Abstract Introduction Evidence for the use of perioperative chemotherapy (PC) in upper tract urothelial carcinoma (UTUC) is largely derived from level I evidence for invasive urothelial carcinoma of ...the bladder (UCB). There has been an increase in PC for urothelial carcinoma of the bladder, as it has disseminated into clinical practice. Therefore, we sought to not only analyze trends in the utilization of PC in UTUC, but also assess factors associated with its use in a large cancer registry database. Methods The National Cancer Database was queried for patients with UTUC who underwent extirpative surgery from 2004 to 2013. Predictors of receiving PC were identified using univariate and multivariate logistic regression. Temporal trends in the utilization of PC were also analyzed using a general analysis of variance linear model. Results From 2004 to 2013, there was significant increase in PC for UTUC from 9.6% to 13.8% ( P = 0.0003). Neoadjuvant chemotherapy increased from 0.7% to 2.1% ( P = 0.0018), whereas adjuvant chemotherapy remained relatively stable at 11.3%. Significant predictors of receiving PC on multivariate analysis were private insurance, ureter as the primary site, poorly differentiated and undifferentiated grade, lymphovascular invasion, positive margins, clinical T3 or T4 disease, nodal metastasis, and reporting from an academic research program. Patients who were≥70 years old,>50 miles to treatment center, had tumor in the kidney, or had an increased Charlson-Deyo Score were significantly less likely to receive PC. Conclusions Over the time period studied, there has been an increase in the use of PC, primarily from increased administration of neoadjuvant chemotherapy. Its use is mostly associated with advanced pathologic characteristics. The study also highlights key demographic and socioeconomic differences that can help identify barriers to receiving PC and aid in making improvements in delivery of health care to patients with UTUC.
Objective
To evaluate the relationship between partial nephrectomy (PN) and hospital availability of robot‐assisted surgery from a population‐based cohort in the USA.
Methods
After merging the ...Nationwide Inpatient Sample (NIS) and the American Hospital Association survey from 2006 to 2008, we identified 21 179 patients who underwent either PN or radical nephrectomy (RN) for renal cell carcinoma (RCC). The primary outcome assessed was the type of nephrectomy performed. Multivariable logistic regression identified the patient and hospital characteristics associated with receipt of PN.
Results
We identified 4832 (22.8%) and 16 347 (77.2%) patients who were treated for RCC with PN and RN, respectively. On multivariable analysis, patients were more likely to receive PN at academic centres (odds ratio OR 2.77; P < 0.001), urban centres (OR 3.66; P < 0.001) and American College of Surgeons (ACOS)‐designated cancer centres (OR: 1.10; P < 0.05) compared with non‐academic, rural and non‐ACOS‐designated cancer centre hospitals, respectively. Robot‐assisted surgery availability at a hospital was also associated with a higher adjusted odds of PN compared with centres without that availability (OR 1.28; P < 0.001).
Conclusions
Although academic and urban locations are established factors that affect the receipt of PN for RCC, the availability of robot‐assisted surgery at a hospital was also independently associated with higher use of PN. Our results are informative in identifying other key hospital characteristics which may facilitate greater adoption of PN.
Objective.
To obtain prospective outcomes data on patients (pts) undergoing palliative operative or endoscopic procedures for malignant bowel obstruction due to recurrent ovarian cancer.
Methods.
An ...institutional study was conducted from July 2002 to July 2003 to prospectively identify pts who underwent an operative or endoscopic procedure to palliate the symptoms of advanced cancer. This report focuses on pts with malignant bowel obstruction due to recurrent ovarian cancer. Procedures performed with an upper or lower gastrointestinal (GI) endoscope were considered “endoscopic.” All other cases were classified as “operative.” Following the procedure, the presence or absence of symptoms was determined and followed over time. All pts were followed until death.
Results.
Palliative interventions were performed on 74 gynecologic oncology pts during the study period, of which 26 (35%) were for malignant GI obstruction due to recurrent ovarian cancer. The site of obstruction was small bowel in 14 (54%) cases and large bowel in 12 (46%) cases. Palliative procedures were operative in 14 (54%) pts and endoscopic in the other 12 (46%). Overall, symptomatic improvement or resolution within 30 days was achieved in 23 (88%) of 26 patients, with 1 (4%) postprocedure mortality. At 60 days, 10 (71%) of 14 pts who underwent operative procedures and 6 (50%) of 12 pts who had endoscopic procedures had symptom control. Median survival from the time of the palliative procedure was 191 days (range, 33–902) for those undergoing an operative procedure and 78 days (range, 18–284) for those undergoing an endoscopic procedure.
Conclusion.
Patients with malignant bowel obstructions due to recurrent ovarian cancer have a high likelihood of experiencing relief of symptoms with palliative procedures. Although recurrence of symptoms is common, durable palliation and extended survival are possible, especially in those patients selected for operative intervention.
Prospective outcomes data on patients undergoing palliative operative or endoscopic procedures for malignant bowel obstruction resulting from recurrent ovarian cancer are presented. These patients often experience recurrence of symptoms, but durable palliation and extended survival are possible.
