERIALS AND METHODS:Self-reported cruciferous vegetable intake, estimated isothiocyanate intake, and urinary isothiocyanate metabolites were collected from 1158 patients with incident NMIBC in the prospective Be-Well Study. Hazard ratios (HRs) and 95% CIs were calculated from Cox proportional hazards regression models for risk of first recurrences, and random effects Cox shared frailty models for multiple recurrences. RESULTS:Over median follow-up of 23 months, 343 (30%) recurrences occurred. Receipt of MMC and BCG was associated with decreased risks of first recurrence (MMC: HR = 0.58; 95% CI: 0.46-0.73; BCG: HR = 0.66; 95% CI: 0.49-0.88) and multiple recurrences (MMC: HR = 0.55; 95% CI: 0.44-0.68; BCG: HR = 0.72; 95% CI: 0.55-0.95). Patients receiving BCG and having high intake (>2.4 servings/mo), but not low intake, of raw cruciferous vegetables had reduced risk of recurrence (HR: 0.56; 95% CI: 0.36-0.86; P for interaction = .02) and multiple recurrences (HR: 0.51; 95% CI: 0.34-0.77; P for interaction < .001). The inverse association between MMC receipt and recurrence risk was not modified. CONCLUSIONS:For NMIBC patients who receive induction BCG, increasing consumption of raw cruciferous vegetables could be a promising strategy to attenuate recurrence risk.

Bladder cancer is primarily diagnosed as non-muscle-invasive bladder cancer (NMIBC), with high recurrence and progression rates. Environmental and occupational exposures to carcinogens are well-known risk factors for developing bladder cancer, yet their effects on prognosis remain unknown. In the Be-Well Study, a population-based prospective cohort study of 1472 Kaiser Permanente patients newly diagnosed with NMIBC in California from 2015 to 2019, we examined history of environmental and occupational exposures in relation to tumor stage and grade at initial diagnosis by multivariable logistic regression, and subsequent recurrence and progression by Cox proportional hazards regression. Exposure to environmental and occupational carcinogens was significantly associated with increased risk of progression (hazard ratio (HR) = 1.79; 95% CI, 1.04-3.09), specifically with increased progression to muscle-invasive disease (HR = 2.28; 95% CI, 1.16-4.50). Exposures to asbestos and arsenic were associated with increased odds of advanced stage at diagnosis (asbestos: odds ratio (OR) = 1.43 [95% CI, 1.11-1.84]; arsenic: OR = 1.27 [95% CI, 1.01-1.63]), and formaldehyde exposure was associated with increased risk of recurrence (HR = 1.38; 95% CI, 1.12-1.69). Our findings suggest that considering a patient's history of these exposures may benefit current risk stratification systems in better tailoring clinical care and improving prognosis among patients with NMIBC.

Background: High recurrence and progression rates are major clinical challenges for non-muscle-invasive bladder cancer (NMIBC). Dietary iso-thiocyanates (ITCs), phytochemicals primarily from cruciferous vegetables (CV), show strong anticancer activities in preclinical BC models, yet their effect on NMIBC prognosis remains unknown.Objectives: This study aimed to investigate the associations of dietary ITC exposure at diagnosis with NMIBC recurrence and progression. Methods: The study analyzed 1143 participants from the Be-Well study, a prospective cohort of newly diagnosed NMIBC cases in 2015-2019 with no prior history of BC. Dietary ITC exposure was indicated by self-reported CV intake, estimated ITC intake, urinary metabolites, and plasma ITC-albumin adducts. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for recurrence and progression, and unconditional logistic regression models were used to calculate odds ratios (ORs) and 95% CIs for delayed and multiple recurrence.Results: Over a mean follow-up of 25 mo, 347 (30%) developed recurrence and 77 (6.7%) had disease progression. Despite no significant associations with the overall risk of recurrence, urinary ITC metabolites (OR: 1.96; 95% CI: 1.01, 4.43) and dietary ITC intake (OR: 2.13; 95% CI: 1.03, 4.50) were associated with late recurrence after 12-mo postdiagnosis compared with before 12-mo postdiagnosis. Raw CV intake was associated with reduced odds of having >= 2 recurrences compared with having one (OR: 0.34; 95% CI: 0.16, 0.68). Higher plasma concentrations of ITC-albumin adducts were associated with a reduced risk of progression, including progression to muscle-invasive disease (for benzyl ITC, HR: 0.40; 95% CI: 0.17, 0.93; for phenethyl ITC, HR: 0.40; 95% CI: 0.19, 0.86).Conclusions: Our findings indicate the possible beneficial role of dietary ITCs in NMIBC prognosis. Given the compelling preclinical evidence, increasing dietary ITC exposure with CV intake could be a promising strategy to attenuate recurrence and progression risks in patients with NMIBC.

