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Urologists frequently treat patients for tobacco-related conditions but infrequently engage in evidence-based practices (EBPs) that screen for and treat tobacco use. Improving the use of EBPs will help to identify smokers, promote cessation, and improve patients' health outcomes.A prospective type I hybrid effectiveness-implementation study was performed to test the feasibility and effectiveness of using a multilevel implementation strategy to improve the use of tobacco EBPs. All urology providers at outpatient urology clinics within the Veterans Health Administration Greater Los Angeles and all patients presenting for a new urology consultation were included. The primary outcome was whether a patient was screened for tobacco use at the time of consultation. Secondary outcomes included a patient's willingness to quit, chosen quit strategy, and subsequent engagement in quit attempts.In total, 5706 consecutive veterans were seen for a new consultation during the 30-month study period. Thirty-six percent of all visits were for a tobacco-related urologic diagnosis. The percentage of visits that included tobacco use screening increased from 18% (before implementation) to 57% in the implementation phase and to 60% during the maintenance phase. There was significant provider-level variation in adherence to screening. Of all screened patients, 38% were willing to quit, and most patients chose a "cold turkey" method; 22% of the patients elected referral to a formal smoking cessation clinic, and 24% chose telephone counseling. Among those willing to quit, 39% and 49% made a formal quit attempt by 3 and 6 months, respectively.A strategy that includes provider education and a customized clinical decision support tool can facilitate provider use of tobacco EBPs in a surgery subspecialty clinic.

BACKGROUND For certain men with low-risk prostate cancer, aggressive treatment results in marginal survival benefits while exposing them to urinary and sexual side effects. Nevertheless, expectant management has been underused. In the current study, the authors evaluated the association between various factors and expectant management use among veterans diagnosed with prostate cancer. METHODS The authors identified men diagnosed with prostate cancer in 2008. The outcome of interest was use of expectant management, based on documentation captured through an in-depth chart review. Multivariable regression models were fit to examine associations between use of expectant management and patient demographics, cancer severity, and facility characteristics. The authors assessed variation across 21 tertiary care regions and 52 facilities by generating predicted probabilities for receipt of expectant management. RESULTS Expectant management was more common among patients aged ≥75 years (40% vs 27% for those aged .05). Among ideal candidates for expectant management, receipt of expectant management varied considerably across individual facilities (0%-85%; P

BACKGROUND The objective of this study was to determine tobacco use knowledge and attribution of cause in patients with newly diagnosed bladder cancer. METHODS A stratified, random sample of bladder cancer survivors diagnosed between 2006 and 2009 was obtained from the California Cancer Registry. Respondents were surveyed about tobacco use, risk factors, and sources of information on the causes of bladder cancer. Contingency tables and logistic regression analyses were used to evaluate tobacco use knowledge and beliefs. RESULTS Of 1198 eligible participants, 790 (66%) completed the survey. Sixty-eight percent of the cohort had a history of tobacco use, and 19% were active smokers at diagnosis. Tobacco use was the most cited risk factor for bladder cancer, with active smokers more knowledgeable than former smokers or never smokers (90% vs 64% vs 61%, respectively; P

BACKGROUND Men with multiple comorbidities are often overtreated for low-risk prostate cancer, but it is unclear whether they are undertreated for high-risk cancer, which has appreciable short-term prostate cancer-specific mortality. This study characterized the impact of comorbidity on treatment and survival in men with differing tumor risks. METHODS The researchers sampled 1482 men with nonmetastatic prostate cancer at 2 Veterans Affairs hospitals between 1998 and 2004, using multivariate probit regression to determine probabilities of aggressive treatment among men with differing Charlson comorbidity scores within D'Amico tumor risk strata. Using competing-risks regression, a comparison was made of 8-year cancer-specific mortality for men treated aggressively and nonaggressively among Charlson score-tumor risk pairs. RESULTS The study sample comprised 516 men (36%) with low-risk, 475 men (33%) with intermediate-risk, and 432 men (30%) with high-risk prostate cancer. Men with high-risk disease tended to have lower probability of aggressive treatment than other risk strata, regardless of comorbidity. Among men with Charlson scores 3+, probabilities of aggressive treatment did not increase with higher tumor risk (0.48, 0.61, 0.49 for low-, intermediate-, and high-risk disease, respectively). In competing-risks analysis, aggressive treatment was not associated with cancer-specific survival benefit in men with multiple comorbidities (Charlson scores of 2 or 3+) and low- and intermediate-risk disease, but there was a strong trend toward survival advantage in such men with high-risk disease. CONCLUSIONS Aggressiveness of treatment is poorly matched with tumor risk in men with significant comorbidity. Men with major comorbidities should consider conservative management for low- and intermediate-risk disease and aggressive treatment for high-risk disease. Cancer 2013;119:3446–3453.. © 2013 American Cancer Society.