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Background: Prostate cancer (PCa) is the most common solid organ malignancy in men and the second leading cause of cancer related death; however, it is the only tumor that is ...diagnosed by a non-targeted sampling method. Fusion targeted prostate biopsy is emerging as a more accurate way to detect PCa. The use of a multiparametric MRI (MP-MRI) with an endorectal coil (ERC) has traditionally been used, though the benefit for detection with ERC is controversial. In addition, there is significant heterogeneity in classification of MRI-identified lesions. We provide an initial report with fusion biopsy without an ERC and utilizing a simplified 3-point Likert scale for grading prostatic lesions. Methods: Patients underwent MRI-USG fusion biopsy for elevated PSA, abnormal DRE, or prior negative biopsy. Lesions visible on MRI were outlined in 3D and assigned increasing cancer suspicion levels using a simplified 3-point Likert scale by dedicated pelvic radiologists. The Artemis
biopsy tracking system was used to fuse the MRI with real-time ultrasound. Using the 3D model, a 12-core systematic biopsy, as well as a targeted biopsy of suspicious areas, was performed by a urologist (PS). Results: 190 patients underwent MRI and fusion biopsy between 12/2012 and 8/2014. The overall cancer detection rate (CDR) for systematic biopsy was 52.3% and the CDR for fusion biopsy was 55.0%. However, the CDR for clinically significant PCa with systematic biopsy was 28.7% and for targeted biopsy was 43.8% (p=0.02). Evaluation of cancer suspicion level for each ROI revealed that patients with high suspicion scores had a higher overall CDR (p<0.0001) and higher risk of detecting clinically significant cancer under the Cochran Armitage Trend test (p=0.0001). Conclusions: MRI-USG fusion prostate biopsy using MP-MRI without an ERC and a read using a simplified 3-point Likert scale demonstrate improved detection of clinically significant PCa compared to a systematic 12 core TRUS biopsy, and further demonstrate that lesion suspicion correlates with CDR. CDR and lesion stratification are comparable to the published literature when using methodologies that may be more practical in a larger number of medical centers.
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Background: Bladder cancer is the second most common urologic malignancy with over 73,350 new cases diagnosed annually of which the incidence is increasing in the elderly. Radical ...cystectomy (RC), the gold standard for muscle invasive disease, carries a particularly high risk of morbidity and mortality, as well as a protracted length of stay (LOS) and increased readmission rates when compared with other major urologic procedures. Furthermore, in 2013, the Institute of Medicine (IOM) declared cancer care in the US a national crisis with a priority to improve quality of care through care coordination (CC). Simultaneously, enhanced recovery after surgery (ERAS) protocols have surfaced as coordinated, evidence-based models designed to standardize medical care, improve outcomes, and lower healthcare costs. At City of Hope (COH), we evaluated our ERAS and CC pathway. Methods: In April of 2014, an ERAS and CC pathway for bladder cancer was launched at COH with an emphasis on the perioperative care of patients (pts) from a multi-disciplinary team perspective. Preoperatively, pts undergo orientation on stoma education, goals of care, and treatment expectations. The pathway clinically focuses on avoidance of bowel preparation, early feeding, minimizing narcotics, and u-opioid antagonists. On discharge, pts are closely monitored via scheduled phone calls as well as clinic visits. Quality metrics including LOS, complications, and readmissions are reported as median and interquartile range along with descriptive statistics including chi-square and Wilcoxon rank-sum tests. Results: Since implementation, the median LOS was statistically significant between cohorts with 6 days for pts on pathway compared to 8 days for those preceding the pathway (p = 0.0007). Furthermore, the complication and readmission rates have decreased from 67.5% to 50% and from 35% to 30%, respectively. Dehydration and urinary tract infection (UTI) accounted for 17.9% and 21.4% of readmissions for those prior to the pathway, while UTI occurred in 5% of pts readmitted after adhering to the pathway. Conclusions: Our ERAS and CC pathway has reduced LOS without an increase in complication nor readmission rates.
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Background: While hospital and surgeon characteristics are associated with the type of nephrectomy performed for renal cell carcinoma (RCC), it is unknown whether hospital presence ...of robotic surgery increases the likelihood of patients receiving partial nephrectomy (PN). Therefore, we evaluate the relationship of PN and hospital presence of robotic surgery from a population-based cohort in the U.S. Methods: After merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association (AHA) survey from 2006 to 2008, we identified 21,999 patients who underwent either PN or radical nephrectomy (RN) for RCC. The primary outcome of this study was the type of nephrectomy performed. Multivariable logistic regression was used to identify hospital characteristics associated with receipt of PN, after adjusting for patient case mix. Results: Overall, we identified 4,832 (22.0%) and 16,347 (88.0%) patients who were surgically treated for RCC with PN and RN, respectively. On multivariable analysis, patients undergoing surgery were more likely to receive PN at academic (OR: 2.77;p<0.001), urban (OR: 3.66; p<0.001), and American College of Surgeon (ACOS) designated cancer centers (OR: 1.10; p<0.05) compared to non-academic, rural, and non-designated hospitals, respectively. After adjusting for patient and hospital characteristics, patients undergoing surgery at hospitals with presence of robotic surgery were also associated with higher adjusted odds ratios for receipt of PN compared to those treated at hospitals without the presence of this advanced treatment technology (OR: 1.28; p<0.001). Conclusions: While academic status and urban locations are established characteristics influencing the type of nephrectomy performed for RCC, ACOS cancer center designation and hospital presence of robotic surgery were also associated with higher use of PN. Our results are informative in identifying key hospital characteristics which may facilitate greater adoption of PN.
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