Access Regional Cancer Hospital Database Research Articles

Addressing racial disparities in prostate cancer pathology prediction models: external validation and comparison of four models of pathological outcome prediction before radical prostatectomy in the multiethnic SEARCH cohort.

Certain widely used pathological outcome prediction models that were developed in tertiary centers tend to overpredict outcomes in the community setting; thus, the Michigan Urological-Surgery Improvement Collaborative (MUSIC) model was developed in general urology practice to address this issue. Additionally, the development of these models involved a relatively small proportion of Black men, potentially compromising the accuracy of predictions in this patient group. We tested the validity of the MUSIC and three widely used nomograms to compare their overall and race-stratified predictive performance. We extracted data from 4139 (1138 Black) men from the Shared Equal Access Regional Cancer Hospital (SEARCH) database of the Veterans Affairs health system. The predictive performance of the MUSIC model was compared to the Memorial-Sloan Kettering (MSK), Briganti-2012, and Partin-2017 models for predicting lymph-node invasion (LNI), extra-prostatic extension (EPE), and seminal vesicle invasion (SVI). The median PSA of Black men was higher than White men (7.8 vs. 6.8 ng/ml), although they were younger by a median of three years and presented at a lower-stage disease. MUSIC model showed comparable discriminatory capacity (AUC:77.0%) compared to MSK (79.2%), Partin-2017 (74.6%), and Briganti-2012 (76.3%), with better calibration for LNI. AUCs for EPE and SVI were 72.7% and 76.9%, respectively, all comparable to the MSK and Partin models. LNI AUCs for Black and White men were 69.6% and 79.6%, respectively, while EPE and SVI AUCs were comparable between races. EPE and LNI had worse calibration in Black men. Decision curve analysis showed MUSIC superiority over the MSK model in predicting LNI, especially among Black men. Although the discriminatory performance of all models was comparable for each outcome, the MUSIC model exhibited superior net benefit to the MSK model in predicting LNI outcomes among Black men in the SEARCH population.

Red Blood Cell Distribution Width Is Associated with All-cause Mortality but Not Adverse Cancer-specific Outcomes in Men with Clinically Localized Prostate Cancer Treated with Radical Prostatectomy: Findings Based on a Multicenter Shared Equal Access Regional Cancer Hospital Registry

BackgroundRecent reports with a small number of patients showed an association of red blood cell distribution width (RDW) with prostate cancer (PCa) progression. ObjectiveTo investigate whether preoperative RDW can serve as a prognostic marker in patients with PCa undergoing radical prostatectomy (RP) in a large, equal access, and diverse patient cohort. Design, setting, and participantsData were retrospectively collected on 4756 men treated with RP at eight Veteran Affairs medical centers within the Shared Equal Access Regional Cancer Hospital (SEARCH) database from 1999 through 2017. Outcome measurements and statistical analysisBiochemical recurrence (BCR) was the primary outcome, while metastasis, all-cause mortality (ACM), and prostate cancer–specific mortality (PCSM) were secondary outcomes. Results and limitationsThe mean (standard deviation) age was 62 yr (6.1), and 1589 (33%) men were black. The median (interquartile range) follow-up was 82 mo (46–127). Preoperative RDW either as a continuous variable or when stratified by quartiles was not associated with BCR. Likewise, preoperative RDW was not associated with metastases or PCSM. However, higher RDW was significantly associated with higher ACM, both as a continuous variable (p < 0.001) and when stratified by quartiles in univariable and multivariable models (p < 0.001). RDW was found to be correlated with D’Amico risk classification of PCa. Study limitations include its retrospective nature and lack of data regarding advanced PCa. ConclusionsPreoperative RDW was not associated with PCa outcomes in men treated with RP but was associated with ACM. While RDW may be a biomarker of overall health, it is not a biomarker for PCa outcomes. These results emphasize the importance of diverse, larger sized studies in genitourinary cancer research. Patient summaryProstate cancer includes a wide spectrum of diseases with different genetic, pathological, and oncological behaviors. Red blood cell distribution width is helpful in predicting the overall survival for a localized prostate cancer patient, and hence, it can help inform personalized treatment decisions and operative care.