BACKGROUND: Accurate estimation of life expectancy is essential for men deciding between aggressive and conservative treatment of prostate cancer. The authors sought to assess the competing risks of nonprostate cancer and prostate cancer mortality among men with differing Charlson comorbidity index scores and tumor risks. METHODS: The authors conducted a retrospective study of 1482 men with nonmetastatic prostate cancer diagnosed from 1997 to 2004 at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers. They performed Kaplan-Meier and competing risks regression analyses to assess survival outcomes. RESULTS: After a mean follow-up of 6.0 years, 370 (25%) men died from other causes, whereas 44 (3%) died of prostate cancer. At 10 years after diagnosis, men with Charlson scores 0, 1, 2, and 3+ had nonprostate cancer mortality rates of 17%, 34%, 52%, and 74%, respectively. In competing risks regression analysis, each point increase in Charlson score was associated with a 2-fold increase in hazard of nonprostate mortality. Men with Charlson 3+ had 8.5× the hazard of death from other causes, compared with men with the lowest scores (subhazard ratio, 8.5; 95% confidence interval, 6.2-11.7). After stratification by tumor risk, nonprostate mortality rates remained markedly elevated among men with higher Charlson scores, whereas prostate cancer mortality was rare, especially among low-risk and intermediate-risk groups (0.4%, 3%, and 8% for low, intermediate, and high risk, respectively). CONCLUSIONS: Men with the highest Charlson scores should consider conservative management of low-risk and intermediate-risk tumors, given their exceedingly high risk of death from other causes and low risk of prostate cancer mortality. Cancer 2011;. © 2011 American Cancer Society.

BACKGROUND: Men with low-risk prostate cancer and significant comorbidity are susceptible to overtreatment. The authors sought to compare the impact of comorbidity and age on treatment choice in men with low-risk disease. METHODS: The authors sampled 509 men with low-risk prostate cancer diagnosed at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers between 1997 and 2004. Rates of aggressive treatment (radical prostatectomy, radiation therapy, brachytherapy) were determined among men of different ages and with different Charlson comorbidity scores. Multivariate modeling was used to determine the influence of both variables in predicting nonaggressive treatment, and Cox proportional hazards analysis was used to compare the risk of other-cause mortality among groups according to Charlson score and age. RESULTS: Men with Charlson scores ≥3 were treated aggressively in 54% of cases (30 of 56 men), while men aged >75 years at diagnosis were treated aggressively in 16% of cases (7 of 44 men). In multivariate analysis, age >75 years was a much stronger predictor of nonaggressive treatment (relative risk, 12.0; 95% confidence interval [CI], 5.4-28.3) than a Charlson score ≥3 (relative risk, 2.0; 95% CI, 1.3-2.9). In survival analysis, men with Charlson scores ≥3 had an 8-fold increased risk (hazard ratio, 8.4; 95% CI, 4.2-16.6) and 70% probability of other-cause mortality at 10 years, whereas age >75 years was associated with a 5-fold increased risk (hazard ratio, 4.9; 95%CI, 1.7-13.8) and a 24% probability of other-cause mortality. CONCLUSIONS: Men with significant comorbidity often were overtreated for low-risk prostate cancer. Like advanced age, significant comorbidity should be a strong relative contraindication to aggressive treatment in men with low-risk disease. Cancer 2011. © 2010 American Cancer Society.