Importance Tobacco smoking is an established risk factor associated with bladder cancer, yet its impact on bladder cancer prognosis is unclear. Objective To examine associations of use of tobacco (cigarettes, pipes, and cigars), e-cigarettes, and marijuana with risk of recurrence and progression of non–muscle-invasive bladder cancer (NMIBC) and to explore use of smoking cessation interventions. Design, Setting, and Participants The Be-Well Study is a prospective cohort study of patients with NMIBC diagnosed from 2015 to 2019 and followed-up for 26.4 months in the Kaiser Permanente Northern and Southern California integrated health care system. Eligibility criteria were age at least 21 years, first NMIBC diagnosis (stages Ta, Tis, or T1), alive, and not in hospice care. Exclusion criteria were previous diagnosis of bladder cancer or other cancer diagnoses within 1 year prior to or concurrent with NMIBC diagnosis. Data were analyzed from April 1 to October 4, 2022. Exposures Use of cigarettes, pipes, cigars, e-cigarettes, and marijuana was reported in the baseline interview. Use of smoking cessation interventions (counseling and medications) was derived from electronic health records. Main Outcomes and Measures Hazard ratios (HRs) and 95% CIs of recurrence and progression of bladder cancer were estimated by multivariable Cox proportional hazards regression. Results A total of 1472 patients (mean [SD] age at diagnosis, 70.2 [10.8%] years; 1129 [76.7%] male patients) with NMIBC were enrolled at a mean (SD) of 2.3 (1.3) months after diagnosis, including 874 patients (59.4%) who were former smokers and 111 patients (7.5%) who were current cigarette smokers; 67 patients (13.7%) smoked pipes and/or cigars only, 65 patients (4.4%) used e-cigarettes, 363 patients (24.7%) used marijuana. Longer cigarette smoking duration and more pack-years were associated with higher risk of recurrence in a dose-dependent manner, with the highest risks for patients who had smoked for 40 or more years (HR, 2.36; 95% CI, 1.43-3.91) or 40 or more pack-years (HR, 1.97; 95% CI, 1.32-2.95). There was no association of having ever smoked, being a former or current cigarette smoker, and years since quit smoking with recurrence risk. No associations with pipes, cigars, e-cigarettes, or marijuana were found. Of 102 patients offered a smoking cessation intervention, 57 (53.8%) received an interventions after diagnosis, with female patients more likely than male patients to engage in such interventions (23 of 30 female patients [76.7%] vs 34 of 76 male patients [44.7%]; P = .003). Conclusions and Relevance These findings suggest that longer duration and more pack-years of cigarette smoking were associated with higher risk of NMIBC recurrence. Cigarette smoking remains a critical exposure before and after diagnosis in survivors of NMIBC.

