Background
The use of adjuvant chemotherapy (AC) in pure urothelial carcinoma of the bladder is established. Regarding variant histology, there is a gap in knowledge concerning the optimal treatment ...after radical cystectomy (RC). The objective of this study was to assess the effect of AC on overall survival (OS) in patients who had pure urothelial carcinoma, urothelial carcinoma with concomitant variant histology, or another pure variant histology.
Methods
Within the National Cancer Data Base, 15,397 patients who underwent RC for nonmetastatic, localized carcinoma of the bladder and had positive lymph nodes (T2N+) or locally advanced stage (≥T3N0/N+) were identified, excluding those who had previously received neoadjuvant chemotherapy. Multivariable Cox regression models were used to examine the specific effect of AC on OS stratified by each distinct histologic subtype, including pure urothelial carcinoma, micropapillary or sarcomatoid differentiation, squamous cell carcinoma, adenocarcinoma, and neuroendocrine tumors. To account for immortal time bias, Cox regression analyses and Kaplan‐Meier analyses were conducted with a landmark at 3 months.
Results
In multivariable landmark analyses, AC compared with initial observation was associated with an OS benefit for patients who had pure urothelial carcinoma (hazard ratio, 0.87; 95% confidence interval, 0.82‐0.91), whereas no differences were observed with regard to those who had variant histology.
Conclusions
Multivariable Cox regression landmark analysis revealed a survival benefit from AC for patients with a pure urothelial carcinoma. However, a survival benefit of AC for patients who had urothelial carcinoma with concomitant variant histology or other pure variant histology was not demonstrated.
In patients who have pure urothelial carcinoma, a comparison of overall survival after adjuvant chemotherapy versus initial observation stratified by histologic subtype reveals a survival benefit from adjuvant chemotherapy. Multivariable landmark Cox regression analyses do not demonstrate a survival benefit after adjuvant chemotherapy for patients who have urothelial carcinoma with concomitant variant histology.
There is few data on what constitutes the distribution of metastatic sites in prostate cancer (PCa). The aim of our study was to systematically describe the most common sites of metastases in a ...contemporary cohort of PCa patients.
Patients with metastatic PCa were abstracted from the Nationwide Inpatient Sample (1998-2010). Most common metastatic sites within the entire population were described. Stratification was performed according to the presence of single or multiple (≥ 2 sites) metastases. Additionally, we evaluated the distribution of metastatic sites amongst patients with and without bone metastases.
Overall, 74,826 patients with metastatic PCa were identified. The most common metastatic sites were bone (84%), distant lymph nodes (10.6%), liver (10.2%), and thorax (9.1%). Overall, 18.4% of patients had multiple metastatic sites involved. When stratifying patients according to the site of metastases, only 19.4% of men with bone metastases had multiple sites involved. Conversely, among patients with lymph nodes, liver, thorax, brain, digestive system, retroperitoneum, and kidney and adrenal gland metastases the proportion of men with multiple sites involved was 43.4%, 76.0%, 76.7%, 73.0%, 52.2%, 60.9%, and 76.4%, respectively. When focusing exclusively on patients with bone metastases, the most common sites of secondary metastases were liver (39.1%), thorax (35.2%), distant lymph nodes (24.6%), and brain (12.4%).
Although the majority of patients with metastatic PCa experience bone location, the proportion of patients with atypical metastases is not negligible. These findings might be helpful when planning diagnostic imaging procedures in patients with advanced PCa.
Objectives
To examine postoperative complications in a contemporary series of patients after radical cystectomy using a standardized reporting system, and to identify readily available preoperative ...risk factors.
Methods
Using the modified Clavien–Dindo classification, we assessed the 90‐day postoperative clinical course of 535 bladder cancer patients who underwent radical cystectomy and urinary diversion (ileal conduit n = 349, ileal neobladder n = 186) between June 2003 and February 2012 at a single institution. All Martin criteria for standardized reporting of complications were met. Uni‐ and multivariable analyses for prediction of complications were carried out; covariates included body mass index, Charlson Comorbidity Index, age, sex, American Society of Anesthesiologists Score, neoadjuvant chemotherapy, prior abdominal or pelvic surgery, localized tumor and urinary diversion type.
Results
The 90‐day rates for overall (Clavien–Dindo classification I‐V) and high‐grade complications (Clavien–Dindo classification III‐V), as well as mortality (Clavien–Dindo classification V), were 56.4, 18.7 and 3.9%, respectively. Infections (16.4%), bleeding (14.2%) and gastrointestinal complications (10.7%) were the most common adverse outcomes. Independent risk factors for overall complications were body mass index (odds ratio 1.08) and Charlson Comorbidity Index ≥3 (odds ratio 1.93). Risk factors for high‐grade complications were Charlson Comorbidity Index ≥3 (odds ratio 1.86), American Society of Anesthesiologists Score ≥3 (odds ratio 1.92) and body mass index (odds ratio 1.07, all P < 0.03).
Conclusions
Radical cystectomy is associated with significant morbidity; nevertheless, the majority of complications are minor. Charlson Comorbidity Index, American Society of Anesthesiologists Score and body mass index might help to identify patients at risk for high‐grade complications after radical cystectomy.
Background
Health insurance is a key mediator of health care disparities. Outcomes in bladder cancer, one of the costliest diseases to treat, may be especially sensitive to a patient's insurance ...status.