BACKGROUND: Being in a supportive relationship may have improved the health-related quality of life (HRQOL) of men with prostate cancer, if the support was strong and positive. In the current study, the authors sought to examine the impact of partnership status on the mental health of men treated for localized prostate cancer. METHODS: Participants had clinically localized prostate cancer and chose treatment with radical prostatectomy (n = 307), external‒beam radiotherapy (n = 78), or brachytherapy (n = 91). The authors prospectively assessed subject characteristics and HRQOL outcomes and evaluated associations between partnership outcomes and HRQOL measures. Two multivariate linear regression models were then created, 1 for baseline HRQOL outcomes and 1 for change in HRQOL from baseline to 12 months, with partnership status as the main predictor and subject characteristics as covariates. RESULTS: Partnership status was not found to be associated with either baseline physical or mental health, but partnered participants had less bowel bother (P = .02) and a lower fear of recurrence (P = .03) at baseline than did unpartnered subjects. Men with fewer comorbid conditions scored better across almost all baseline HRQOL domains. Primary treatment type was significantly associated with changes in physical HRQOL, with men undergoing radical prostatectomy describing better changes in physical health than those treated with brachytherapy (P = .04) or those receiving external‒beam radiotherapy (P ≤ .01). CONCLUSIONS: Physical and mental health was found to be comparable in the study cohort of partnered and unpartnered men treated for prostate cancer. The universally high socioeconomic status of the current study cohort may mitigate differences in HRQOL by partnership status. Cancer 2009. © 2009 American Cancer Society.

BACKGROUND Despite the growing recognition of the importance of colorectal cancer (CRC) screening in reducing cancer mortality, national screening rates are low, indicating a critical need to understand the barriers and remedies for underutilization of CRC screening tests. METHODS Using results from independent cross-sectional telephone surveys with patients aged ≥50 years performed before (2000; n = 498) and after (2003; n = 482) a quality improvement intervention for CRC screening within a large managed care health plan, the trends and predictors of CRC screening with fecal occult blood test (FOBT) and/or endoscopy (flexible sigmoidoscopy/colonoscopy) were examined from a patient perspective. RESULTS In 2000, patient reported screening rates within guidelines were 38% for any test, 23% for endoscopy, and 22% for FOBT. In 2003, screening rates increased to 50% for any test, 39% for endoscopy, and 24% for FOBT. Having discussed CRC with a doctor significantly increased the odds of being screened (FOBT: odds ratio [OR], 2.09 [95% confidence interval (95% CI), 1.47–2.96]; endoscopy: OR, 2.33 [95% CI, 1.67–3.26]; and any test: OR, 2.86 [95% CI, 2.06–3.96]), and reporting barriers to CRC in general decreased the odds of being screened (FOBT: OR, 0.76 [95% CI, 0.60–0.95]; endoscopy: OR, 0.74 [95% CI, 0.60–0.92]; and any test: OR, 0.66 [95% CI, 0.54–0.80]). CONCLUSIONS Although screening rates increased over the 3-year period, evidence was found of ongoing underutilization of CRC screening. The 2 strongest determinants of obtaining CRC screening were provider influence and patient barriers related to CRC screening in general, pointing to the need for multilevel interventions that target both the provider and patient. Cancer 2008. © 2008 American Cancer Society.