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation II (MP54)1 Sep 2021MP54-20 APPLICATION OF ARTIFICIAL INTELLIGENCE TO IMPROVE PATIENT SELECTION FOR THE KAISER PERMANENTE HEALTHY STONE POPULATION MANAGEMENT PROGRAM Reza Goharderakhshan, Nikhil Crain, Drew Clausen, Dennis Walsh, Gary Chien, and Ronald Loo Reza GoharderakhshanReza Goharderakhshan More articles by this author , Nikhil CrainNikhil Crain More articles by this author , Drew ClausenDrew Clausen More articles by this author , Dennis WalshDennis Walsh More articles by this author , Gary ChienGary Chien More articles by this author , and Ronald LooRonald Loo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002084.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Healthy Stone (HS) program follows the AUA kidney stone medical management guidelines with the goals of reducing both stone recurrence and additional treatments in high risk patients. We previously presented on the predictive accuracy of a machine learning algorithm to assess the risk of stone recurrence. This algorithm was used to risk stratify eligible patients diagnosed with a kidney stone who participated in the HS program vs. those who did not. We examined the impact of our Healthy Stone program for each risk category over a three year follow up period. METHODS: The predictive algorithm was retrospectively applied to two groups of patients who remained within the Kaiser Permanente health plan with three year follow up data. The treatment group (N=537) included patients enrolled in the HS program. The control group (N=1984) included patients diagnosed with kidney stones in the same period as the treatment group who did not enroll in the HS program. The kidney stone recurrence risk was computed for all patients. They were then stratified into four risk groups (lowest, low, moderate, high). The volume of kidney stone related surgical procedures and Emergency Department (ED) encounters was examined for both groups. RESULTS: The AI algorithm identified 242 (45%) high risk patients in the treatment group, and 397(20%) high risk patients in the control group. In the high-risk group, there was a reduction in ED visits (36%) (Figure 1) and surgical procedures (44%) (Figure 2) for patients managed by the HS program over those not enrolled in the program. In the lower risk groups, the impact of the HS program on ED visits and surgeries was less significant. CONCLUSIONS: Our study demonstrates a significant reduction in recurrent stone treatment encounters for high-risk patients who were enrolled in the Healthy Stone program vs. those who were not. Using an AI algorithm may augment our clinical decision making for patients who are most likely to benefit from a prevention program and therefore improve resource utilization. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e957-e957 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Reza Goharderakhshan More articles by this author Nikhil Crain More articles by this author Drew Clausen More articles by this author Dennis Walsh More articles by this author Gary Chien More articles by this author Ronald Loo More articles by this author Expand All Advertisement Loading ...

INTRODUCTIONNephrolithiasis is a chronic condition with 5 to 10-year recurrence rates as high as 50%. Stone recurrence can be reduced by implementing American Urological Association kidney stone medical management guidelines, which recommend additional metabolic testing for high risk, recurrent and interested first-time stone formers. However, clinician adherence to guidelines is variable, and patient compliance with preventive evaluations is low. We evaluated our kidney stone population management program's role in patient compliance with completing American Urological Association metabolic studies. We assessed the program's impact on office encounters, operating room procedures and emergency department visits for known high risk kidney stone patients.METHODSA retrospective review of electronic medical records between 2009 and 2017 identified 4,029 kidney stone patients. A total of 873 patients were at high risk for kidney stone recurrence. In 2013, we established a population management program in which high risk patients were referred and followed by a nurse case manager. Patients were contacted by email or telephone if metabolic serum and urine collections were incomplete. Office, operating room and emergency department visits were compared before and after the program's implementation.RESULTSMetabolic evaluation orders increased from 17% to 35% in our institution's urology department. Patient compliance with recommended studies improved from <10% to 82%, and reductions in office visits by 48%, surgical procedures by 38% and emergency department encounters by 40% were observed.CONCLUSIONSOur program improved patient compliance with American Urological Association recommended studies for high risk kidney stone patients. Reductions in stone events may have been due to our program but require further study in the future.

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation III (PD35)1 Apr 2020PD35-02 APPLICATION OF ARTIFICIAL INTELLIGENCE TOOL TO IDENTIFY PATIENTS AT HIGH RISK FOR SYMPTOMATIC KIDNEY STONE RECURRENCE Reza Goharderakhshan*, Drew Clausen, Oleg Shvarts, Michelle West, and Ronald Loo Reza Goharderakhshan*Reza Goharderakhshan* More articles by this author , Drew ClausenDrew Clausen More articles by this author , Oleg ShvartsOleg Shvarts More articles by this author , Michelle WestMichelle West More articles by this author , and Ronald LooRonald Loo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000906.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephrolithiasis is a chronic disease and stone recurrence rates can be reduced by implementing the AUA kidney stone medical management guidelines. It is recommended that clinicians should perform additional metabolic testing in high-risk or interested first-time stone formers and recurrent stone formers. This investigation assessed the ability of artificial intelligence to identify patients who are at high risk for symptomatic kidney stone recurrence and predict when a patient will recur. METHODS: A 10 year period (January 2008 to December 2018) retrospective review of electronic medical records of patients with diagnosis of kidney stones. We used machine learning and developed two models to identify symptomatic stone recurrence: 1. Which patients are at risk of symptomatic recurrence 2. When will these patients present with a symptomatic recurrence. Symptomatic stone recurrence was defined as any kidney stone encounter occurring more than 90 days after initial diagnosis that involved an Emergency Department visit, admission, or surgery. The algorithm was developed on patients with kidney stone diagnosis encounters. The algorithm was validated on members with kidney stones between January 2019 to June 2019. RESULTS: A total of 108,000 patients were identified with the diagnosis of kidney stones. The algorithm was applied to 516,000 kidney stone encounters attributed to this cohort. The algorithm was validated on 1,123 patients with kidney stones between January 2019 to June 2019. The models consider 655 attributes that were identified through data analysis and clinician input. The models can predict which patients are at risk for symptomatic kidney stone recurrence with AUCROC = 0.83 (see Figure 1). The time to recurrence model prioritized patients within the high risk group. C-statistic value is 0.79. CONCLUSIONS: Artificial Intelligence can analyze large and complex data sets and improve clinicians ability to triage patients into low, moderate and high-risk groups. This will improve patient counseling and may improve quality of care by implementing preventive measures on high risk patients and reduce metabolic workup, invasive endoscopy and ionizing radiation exposure for low risk kidney stone patients. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e717-e718 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Reza Goharderakhshan* More articles by this author Drew Clausen More articles by this author Oleg Shvarts More articles by this author Michelle West More articles by this author Ronald Loo More articles by this author Expand All Advertisement PDF downloadLoading ...