Do Hispanic Men Have Worse Outcomes After Radical Prostatectomy? Results From SEARCH

ObjectiveTo examine the associations between ethnicity and outcomes after radical prostatectomy (RP) among Hispanics. While non-Hispanic Black men have worse prostate cancer (PC) outcomes, there are limited data on outcomes of Hispanic men, especially after RP. MethodsWe identified 3789 White men who underwent RP between 1988 and 2017 in the Shared Equal Access Regional Cancer Hospital database. Men were categorized as Hispanic or non-Hispanic. Logistic regression was used to test the association between ethnicity and PC adverse features. Cox models were used to test the association between ethnicity and biochemical recurrence (BCR), metastases, and castration-resistant PC (CRPC). All models were adjusted for age, prostate-specific antigen, clinical stage, biopsy grade group, surgery year, and surgical center. ResultsOf 3789 White men, 236 (6%) were Hispanic. Hispanic men had higher prostate-specific antigen, but all other characteristics were similar between ethnicities. On multivariable analysis, there was no difference between ethnicities in odds of extracapsular extension, seminal vesicle invasion, positive margins, positive lymph nodes, or high-grade disease (odds ratio 0.62-0.89, all P > .07). A total of 1168 men had BCR, 182 developed metastasis, and 132 developed CRPC. There was no significant association between Hispanic ethnicity and risk of BCR, metastases, or CRPC (hazards ratio 0.39-0.85, all P > .06). ConclusionIn an equal access setting, we found no evidence Hispanic White men undergoing RP had worse outcomes than non-Hispanic White men. In fact, all hazard ratios were <1 and although they did not achieve statistical significance, suggest perhaps slightly better outcomes for Hispanic men. Larger studies are needed to confirm findings.

Obesity, race, and long-term prostate cancer outcomes.

The authors previously found that obesity was linked with prostate cancer (PC)-specific mortality (PCSM) among men who underwent radical prostatectomy (RP). Herein, in a larger RP cohort, the authors investigated whether the association between obesity and long-term PC outcomes, including PCSM, differed by race. Data from 5929 patients who underwent RP and were in the Shared Equal Access Regional Cancer Hospital (SEARCH) database were analyzed. Prior to RP, body mass index (BMI) was measured and recorded in the medical records. BMI was categorized as normal weight (<25kg/m2 ), overweight (25-29.9kg/m2 ), and obese (≥30kg/m2 ). The authors assessed the association between BMI and biochemical disease recurrence (BCR), castration-resistant prostate cancer (CRPC), metastasis, and PCSM, accounting for confounders. Of the 5929 patients, 1983 (33%) were black, 1321 (22%) were of normal weight, 2605 (44%) were overweight, and 2003 (34%) were obese. Compared with white men, black men were younger; had higher prostate-specific antigen levels; and were more likely to have a BMI ≥30kg/m2 , seminal vesicle invasion, and positive surgical margins (all P≤.032). During a median follow-up of 7.4years, a total of 1891 patients (32%) developed BCR, 181 patients (3%) developed CRPC, 259 patients (4%) had metastasis, and 135 patients (2%) had died of PC. On multivariable analysis, obesity was found to be associated with an increased risk of PCSM (hazard ratio, 1.78; 95% confidence interval, 1.04-3.04 [P=.035]). No interaction was found between BMI and race in predicting PCSM (P≥.88), BCR (P≥.81), CRPC (P≥.88), or metastasis (P≥.60). Neither overweight nor obesity was associated with risk of BCR, CRPC, or metastasis (all P≥.18). Obese men undergoing RP at several Veterans Affairs hospitals were found to be at an increased risk of PCSM, regardless of race.

Predictors of skeletal-related events and mortality in men with metastatic, castration-resistant prostate cancer: Results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database.