For certain men with low-risk prostate cancer, aggressive treatment results in marginal survival benefits while exposing them to urinary and sexual side effects. Nevertheless, expectant management has been underused. In the current study, the authors evaluated the association between various factors and expectant management use among veterans diagnosed with prostate cancer.The authors identified men diagnosed with prostate cancer in 2008. The outcome of interest was use of expectant management, based on documentation captured through an in-depth chart review. Multivariable regression models were fit to examine associations between use of expectant management and patient demographics, cancer severity, and facility characteristics. The authors assessed variation across 21 tertiary care regions and 52 facilities by generating predicted probabilities for receipt of expectant management.Expectant management was more common among patients aged ≥75 years (40% vs 27% for those aged 55 years; odds ratio, 2.57) and those with low-risk tumors (49% vs 20% for patients with high-risk tumors; odds ratio, 5.35). There was no association noted between patient comorbidity and receipt of expectant management (P = .90). There were also no associations found between facility factors and use of expectant management (all P.05). Among ideal candidates for expectant management, receipt of expectant management varied considerably across individual facilities (0%-85%; P.001).Patient age and tumor risk were found to be more strongly associated with use of expectant management than patient comorbidity. Although use of expectant management appears broadly appropriate, there was variation in expectant management noted between hospitals that was apparently not attributable to facility factors. Research determining the basis of this variation, with a focus on providers, will be critical to help optimize prostate cancer treatment for veterans.

BACKGROUND Being married confers significant benefits in survival for patients with a variety of chronic conditions including breast and prostate carcinoma. The authors attempted to determine whether marital status is associated with survival in patients undergoing radical cystectomy for bladder carcinoma. METHODS The authors identified 7262 subjects from the Surveillance, Epidemiology, and End Results public-use database who underwent radical cystectomy for transitional cell carcinoma of the bladder. They performed survival analyses using Kaplan–Meier estimates and Cox proportional hazards models. The authors created multivariate models to evaluate the independent association between marital status and survival, controlling for pathologic stage, lymph node status, age, race/ethnicity, and gender. RESULTS Married subjects were older and more often male, white, and had earlier disease stage at diagnosis. Married subjects had significantly better survival than did single or widowed subjects (P < 0.001), and married subjects revealed a trend toward better survival than separated/divorced subjects (P = 0.20). Multivariate modeling revealed that compared with single subjects, those who were married had better survival, independent of age at the time of diagnosis, gender, race/ethnicity, disease stage, and lymph node status (P < 0.001). CONCLUSIONS Marriage was associated with improved survival in patients with bladder carcinoma, independent of other factors known to influence mortality in this population. Although the mechanisms underlying this survival advantage are unknown, possibilities include differences in cancer screening, risk behaviors, and access to medical care. The interaction between psychosocial factors and the body's immune function may further explain the differential survival in this cohort. Cancer 2005. © 2005 American Cancer Society.

The objective of this study was to determine tobacco use knowledge and attribution of cause in patients with newly diagnosed bladder cancer.A stratified, random sample of bladder cancer survivors diagnosed between 2006 and 2009 was obtained from the California Cancer Registry. Respondents were surveyed about tobacco use, risk factors, and sources of information on the causes of bladder cancer. Contingency tables and logistic regression analyses were used to evaluate tobacco use knowledge and beliefs.Of 1198 eligible participants, 790 (66%) completed the survey. Sixty-eight percent of the cohort had a history of tobacco use, and 19% were active smokers at diagnosis. Tobacco use was the most cited risk factor for bladder cancer, with active smokers more knowledgeable than former smokers or never smokers (90% vs 64% vs 61%, respectively; P.001). Urologists were the predominant source of information and were cited most often by active smokers (82%). In multivariate analyses, active smokers had 6.37 times greater odds (95% confidence interval, 3.35-12.09) than never smokers of endorsing tobacco use as a risk factor for bladder cancer, and smokers who named the urologist as their information source had 2.80 times greater odds (95% confidence interval, 1.77-4.43) of believing tobacco use caused their cancer.Patients' smoking status and primary source of information were associated with knowledge of the harms of tobacco use and, in smokers, acknowledgment that tobacco use increased the risk of their own disease. Urologists play a critical role in ensuring patients' knowledge of the connection between smoking and bladder cancer, particularly for active smokers who may be motivated to quit.

