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BackgroundSeveral treatment options for clinically localized prostate cancer currently exist under the established guidelines. We aim to assess nationally representative trends in treatment over time and determine potential geographic variation using two large national claims registries.MethodsMen with prostate cancer insured by Medicare (1998-2006) or a private insurer (Ingenix database, 2002-2006) were identified using International Classification of Diseases-9 and Current Procedural Terminology-4 codes. Geographic variation and trends in the type of treatment utilized over time were assessed. Geographic data were mapped using the GeoCommons online mapping platform. Predictors of any treatment were determined using a hierarchical generalized linear mixed model using the logit link function.ResultsThe use of radical prostatectomy increased, 33-48%, in the privately insured i3 database while remaining stable at 12% in the Medicare population. There was a rapid uptake in the use of newer technologies over time in both the Medicare and i3 cohorts. The use of laparoscopic-assisted prostatectomy increased from 1% in 2002 to 41% in 2006 in i3 patients, whereas the incidence increased from 3% in 2002 to 35% in 2006 for Medicare patients. The use of neoadjuvant/adjuvant androgen deprivation therapy was lower in the i3 cohort and has decreased over time in both i3 and Medicare. Physician density had an impact on the type of primary treatment received in the New England region; however, this trend was not seen in the western or southern regions of the United States.ConclusionsUsing two large national claims registries, we have demonstrated trends over time and substantial geographic variation in the type of primary treatment used for localized prostate cancer. Specifically, there has been a large increase in the use of newer technologies (that is, laparoscopic-assisted prostatectomy and intensity-modulated radiation therapy). These results elucidate the need for improved data collection on prostate cancer treatment outcomes to reduce unwarranted variation in care.

PURPOSE OF REVIEW: Concern for over and under-treatment of men with prostate cancer has led to an increased focus on the identification and selective treatment of men with high-risk features. The purpose of this review is to summarize the epidemiology, risk factors, and treatment trends of men with high-risk prostate cancer. RECENT FINDINGS: Findings from recent trials on prostate-specific antigen-based screening suggest that screening has substantially reduced the incidence of high-risk prostate cancer. Men with high-risk disease tend to be older at diagnosis than those with low-risk disease. There is marked variation in the treatment of men with high-risk features; contemporary studies favor multimodal therapy, but high-risk disease is often under-treated with androgen deprivation alone, particularly among older men. SUMMARY: Variations in the incidence, mortality, and treatment of men with high-risk prostate cancer may reflect heterogeneity among studies in the definition of high-risk disease. Future research should attempt to standardize definitions of high-risk prostate cancer to allow better comparison between studies and provide a more homogeneous assessment of natural history. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although phosphodiesterase inhibitor use post radical prostatectomy improves potency, little is known about its affects on sexual bother. We found no difference in sexual bother scores between patients who use and do not use phosphodiesterase inhibitors. This suggests that the current definition of potency, inclusive of medication use, is valid with respect to sexual bother. OBJECTIVE To determine whether the current definition of potency, inclusive of phosphodiesterase inhibitor (PDEi) use, is valid with respect to sexual bother (SB). This will be assessed by characterizing the effect of PDEi use on SB scores in men who are potent post radical prostatectomy. PATIENTS AND METHODS The study population consisted of patients who were potent both before and after radical prostatectomy, with at least 2 years of follow-up. Disease-specific quality of life data were evaluated by the University of California, Los Angeles, Prostate Cancer Index (PCI) survey. The relationships between changes in sexual function (SF) and SB and use of PDEi over time were evaluated by mixed model analysis controlling for age, clinical risk group, marital status, and time of PCI assessment. RESULTS Of the 246 patients who met the study criteria, 39% reported PDEi use at some point after treatment. PDEi use was not associated with improved SF (P= 0.81). Furthermore, PDEi use was not associated with a change in SB (P= 0.36). Both SF and SB were significantly associated with time of assessment and age, and SF and SB each improved over time. In addition, SB was significantly associated with marital status. CONCLUSIONS In this analysis, there was no difference in SF scores between men who were potent with or without the use of PDEi. Furthermore, there was no difference in SB scores between men who were potent with or without the use of PDEi. This suggests that the current, inclusive, definition of potency is valid with respect to SB. © 2011 BJU INTERNATIONAL.