Methods
The Surveillance, Epidemiology, and End Results registry and the National Cancer Data Base were used to identify individuals younger than 65 years who were diagnosed with bladder cancer from 2007 to 2014. The associations between the insurance status (privately insured, insured by Medicaid, or uninsured) and the following outcomes were evaluated: diagnosis with advanced disease, cancer‐specific survival, delay in treatment longer than 90 days, treatment in a high‐volume hospital, and receipt of neoadjuvant chemotherapy (NAC).
Results
Compared with those with private insurance, uninsured and Medicaid‐insured individuals were nearly twice as likely to receive a diagnosis of muscle‐invasive bladder cancer (odds ratio OR for uninsured individuals, 1.90; 95% confidence interval CI, 1.70‐2.12; OR for Medicaid‐insured individuals, 2.03; 95% CI, 1.87‐2.20). They were also more likely to die of bladder cancer (adjusted hazard ratio AHR for uninsured individuals, 1.49; 95% CI, 1.31‐1.71; AHR for Medicaid‐insured individuals, 1.61; 95% CI, 1.46‐1.79). Delays in treatment longer than 90 days were more likely for uninsured (OR, 1.36; 95% CI, 1.12‐1.65) and Medicaid‐insured individuals (OR, 1.22; 95% CI, 1.03‐1.44) in comparison with the privately insured. Uninsured patients had lower odds of treatment at a high‐volume facility, and Medicaid‐insured patients had lower odds of receiving NAC (P < .001 for both).
Conclusions
Compared with privately insured individuals, uninsured and Medicaid‐insured individuals experience worse prognoses and poorer care quality. Expanding high‐quality insurance coverage to marginalized populations may help to reduce the burden of this disease.
Individuals who lack adequate insurance experience relatively poor outcomes with bladder cancer. Compared with the privately insured, those who are uninsured or Medicaid‐insured have worse prognoses and receive lower quality care.
Objectives
To evaluate the relationship between surgeon volume of radical cystectomy (RC) and postoperative morbidity, and to assess the economic burden of bladder cancer in the USA.
Methods
We ...captured all patients who underwent RC (International Classification of Diseases, ninth revision, code 57.71) between 2003 and 2010, using a nationwide hospital discharge database. Patient, hospital and surgical characteristics were evaluated. The annual volume of RCs performed by the surgeons was divided into quintiles. Multivariable regression models were developed, adjusting for clustering and survey weighting, to evaluate the outcomes, including 90‐day major complications (Clavien grade III–V) and direct patient costs. We adjusted for clustering and weighting to achieve a nationally representative analysis.
Results
The weighted cohort included 49 792 patients who underwent RC, with an overall 90‐day major complication rate of 16.2%. Compared with surgeons performing one RC annually, surgeons performing ≥7 RCs each year had 45% lower odds of major complications (odds ratio OR 0.55; P < 0.001) and lower costs by $1690 (P = 0.02). Results were consistent when we analysed surgeon volume as a continuous variable and when we examined the surgeons with the highest volumes (≥28 cases annually), which showed markedly lower odds of major complications compared with the surgeons with the lowest volumes (OR 0.45, 95% CI 0.31–0.67; P < 0.001). Compared with patients who did not have any complications, those who had a major complication were associated with significantly higher 90‐day median direct hospital costs ($43 965 vs $24 341; P < 0.001).
Conclusions
We showed that there was an inverse relationship between surgeon volume and the development of postoperative 90‐day major complication rates as well as direct hospital costs. Centralisation of RC to surgeons with higher volumes may reduce the development of postoperative major complications, thereby decreasing the burden of bladder cancer on the healthcare system.
Robust prediction of survival can facilitate clinical decision-making and patient counselling. Non-Caucasian males are underrepresented in most prostate cancer databases. We evaluated the variation ...in performance of a machine learning (ML) algorithm trained to predict survival after radical prostatectomy in race subgroups.
We used the National Cancer Database (NCDB) to identify patients undergoing radical prostatectomy between 2004 and 2016. We grouped patients by race into Caucasian, African-American, or non-Caucasian, non-African-American (NCNAA) subgroups. We trained an Extreme Gradient Boosting (XGBoost) classifier to predict 5-year survival in different training samples: naturally race-imbalanced, race-specific, and synthetically race-balanced. We evaluated performance in the test sets.
A total of 68,630 patients met inclusion criteria. Of these, 57,635 (84%) were Caucasian, 8173 (12%) were African-American, and 2822 (4%) were NCNAA. For the classifier trained in the naturally race-imbalanced sample, the F1 scores were 0.514 (95% confidence interval: 0.513-0.511), 0.511 (0.511-0.512), 0.545 (0.541-0.548), and 0.378 (0.378-0.389) in the race-imbalanced, Caucasian, African-American, and NCNAA test samples, respectively. For all race subgroups, the F1 scores of classifiers trained in the race-specific or synthetically race-balanced samples demonstrated similar performance compared to training in the naturally race-imbalanced sample.
A ML algorithm trained using NCDB data to predict survival after radical prostatectomy demonstrates variation in performance by race, regardless of whether the algorithm is trained in a naturally race-imbalanced, race-specific, or synthetically race-balanced sample. These results emphasize the importance of thoroughly evaluating ML algorithms in race subgroups before clinical deployment to avoid potential disparities in care.
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