Men with multiple comorbidities are often overtreated for low-risk prostate cancer, but it is unclear whether they are undertreated for high-risk cancer, which has appreciable short-term prostate cancer-specific mortality. This study characterized the impact of comorbidity on treatment and survival in men with differing tumor risks.The researchers sampled 1482 men with nonmetastatic prostate cancer at 2 Veterans Affairs hospitals between 1998 and 2004, using multivariate probit regression to determine probabilities of aggressive treatment among men with differing Charlson comorbidity scores within D'Amico tumor risk strata. Using competing-risks regression, a comparison was made of 8-year cancer-specific mortality for men treated aggressively and nonaggressively among Charlson score-tumor risk pairs.The study sample comprised 516 men (36%) with low-risk, 475 men (33%) with intermediate-risk, and 432 men (30%) with high-risk prostate cancer. Men with high-risk disease tended to have lower probability of aggressive treatment than other risk strata, regardless of comorbidity. Among men with Charlson scores 3+, probabilities of aggressive treatment did not increase with higher tumor risk (0.48, 0.61, 0.49 for low-, intermediate-, and high-risk disease, respectively). In competing-risks analysis, aggressive treatment was not associated with cancer-specific survival benefit in men with multiple comorbidities (Charlson scores of 2 or 3+) and low- and intermediate-risk disease, but there was a strong trend toward survival advantage in such men with high-risk disease.Aggressiveness of treatment is poorly matched with tumor risk in men with significant comorbidity. Men with major comorbidities should consider conservative management for low- and intermediate-risk disease and aggressive treatment for high-risk disease.

Accurate estimation of life expectancy is essential for men deciding between aggressive and conservative treatment of prostate cancer. The authors sought to assess the competing risks of nonprostate cancer and prostate cancer mortality among men with differing Charlson comorbidity index scores and tumor risks.The authors conducted a retrospective study of 1482 men with nonmetastatic prostate cancer diagnosed from 1997 to 2004 at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers. They performed Kaplan-Meier and competing risks regression analyses to assess survival outcomes.After a mean follow-up of 6.0 years, 370 (25%) men died from other causes, whereas 44 (3%) died of prostate cancer. At 10 years after diagnosis, men with Charlson scores 0, 1, 2, and 3+ had nonprostate cancer mortality rates of 17%, 34%, 52%, and 74%, respectively. In competing risks regression analysis, each point increase in Charlson score was associated with a 2-fold increase in hazard of nonprostate mortality. Men with Charlson 3+ had 8.5× the hazard of death from other causes, compared with men with the lowest scores (subhazard ratio, 8.5; 95% confidence interval, 6.2-11.7). After stratification by tumor risk, nonprostate mortality rates remained markedly elevated among men with higher Charlson scores, whereas prostate cancer mortality was rare, especially among low-risk and intermediate-risk groups (0.4%, 3%, and 8% for low, intermediate, and high risk, respectively).Men with the highest Charlson scores should consider conservative management of low-risk and intermediate-risk tumors, given their exceedingly high risk of death from other causes and low risk of prostate cancer mortality.

The authors compared the types of treatments prostate cancer patients received from county hospitals and private providers as part of a statewide public assistance program.This was a cohort study of 559 men enrolled in a state-funded program for low-income patients known as Improving Access, Counseling, and Treatment for Californians With Prostate Cancer (IMPACT). Multinomial regression was used to compare types of treatments patients received from different providers.Between 2001 and 2006, 315 (56%) participants received treatment from county hospitals and 244 (44%) from private providers. There were no significant between-group differences with respect to age (P = .22), enrollment year (P = .49), Charlson comorbidity index (P = .47), Gleason sum (P = .33), clinical T stage (P = .36), prostate-specific antigen (P = .39), or D'Amico risk criteria (P = .45). Participants treated by private providers were more likely than those treated in county hospitals to be white (35% vs 10%, P.01) and less likely to undergo surgery (29% vs 54%, P.01). Multinomial regression analyses showed that participants treated by private providers were nearly 2(1/2) times more likely than those treated by public providers to receive radiotherapy (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.37-4.07) and4(1/2) times more likely to receive primary androgen deprivation (OR, 4.71; 95% CI, 2.15-10.36) than surgery.In this economically disadvantaged cohort, prostate cancer treatments differed significantly between county hospitals and private providers. These data reveal substantial variations in treatment patterns between different types of healthcare institutions that-given the implications for health policy and quality of care-merit further scrutiny.