Disparities in stage at diagnosis for bladder cancer were observed by race/ethnicity and gender within a large, diverse integrated delivery system. As health care coverage within an equal-access system did not eliminate previously reported disparities, research is needed to identify etiologic factors or aspects of care delivery that may contribute to disparities in stage at diagnosis. Background: Disparities in bladder cancer survival by race/ethnicity and gender are likely related to differences in diagnosis. We assessed disparities in stage at diagnosis and potential contributing factors within a large, integrated delivery system. Patients and Methods: We conducted a retrospective cohort study of 7244 patients with bladder cancer age >= 21 years diagnosed from January 2001 to June 2015 within Kaiser Permanente Southern California. Bivariate analyses compared stage at diagnosis - as well as comorbidities, health plan membership length, and health care utilization prior to diagnosis - by race/ethnicity, gender, and age. Multivariable generalized linear mixed models with urologist as a random effect were used to estimate odds ratios (ORs) and 95% confidence intervals (Cis) for diagnosis of muscle-invasive bladder cancer (MIBC) versus non-muscle-invasive bladder cancer. Results: In multivariable analyses, stage at diagnosis varied significantly by race/ethnicity (P < .001). Non-Hispanic black patients had significantly higher odds of being diagnosed with MIBC than non-Hispanic white patients (OR, 1.33; 95% CI, 1.05-1.67), whereas Asian patients had significantly lower odds (OR, 0.67; 95% CI, 0.49-0.91). Women were significantly more likely to be diagnosed with MIBC than men (OR, 1.40; 95% CI, 1.22-1.61). Non-Hispanic black women had the highest proportion (39%) of MIBC diagnoses. Among Hispanic and Asian patients, a greater proportion of diagnoses occurred at younger ages.Co nclusions: Health care coverage within an equal-access system did not eliminate disparities in stage at diagnosis by race/ethnicity or gender. Studies are needed to identify etiologic factors and aspects of care delivery (eg, patient-physician interactions) that may affect the diagnostic process to inform efforts to improve health equity. (C) 2019 Elsevier Inc. All rights reserved.

OBJECTIVES:To examine treatment variability, disparities, and quality among newly diagnosed nonmuscle invasive bladder cancer (NMIBC) patients, and to identify factors associated with treatment use in a large, diverse integrated delivery system. METHODS:Retrospective cohort study of 5386 NMIBC patients diagnosed between January 2001 and June 2015 within Kaiser Permanente Southern California. Electronic health data were used to identify treatment outcomes and patient, provider, and tumor characteristics. Outcomes were use of (1) postoperative intravesical chemotherapy, (2) induction Bacille Calmette-Guérin (BCG) immunotherapy, and (3) any intravesical therapy. Multivariable odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using generalized linear mixed models with a binary outcome and urologist as a random effect. RESULTS:From 2001 to 2015, 41% of newly diagnosed NMIBC patients were treated with intravesical therapy. Postoperative chemotherapy use increased significantly over this period (OR per-year = 1.16, 95% CI: 1.07-1.25). BCG use was strongly associated with tumor characteristics: patients with high-grade or carcinoma in situ tumors were more likely to receive BCG (OR = 10.10, 95% CI: 8.39-12.16). Few treatment differences were found by sex or race/ethnicity, but were observed by age. Wide treatment variability across urologists was observed, with some urologists never using intravesical therapy as part of initial treatment while others almost always used it. Differences across urologists accounted for more variability in postoperative chemotherapy (intraclass correlation coefficient = 0.52) than BCG immunotherapy (intraclass correlation coefficient = 0.11) use. CONCLUSION:Substantial variability in initial treatment of NMIBC was observed across urologists, accounting for tumor, patient, and provider characteristics. Results suggest a considerable opportunity for quality improvement programs to reduce unwanted treatment variability and improve care for patients.