Although skeletal-related events (SREs) are linked with a reduced quality of life and worse outcomes, to the authors' knowledge the factors that predict SREs are minimally understood. The objective of the current study was to identify predictors of SREs and all-cause mortality among men with metastatic castration-resistant prostate cancer (mCRPC). Data were collected on 837 men with bone mCRPC at 8 Veterans Affairs medical centers within the Shared Equal Access Regional Cancer Hospital (SEARCH) database from 2000 through 2017. Patients were followed to assess development of SREs (pathological fracture, radiotherapy to bone, spinal cord compression, or surgery to bone). Cox proportional hazards models were used to evaluate predictors of SREs and mortality. Of the 837 men with bone mCRPC, 287 developed a SRE and 740 men died (median follow-up, 26months). Bone pain was found to be the strongest predictor of SREs (hazard ratio [HR], 2.96; 95% CI, 2.25-3.89). A shorter time from CRPC to the development of metastasis (HR, 0.92; 95% CI, 0.85-0.99), shorter progression to CRPC (HR, 0.94; 95% CI, 0.91-0.98), and visceral metastasis at the time of diagnosis of bone metastasis (HR, 1.91; 95% CI, 1.18-3.09) were associated with an increased risk of SREs. Ten or more bone metastases (HR, 2.17; 95% CI, 1.72-2.74), undergoing radical prostatectomy (HR, 0.73; 95% CI, 0.61-0.89), shorter progression to CRPC (HR, 0.97; 95% CI, 0.94-0.99), older age (HR, 1.03; 95% CI, 1.02-1.04), higher prostate-specific antigen level at the time of diagnosis of metastasis (HR, 1.21; 95% CI, 1.14-1.28), bone pain (HR, 1.44; 95% CI, 1.23-1.70), and visceral metastasis (HR, 1.72; 95% CI, 1.23-2.39) were associated with an increased mortality risk. Among men with bone mCRPC, bone pain was found to be the strongest predictor of SREs and the number of bone metastases was a strong predictor of mortality. If validated, these factors potentially may be used for risk stratification and for SRE prevention strategies.

Salvage Radiotherapy for Recurrent Prostate Cancer: Can the Prognostic Grade Group System Inform Treatment Timing?

In order to better time salvage radiotherapy (SRT) for post-radical prostatectomy biochemical failure, we examined the association between pre-SRT prostate-specific antigen (PSA) and PSA control as a function of the new prognostic grade group (PGG) system. Using the Shared Equal Access Regional Cancer Hospital database, we identified men after radical prostatectomy with PSA > 0.2 ng/mL and without cancer involvement of lymph nodes who underwent SRT alone. SRT failure was defined as post-SRT PSA nadir+ 0.2 ng/mL or receipt of post-SRT hormone therapy. Men were stratified by pre-SRT PSA (0.2-0.49, 0.5-0.99, and≥ 1.0 ng/mL). Multivariable Cox models were used to test the association between pre-SRT PSA and SRT failure, stratified by PGG. A total of 358 men met the inclusion criteria and comprised our study cohort. Median post-SRT follow-up was 78 months. A total of 174 men (49%) had pre-SRT PSA 0.2-0.49 ng/mL, 97 (27%) PSA 0.5-0.99 ng/mL, and 87 (24%) PSA≥ 1.0 ng/mL. On multivariable analysis among men with PGG 1-2, pre-SRT PSA 0.2-0.49 ng/mL had similar outcomes as PSA 0.5-0.99 ng/mL; those with PSA≥ 1.0 ng/mL had higher recurrence risks (hazard ratio= 2.78, P< .001). Among PGG 3-5, PSA 0.5-0.99 ng/mL or≥ 1.0 ng/mL had a higher recurrence risk (hazard ratio= 2.15, P= .021; and hazard ratio= 2.49, P= .010, respectively) versus PSA 0.2-0.49 ng/mL. In men with higher-grade prostate cancer (PGG 3-5), SRT should be provided earlier (PSA< 0.5 ng/mL), while among men with lower-grade disease (PGG 1-2), SRT results in equal PSA control up to PSA 1.0 ng/mL.

Validity of the National Death Index to ascertain the date and cause of death in men having undergone prostatectomy for prostate cancer.