Minimally invasive nephroureterectomy (MINU) and open nephroureterectomy (ONU) have similar oncological outcomes for treatment of upper tract urothelial carcinoma (UTUC). We investigated perioperative outcomes and predictors of complications associated with MINU and ONU.Using the National Surgical Quality Improvement Program (NSQIP) database, 912 patients were identified that underwent radical nephroureterectomy for UTUC between 2005 and 2013. Logistic regression and contingency table methods used preoperative covariates to predict rates of major (Clavien-Dindo grade ≥ 3) and 16 common perioperative complications. Additional comparisons between treatment groups were performed using unpaired t-tests, Wilcoxon rank-sum tests, or Fisher's Exact tests. P values were adjusted to maintain an experiment-wise p0.05.A total of 625 (69%) and 287 (31%) patients underwent MINU and ONU, respectively. ONU was associated with a higher rate of major complications (OR: 2.5, CI: 1.2-5.1, p0.03). The incidence of pulmonary embolism (bias adjusted OR: 24, CI: 1.3-441, p0.003), postoperative pneumonia (OR: 4.9, CI: 1.7-16, p0.0016), and transfusion (OR: 2.7, CI: 1.8-4.0, p0.0001) was higher for ONU compared to MINU. There were no significant differences in the incidence of other complications. MINU took longer on average (median 223 versus 213 mins, p0.02). Time to discharge was longer for ONU (median 5 versus 4 days, p0.0001). No other covariates were independent predictors of major complications regardless of surgical approach.Occurrence of major complications were higher for ONU compared to MINU. These data suggest that MINU is an acceptable surgical option with lower morbidity compared to ONU for the management of UTUC.

Objective To determine whether there is a survival difference for African-American men (AAM) versus Caucasian American men (CM) with penile squamous cell carcinoma (pSCC), particularly in locally advanced and metastatic cases where disease mortality is highest. Patients and methods Using the Florida Cancer Data System, we identified men with pSCC from 2005 to 2013. We compared age, follow-up, stage, race, and treatment type between AAM and CM. We performed Kaplan-Meier analysis for overall survival (OS) between AAM and CM for all stages, and for those with locally advanced and metastatic disease. A multivariable model was developed to determine significant predictors of OS. Results In all, 653 men (94 AAM and 559 CM) had pSCC and 198 (30%) had locally advanced and/or metastatic disease. A higher proportion of AAM had locally advanced and/or metastatic disease compared to CM (38 [40%] vs 160 [29%], P = 0.03). The median (interquartile range) follow-up for the entire cohort was 12.6 (5.4-32.0) months. For all stages, AAM had a significantly lower median OS compared to CM (26 vs 36 months, P = 0.03). For locally advanced and metastatic disease, there was a consistent trend toward disparity in median OS between AAM and CM (17 vs 22 months, P = 0.06). After adjusting for age, stage, grade, and treatment type, AAM with pSCC had a greater likelihood of death compared to CM (hazard ratio 1.64, P = 0.014). Conclusions AAM have worse OS compared to CM with pSCC and this may partly be due to advanced stage at presentation. Treatment disparity may also contribute to lessened survival in AAM, but we were unable to demonstrate a significant difference in treatment utilisation between the groups.

Objective To compare the predictive accuracy of prostate-specific antigen (PSA) density vs PSA across different PSA ranges and by prior biopsy status in a prospective cohort undergoing prostate biopsy. Materials and Methods Men from a prospective trial underwent an extended template biopsy to evaluate for prostate cancer at 26 sites throughout the United States. The area under the receiver operating curve assessed the predictive accuracy of PSA density vs PSA across 3 PSA ranges (10 ng/mL). We also investigated the effect of varying the PSA density cutoffs on the detection of cancer and assessed the performance of PSA density vs PSA in men with or without a prior negative biopsy. Results Among 1290 patients, 585 (45%) and 284 (22%) men had prostate cancer and significant prostate cancer, respectively. PSA density performed better than PSA in detecting any prostate cancer within a PSA of 4-10 ng/mL (area under the receiver operating characteristic curve [AUC]: 0.70 vs 0.53, P 10 mg/mL (AUC: 0.84 vs 0.65, P