PURPOSE:Bladder cancer is one of the top five cancers diagnosed in the U.S. with a high recurrence rate, and also one of the most expensive cancers to treat over the life-course. However, there are few observational, prospective studies of bladder cancer survivors.METHODS:The Bladder Cancer Epidemiology, Wellness, and Lifestyle Study (Be-Well Study) is a National Cancer Institute-funded, multi-center prospective cohort study of non-muscle-invasive bladder cancer (NMIBC) patients (Stage Ta, T1, Tis) enrolled from the Kaiser Permanente Northern California (KPNC) and Southern California (KPSC) health care systems, with genotyping and biomarker assays performed at Roswell Park Comprehensive Cancer Center. The goal is to investigate diet and lifestyle factors in recurrence and progression of NMIBC, with genetic profiles considered, and to build a resource for future NMIBC studies.RESULTS:Recruitment began in February 2015. As of 30 June 2018, 1,281 patients completed the baseline interview (774 KPNC, 511 KPSC) with a recruitment rate of 54%, of whom 77% were male and 23% female, and 80% White, 6% Black, 8% Hispanic, 5% Asian, and 2% other race/ethnicity. Most patients were diagnosed with Ta (69%) or T1 (27%) tumors. Urine and blood specimens were collected from 67% and 73% of consented patients at baseline, respectively. To date, 599 and 261 patients have completed the 12- and 24-month follow-up questionnaires, respectively, with additional urine and saliva collection.CONCLUSIONS:The Be-Well Study will be able to answer novel questions related to diet, other lifestyle, and genetic factors and their relationship to recurrence and progression among early-stage bladder cancer patients.

You have accessJournal of UrologyProstate Cancer: Detection & Screening VII (PD60)1 Apr 2019PD60-09 ROLE AND VALUE OF SECOND OPINION REVIEWS IN DNA METHYLATION POSITIVE EPIGENETIC ASSAYS IN NEGATIVE HISTOPATHOLGICAL PROSTATE BIOPSIES John Lam*, David Finley, Stephen Poon, William Sohn, Yu Wang, Philip Kim, Stephen Williams, Eugene Rhee, Ronald Loo, Gary Gochman, and Jeffrey Shiffer John Lam*John Lam* More articles by this author , David FinleyDavid Finley More articles by this author , Stephen PoonStephen Poon More articles by this author , William SohnWilliam Sohn More articles by this author , Yu WangYu Wang More articles by this author , Philip KimPhilip Kim More articles by this author , Stephen WilliamsStephen Williams More articles by this author , Eugene RheeEugene Rhee More articles by this author , Ronald LooRonald Loo More articles by this author , Gary GochmanGary Gochman More articles by this author , and Jeffrey ShifferJeffrey Shiffer More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000557269.89460.3eAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Genomic markers have been increasingly utilized to assist in the early detection of prostate cancer and an epigenetic assay has been able to identify men who may forego an unnecessary repeat biopsy. This study looked at the value of a second opinion review in positive epigenetic assays in negative histopathological prostate biopsies. METHODS: We evaluated the archived, cancer negative prostate biopsy core tissue samples of 49 subjects from an integrated health care system in Southern California. Biopsy cores were epigenetically profiled for GSTP1, APC and RASSF1 relative to the ACTB reference gene using quantitative methylation specific polymerase chain reaction in patients with rising PSA or increasing clinical suspicion. Predetermined analytical marker cutoffs were used to determine assay performance. DNA methylation positive biopsy cores underwent second opinion review by a pathologist. RESULTS: The epigenetic assay was performed in 49 cases of negative histopathological prostate biopsy cores, and found to be negative in 32 (65%) cases and positive in 17 (35%) cases. ASAP was present in 3 (6%) cases and HGPIN was present in 2 (4%) cases. Four (24%) of 17 positive cases that underwent second opinion review revealed the presence of prostate cancer. All prostate cancer diagnosed were Gleason score 6. In addition, there were 4 (24%) cases of ASAP and 4 (24%) cases of HGPIN diagnosed. CONCLUSIONS: Second opinion review of a positive epigenetic assay in histopathological negative prostate biopsies resulted in a proportion of cases having the diagnosis of prostate cancer. These results suggest that epigenetic assays can be used to assist with prostate cancer diagnosis and may circumvent need for repeat prostate biopsy or have implications in surveillance strategies. Source of Funding: None. Pasadena, CA© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e1099-e1100 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Lam* More articles by this author David Finley More articles by this author Stephen Poon More articles by this author William Sohn More articles by this author Yu Wang More articles by this author Philip Kim More articles by this author Stephen Williams More articles by this author Eugene Rhee More articles by this author Ronald Loo More articles by this author Gary Gochman More articles by this author Jeffrey Shiffer More articles by this author Expand All Advertisement PDF downloadLoading ...