BACKGROUND. The primary treatments for clinically localized prostate cancer confer equivalent cancer control for most patients but disparate side effects. In the current study, the authors sought to compare health-related quality of life (HRQOL) outcomes after the most commonly used treatments. METHODS. A total of 580 men completed the Medical Outcomes Study Short Form-36, the University of California-Los Angeles (UCLA) Prostate Cancer Index, and the American Urological Association Symptom Index before and through 24 months after treatment with radical prostatectomy (RP), external beam radiation therapy (EBRT), or brachytherapy (BT). RESULTS. General HRQOL did not appear to be affected by treatment. Obstructive and irritative urinary symptoms were more common after BT (P < .001). Urinary control and sexual function were better after EBRT than BT (P < .001 and P = .02, respectively) and better after BT than RP (P < .001 and P = .01, respectively). Among potent men, recovery of sexual function was best after EBRT and was equivalent after bilateral nerve-sparing surgery or BT. Sexual bother was more common than urinary or bowel bother after all 3 treatments. Bowel dysfunction was more common after EBRT or BT than RP (P < .001). CONCLUSIONS. In the current study, treatment for localized prostate cancer was found to differentially affect HRQOL outcomes. Urinary control and sexual function were better after EBRT, although bilateral nerve-sparing surgery diminished these differences among potent men undergoing RP. BT caused more obstructive and irritative symptoms, while both forms of radiation caused more bowel dysfunction. These results may inform medical decision-making in men with localized prostate cancer. Cancer 2007. © 2007 American Cancer Society.

BACKGROUND The authors evaluated the feasibility of measuring quality of care in a statewide public assistance program for men with prostate carcinoma. METHODS The sample consisted of 84 men who were followed for ≥ 6 months after receiving primary treatment for early-stage prostate carcinoma (55 received radical prostatectomy and 29 received radiotherapy) through a free public program for low-income, uninsured men. Quality was assessed by chart review with 16 indicators previously developed and validated at the RAND Corporation, as well as by telephone and mail surveys that included the University of California at Los Angeles Prostate Cancer Index short form. RESULTS Quality of care measurement was feasible for 13 (81%) indicators from electronic chart abstraction, administrative documents, and patient questionnaires. Communication between specialist and primary physician was better for men treated with radiotherapy than with surgery (84% vs. 45%, P = 0.004). Subjects treated in private institutions were more likely than those treated in public institutions to have ≥ 2 follow-up visits with the treating physician or institution within 1 year of treatment (93% vs. 63%, P = 0.003) and to have documentation of communication with the primary care physician (90% vs. 40%, P << 0.0001). Disease-specific, health-related quality of life 6 months after treatment did not appear to differ between public and private facilities. CONCLUSIONS The authors found the application of quality of care indicators to be feasible in a statewide public assistance program, but with some differences between public and private providers. These quality of care indicators identified target areas for improvement. Cancer 2005. © 2005 American Cancer Society.

BACKGROUND Being partnered confers significant benefits in survival for patients with prostate cancer, yet little is known of the impact of relationship status on health-related quality of life (HRQOL). The authors evaluated the influence of partnership on measures of HRQOL. METHODS The authors studied 291 patients who were enrolled in a program that provided free treatment to impoverished, uninsured men with prostate cancer. The associations between relationship status and measures of general and disease-specific HRQOL were evaluated. Results from multivariate models determined the independent effect of partnership on HRQOL. RESULTS Partnered patients were more likely than unpartnered patients to be Hispanic (58% vs. 34%) and were more likely to have elected surgical therapy (49% vs. 34%). Multivariate analyses, controlling for age, ethnicity, disease stage, and treatment type, revealed that partnered patients had better mental health (P = 0.009), less urinary bother (P = 0.011), higher spirituality (P = 0.037), and lower symptom distress (P = 0.005) than unpartnered participants. CONCLUSIONS Relationship status had a positive effect on the quality of life of low-income, uninsured men with prostate cancer. Cancer 2005. © 2005 American Cancer Society.