BackgroundThe National Death Index (NDI) is a centralized database containing information from death certificates that is frequently referenced by health and medical investigators to ascertain vital statistics. Yet, it commonly includes misclassified causes of death. Since the NDI is frequently relied upon in studies that evaluate outcomes following radical prostatectomy (RP) for prostate cancer (PC), we evaluated its validity by referencing mortality data from the Shared Equal Access Regional Cancer Hospital (SEARCH) database which is a prospectively managed database of 5,009 Veterans who underwent a RP at eight Veterans Affairs medical centers between 1982 and 2016.MethodsWe compared vital status, cause of death and date of death from the SEARCH database with the NDI.ResultsA total of 1,312 men in SEARCH were deceased, yet the NDI reported 17% (219) of those men as still alive. Among the 1,093 men who had concordant vital status in both SEARCH and NDI, the date of death was an exact match within one day, a week, or 31 days in 94%, 97%, 99%, and 100%, respectively. Of those men coded as dying from prostate cancer in the SEARCH database (n=105), 12% were coded as having died from non-PC causes in the NDI. Meanwhile, among patients coded by the NDI as having died of PC (n=139), 34% were coded in SEARCH as having died of non-PC causes.ConclusionsThese findings demonstrate that the NDI provides accurate dates of death, but frequently misclassifies whether a death was due to prostate cancer. Studies that rely upon death certificates, as capture in the NDI, may be unreliable to report prostate cancer specific mortality rates after prostatectomy.

Obesity, risk of biochemical recurrence, and prostate-specific antigen doubling time after radical prostatectomy: results from the SEARCH database.

To examine the association between body mass index (BMI) and aggressive biochemical recurrence (BCR) using the Shared Equal Access Regional Cancer Hospital (SEARCH) database. We identified 4123 men with complete data treated by radical prostatectomy between 1988 and 2015. We tested the association between BMI and BCR using Cox models, and among men with BCR, prostate-specific antigen doubling time (PSADT) was compared across BMI categories using linear regression. Models were adjusted for age, race, prostate-specific antigen, biopsy Gleason score, clinical stage, year and surgical centre. Overall, 922 men (22%) were of normal weight (BMI <25kg/m2 ), 1863 (45%) were overweight (BMI 25-29.9 kg/m2 ), 968 (24%) were obese (BMI 30-34.9 kg/m2 ), and 370 (9%) were moderately or severely obese (BMI ≥35 kg/m2 ). After adjustment for multiple clinical characteristics, higher BMI was significantly associated with higher risk of BCR (P = 0.008). Among men with BCR, men in the four BMI categories had similar multivariable-adjusted PSADT values (increasing BMI categories: 20.9 vs 21.3 vs 21.0 vs 14.9months; P = 0.48). While we confirmed that higher BMI was associated with BCR, we found no link between BMI and PSADT at the time of recurrence. Our data suggest obese men do not have more aggressive recurrences. Future studies are needed to test whether obesity predicts response to salvage therapies.

Obese patients with castration-resistant prostate cancer may be at a lower risk of all-cause mortality: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database.

To assess whether obesity is associated with progression to metastasis, prostate cancer-specific mortality (PCSM), and all-cause mortality (ACM), in patients with non-metastatic castration-resistant prostate cancer (non-mCRPC). At the population level, obesity is associated with prostate cancer mortality; however, some studies have found that higher body mass index (BMI) is associated with better long-term prostate cancer outcomes amongst men with mCRPC. We identified 1 192 patients with non-mCRPC from the Shared Equal Access Regional Cancer Hospital (SEARCH) database. BMI was calculated from height and weight abstracted from the medical records at the time closest to but prior to CRPC diagnosis and categorised as underweight (<21 kg/m2 ), normal weight (21-24.9 kg/m2 ), overweight (25-29.9 kg/m2 ), and obese (≥30 kg/m2 ). Competing risks regression and Cox models were used to test associations between obesity and progression to metastasis, PCSM, and ACM, accounting for confounders. Overall, 51 (4%) men were underweight, 239 (25%) were normal weight, 464 (39%) were overweight, and 438 (37%) were obese. In adjusted analysis, higher BMI was significantly associated with reduced ACM (hazard ratio [HR] 0.98, P = 0.012) but not PCSM (HR 1.00, P = 0.737) or metastases (HR 0.99, P = 0.225). Likewise, when BMI was treated as a categorical variable in adjusted models, obesity was not associated with PCSM (HR 1.11, P = 0.436) or metastases (HR 1.06, P = 0.647), but was associated with decreased ACM (HR 0.79, P = 0.016) compared to normal weight. No data were available on treatments received after CRPC diagnosis. Amongst patients with non-mCRPC obesity was associated with better overall survival. Although this result mirrors evidence from men with mCRPC, obesity was not associated with prostate cancer outcomes. Larger studies are needed to confirm these findings.