IMPORTANCE:Existing recommendations for the diagnostic testing of hematuria range from uniform evaluation of varying intensity to patient-level risk stratification. Concerns have been raised about not only the costs and advantages of computed tomography (CT) scans but also the potential harms of CT radiation exposure.OBJECTIVE:To compare the advantages, harms, and costs associated with 5 guidelines for hematuria evaluation.DESIGN, SETTING, AND PARTICIPANTS:A microsimulation model was developed to assess each of the following guidelines (listed in order of increasing intensity) for initial evaluation of hematuria: Dutch, Canadian Urological Association (CUA), Kaiser Permanente (KP), Hematuria Risk Index (HRI), and American Urological Association (AUA). Participants comprised a hypothetical cohort of patients (n = 100 000) with hematuria aged 35 years or older. This study was conducted from August 2017 through November 2018.EXPOSURES:Under the Dutch and CUA guidelines, patients received cystoscopy and ultrasonography if they were 50 years or older (Dutch) or 40 years or older (CUA). Under the KP and HRI guidelines, patients received different combinations of cystoscopy, ultrasonography, and CT urography or no evaluation on the basis of risk factors. Under the AUA guidelines, all patients 35 years or older received cystoscopy and CT urography.MAIN OUTCOMES AND MEASURES:Urinary tract cancer detection rates, radiation-induced secondary cancers (from CT radiation exposure), procedural complications, false-positive rates per 100 000 patients, and incremental cost per additional urinary tract cancer detected.RESULTS:The simulated cohort included 100 000 patients with hematuria, aged 35 years or older. A total of 3514 patients had urinary tract cancers (estimated prevalence, 3.5%; 95% CI, 3.0%-4.0%). The AUA guidelines missed detection for the fewest number of cancers (82 [2.3%]) compared with the detection rate of the HRI (116 [3.3%]) and KP (130 [3.7%]) guidelines. However, the simulation model projected 108 (95% CI, 34-201) radiation-induced cancers under the KP guidelines, 136 (95% CI, 62-229) under the HRI guidelines, and 575 (95% CI, 184-1069) under the AUA guidelines per 100 000 patients. The CUA and Dutch guidelines missed detection for a larger number of cancers (172 [4.9%] and 251 [7.1%]) but had 0 radiation-induced secondary cancers. The AUA guidelines cost approximately double the other 4 guidelines ($939/person vs $443/person for Dutch guidelines), with an incremental cost of $1 034 374 per urinary tract cancer detected compared with that of the HRI guidelines.CONCLUSIONS AND RELEVANCE:In this simulation study, uniform CT imaging for patients with hematuria was associated with increased costs and harms of secondary cancers, procedural complications, and false positives, with only a marginal increase in cancer detection. Risk stratification may optimize the balance of advantages, harms, and costs of CT.