Radical prostatectomy and the effect of close surgical margins: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database.

To evaluate biochemical recurrence (BCR) patterns amongst men undergoing radical prostatectomy (RP) with specimens having negative (NSM), positive (PSM), and close surgical margins (CSM) from the Shared Equal Access Regional Cancer Hospital (SEARCH) cohort, as PSM after RP are a significant predictor of biochemical failure and possible disease progression, with CSM representing a diagnostic challenge for surgeons. Men undergoing RP between 1988 and 2015 with known final pathological margin status were evaluated. The cohort was divided into three groups based on margin status; NSM, PSM, and CSM. CSM were defined by distance of tumour ≤1 mm from the surgical margin. BCR was defined as a prostate-specific antigen (PSA) level of >0.2 ng/mL, two values at 0.2 ng/mL, or secondary treatment for an elevated PSA level. Predictors of BCR, metastases, and mortality were analysed using Cox proportional hazard models. Of 5515 men in the SEARCH database, 4337 (79%) men met criteria for inclusion in the analysis. Of these, 2063 (48%) had NSM, 1902 (44%) had PSM, and 372 (8%) had CSM. On multivariable analysis, relative to NSM, men with CSM had a higher risk of BCR (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.25-1.82; P < 0.001) but a decreased risk of BCR when compared to those men with PSM (HR 2.09, 95% CI 1.86-2.36; P < 0.001). Metastases, prostate cancer-specific mortality and all-cause mortality did not differ based on margin status alone. Management of men with CSM is a diagnostic challenge, with a disease course that is not entirely benign. The evaluation of other known risk factors probably provides greater prognostic value for these men and may ultimately better select those who may benefit from adjuvant therapy.

First postoperative PSA is associated with outcomes in patients with node positive prostate cancer: Results from the SEARCH database

ObjectiveTo analyze factors associated with metastases, prostate cancer-specific mortality, and all-cause mortality in pN1 patients. Materials and methodsWe analyzed 3,642 radical prostatectomy patients within the Shared Equal Access Regional Cancer Hospital (SEARCH) database. Pathologic Gleason grade, number of lymph nodes (LN) removed, and first postoperative prostate-specific antigen (PSA) (<0.2 ng/ml or ≥0.2 ng/ml) were among covariates assessed. Cox regression was used to analyze the association between characteristics and survival outcomes. Kaplan-Meier was used to estimate survival in pN1 patients stratified by first postoperative PSA. ResultsOf 3,642 patients, 124 (3.4%) had pN1. There were 71 (60%) patients with 1 positive LN, 32 (27%) with 2 positive LNs, and 15 (13%) with ≥3. Among men with pN1, first postoperative PSA was<0.2ng/ml in 46 patients (51%) and ≥0.2ng/ml in 44 patients (49%). Univariable Cox regression determined pathological Gleason grade (P = 0.021), seminal vesicle invasion (P = 0.010), and first postoperative PSA ≥0.2 ng/ml (P = 0.005) were associated with metastases. First postoperative PSA ≥0.2ng/ml was associated with metastasis on multivariable analysis (P = 0.046). Log-rank analysis revealed a more favorable metastases-free survival in patients with a first postoperative PSA<0.2ng/ml (P = 0.001). Estimated 5-year metastases-free survival rate was 99% for patients with a first postoperative PSA<0.2ng/ml and 87% for ≥0.2ng/ml. ConclusionspN1 patients with a first postoperative PSA ≥0.2ng/ml were more likely to develop metastases. First postoperative PSA may be useful in identifying pN1 patients who harbor distant disease and aid in secondary treatment decisions.

Predictors of operative time during radical retropubic prostatectomy and robot-assisted laparoscopic prostatectomy.

To better predict operative time using patient/surgical characteristics among men undergoing radical retropubic prostatectomy or robot-assisted laparoscopic prostatectomy in order to achieve more efficient operative scheduling and potentially decrease costs in the Veterans Health System. We analyzed 2619 men treated with radical retropubic prostatectomy (n = 2005) or robot-assisted laparoscopic prostatectomy (n = 614) from 1993 to 2013 from six Veterans Affairs Hospitals in the Shared Equal Access Regional Cancer Hospital database. Age, body mass index, race, biopsy Gleason, prostate weight, undergoing a nerve-sparing procedure or lymph node dissection, and hospital surgical volume were analyzed in multivariable linear regression to identify predictors of operative time and to quantify the increase/decrease observed. In men undergoing radical retropubic prostatectomy, body mass index, black race, prostate weight and a lymph node dissection all predicted longer operative times (all P ≤ 0.004). In men undergoing robot-assisted laparoscopic prostatectomy, biopsy Gleason score and a lymph node dissection were associated with increased operative time (P ≤ 0.048). In both surgical methods, a lymph node dissection added 25-40 min to the operation. Also, in both, each additional operation per year per center predicted a 0.80-0.89-min decrease in operative time (P ≤ 0.001). Overall, several factors seem to be associated with quantifiable changes in operative time. If confirmed in future studies, these findings can allow for a more precise estimate of operative time, which could decrease the overall cost to the patient and hospital by aiding in operating room time management.

Validation of the 2015 prostate cancer grade groups for predicting long-term oncologic outcomes in a shared equal-access health system.

A 5-tier prognostic grade group (GG) system was enacted to simplify the risk stratification of patients with prostate cancer in which Gleason scores of ≤6, 3 + 4, 4 + 3, 8, and 9 or 10 are considered GG 1 through 5, respectively. The authors investigated the utility of biopsy GG for predicting long-term oncologic outcomes after radical prostatectomy in an equal-access health system. Men who underwent prostatectomy at 1 of 6 Veterans Affairs hospitals in the Shared Equal Access Regional Cancer Hospital database between 2005 and 2015 were reviewed. The prognostic ability of biopsy GG was examined using Cox models. Interactions between GG and race also were tested. In total, 2509 men were identified who had data available on biopsy Gleason scores, covariates, and follow-up. The cohort included men with GG 1 (909 patients; 36.2%), GG 2 (813 patients; 32.4%), GG 3 (398 patients; 15.9%), GG 4 (279 patients; 11.1%), and GG 5 (110 patients; 4.4%) prostate cancer. The cohort included 1002 African American men (41%). The median follow-up was 60 months (interquartile range, 33-90 months). Higher GG was associated with higher clinical stage, older age, more recent surgery, and surgical center (P < .001) as well as increased biochemical recurrence, secondary therapy, castration-resistant prostate cancer, metastases, and prostate cancer-specific mortality (all P < .001). There were no significant interactions with race in predicting measured outcomes. The 5-tier GG system predicted multiple long-term endpoints after radical prostatectomy in an equal-access health system. The predictive value was consistent across races. Cancer 2017;123:4122-4129. © 2017 American Cancer Society.

Characterization of a "low-risk" cohort of grade group 2 prostate cancer patients: Results from the Shared Equal Access Regional Cancer Hospital database.