OBJECTIVE:To compare the risk of mortality among men treated for benign prostatic hyperplasia (BPH) with 5 alpha-reductase inhibitors (5ARI) to those treated with alpha-blockers (AB) in community practice settings. METHODS:We employed a retrospective matched cohort study in 4 regions of an integrated healthcare system. Men aged 50 years and older who initiated pharmaceutical treatment for BPH and/or lower urinary tract symptoms between 1992 and 2008 and had at least 3 consecutive prescriptions that were eligible and followed through 2010 (N = 174,895). Adjusted hazard ratios were used to estimate the risk of mortality due to all-causes associated with 5ARI use (with or without concomitant ABs) as compared to AB use. RESULTS:In this large and diverse sample with 543,523 person-years of follow-up, 35,266 men died during the study period, 18.9% of the 5ARI users and 20.4% of the AB users. After adjustment for age, medication initiation year, race, region, prior AB history, Charlson score, and comorbidities, 5ARI use was not associated with an increased risk of mortality when compared to AB use (Adjusted hazard ratios: 0.64, 95% confidence interval: 0.62, 0.66). CONCLUSION:Among men receiving medications for BPH in community practice settings, 5ARI use was not associated with an increased risk of mortality when compared to AB use. These data provide reassurance about the safety of using 5ARIs in general practice to manage BPH and/or lower urinary tract symptoms.

You have accessJournal of UrologyBladder Cancer: Epidemiology & Evaluation II1 Apr 2018MP71-13 INITIAL TREATMENT OF NON-MUSCLE INVASIVE BLADDER CANCER (NMIBC) IN A LARGE INTEGRATED DELIVERY SYSTEM Stephen Williams, Tiffany Luong, David Yi, Ayae Yamamoto, Aniket Kawatkar, Philip Kim, Ronald Loo, Margo Sidell, and Kim Danforth Stephen WilliamsStephen Williams More articles by this author , Tiffany LuongTiffany Luong More articles by this author , David YiDavid Yi More articles by this author , Ayae YamamotoAyae Yamamoto More articles by this author , Aniket KawatkarAniket Kawatkar More articles by this author , Philip KimPhilip Kim More articles by this author , Ronald LooRonald Loo More articles by this author , Margo SidellMargo Sidell More articles by this author , and Kim DanforthKim Danforth More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2277AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Quality gaps and treatment inequity for bladder cancer may contribute to disparities in tumor recurrence or progression. We assessed care quality, treatment disparities, and variability by urologist in the initial treatment of NMIBC. METHODS We conducted a retrospective cohort study of 5,386 NMIBC patients diagnosed age >= 21 years from 1/2001-6/2015 within Kaiser Permanente Southern California, an equal-access healthcare system. Patients were excluded if they had a cancer diagnosis within the previous 5 years, or if they had radical cystectomy/urinary diversion surgery, infusion chemotherapy, or hospice care within 92 days of diagnosis. High grade tumors and carcinoma in situ were combined into a high-risk tumor variable. Post-operative chemotherapy (post-op MMC) was defined as use within 1 day of tumor resection. Bacillus Calmette-Guerin (BCG) immunotherapy was defined as use within 92 days of tumor resection. Multivariable generalized linear mixed models with physician as a random effect were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS The average age at diagnosis was 70 years, 79% of patients were male, and 73% of patients were non-Hispanic white, 14% were Hispanic, 7% were non-Hispanic black, and 5% were Asian. Tumor stage was classified as 0a (61%), 0is (7%) or 1 (32%), and 43% of patients had high-risk tumors. Post-op MMC was used in 17% of cases. In multivariable models, race/ethnicity (p=0.04), year of diagnosis (p<0.001), body mass index (p<0.001), and diabetes (p=0.03) were associated with post-op MMC use. Post-op MMC use varied substantially by urologist (ICC=0.52) and increased over time. Induction BCG was used in 23% of patients. In multivariable models, high-risk tumors were strongly associated with BCG use (OR=10.1, 95% CI: 8.4-12.2). Age, body mass index, kidney disease, and diabetes also were significantly associated with BCG use. No significant differences in BCG use were observed by sex or race/ethnicity. BCG variability by physician was smaller (ICC=0.11) than with post-op MMC and did not increase over time. CONCLUSIONS In this large study, intravesical therapy was used as part of initial treatment 41% of the time, with increasing MMC use over time. While tumor characteristics were strongly associated with BCG use, there was substantial urologist variability in post-op MMC use. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e948 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Stephen Williams More articles by this author Tiffany Luong More articles by this author David Yi More articles by this author Ayae Yamamoto More articles by this author Aniket Kawatkar More articles by this author Philip Kim More articles by this author Ronald Loo More articles by this author Margo Sidell More articles by this author Kim Danforth More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...