To examine if there is a subset of men with grade group 2 prostate cancer who could be potential candidates for active surveillance. We used the Shared Equal Access Regional Cancer Hospital database to identify 776 men undergoing radical prostatectomy from 2006 to 2015 with >8 biopsy cores obtained and complete information. We compared men who fulfilled low-risk disease criteria (clinical stage T1c/T2a; grade group 1; prostate-specific antigen ≤10 ng/mL) with the exception of grade group 2 versus men who met all three low-risk criteria. Logistic regression was used to test the association between grade group and radical prostatectomy pathological features. Biochemical recurrence was examined using Cox models. To examine whether there was a subset of men with low-volume grade group 2 with comparable outcomes to low-risk men, we repeated all analyses limiting the percentage of positive cores in the grade group 2 group to ≤33%, and positive cores to ≤4, ≤3 or ≤2. Grade group 2 low-risk men had increased risk of pathological grade group 3 or higher (P < 0.001), extraprostatic extension (P < 0.001), seminal vesicle invasion (P < 0.001) and higher risk of biochemical recurrence (hazard ratio = 1.76, P = 0.006). Using increasingly strict definitions of low-volume disease, at ≤2 positive cores there was no difference in adverse pathology between groups (all P > 0.2), except higher pathological grade group (P = 0.006). Biochemical recurrence was similar in men in grade group 1 and grade group 2 (hazard ratio = 1.24; P = 0.529). Among men with prostate-specific antigen ≤10 ng/mL and clinical stage T1c/T2a, those in grade group 2 with ≤2 total positive cores have similar rates of adverse pathology and biochemical recurrence as men with grade group 1.

PD10-11 ANALYSIS OF THE PREDICTIVE UTILITY OF PROGNOSTIC GRADE GROUPS (PGG) FOR PREDICTING PERIOPERATIVE ONCOLOGIC OUTCOMES OF RADICAL PROSTATECTOMY IN THE SHARED EQUAL ACCESS REGIONAL CANCER HOSPITAL (SEARCH) DATABASE

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I1 Apr 2017PD10-11 ANALYSIS OF THE PREDICTIVE UTILITY OF PROGNOSTIC GRADE GROUPS (PGG) FOR PREDICTING PERIOPERATIVE ONCOLOGIC OUTCOMES OF RADICAL PROSTATECTOMY IN THE SHARED EQUAL ACCESS REGIONAL CANCER HOSPITAL (SEARCH) DATABASE Ariel Schulman, Lauren Howard, Kae Jack Tay, Rajan Gupta, Efrat Tsivian, Christopher Amling, William Aronson, Matthew Cooperberg, Christopher Kane, Martha Terris, Stephen Freedland, and Thomas Polascik Ariel SchulmanAriel Schulman More articles by this author , Lauren HowardLauren Howard More articles by this author , Kae Jack TayKae Jack Tay More articles by this author , Rajan GuptaRajan Gupta More articles by this author , Efrat TsivianEfrat Tsivian More articles by this author , Christopher AmlingChristopher Amling More articles by this author , William AronsonWilliam Aronson More articles by this author , Matthew CooperbergMatthew Cooperberg More articles by this author , Christopher KaneChristopher Kane More articles by this author , Martha TerrisMartha Terris More articles by this author , Stephen FreedlandStephen Freedland More articles by this author , and Thomas PolascikThomas Polascik More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.574AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In 2015, Prognostic Grade Groups (PGG) 1 through 5 were introduced to reclassify Gleason pathology reporting. We studied the performance of the Prognostic Grade Groups (PGG) in the Shared Equal Access Regional Cancer Hospital (SEARCH) database for predicting perioperative oncologic outcomes within a multiracial equal access healthcare system. METHODS We reviewed records of men who underwent radical prostatectomy at one of six Veterans Affairs hospitals between 1988 and 2015. 4,200 men with available data were included. The predictive utility of biopsy PGG for multiple perioperative clinical endpoints was examined using logistic regression models. Interactions between PGG and race were tested. RESULTS The cohort consisted of PGG 1 through 5, respectively: 1,989(47%), 1,142(27%), 515(12%), 402(10%), 152(4%). 1,569(38%) were African American(AA). Higher biopsy PGG was associated with higher stage, older age, higher preoperative PSA and more positive biopsy cores (p≤0.012). Higher PGG was associated with higher risk of extracapsular extension(ECE), seminal vesicle invasion(SVI), positive surgical margins(PSM) and lymph node involvement(LNI) and lower likelihood of achieving PSA nadir <0.01 after surgery (all p<0.001). Lower PGG was more likely to be upgraded at surgery (p=<0.001). [Table 1 outlines risks associated with each PGG group.] AA men had decreased risk of upgrading (p=0.001). None of the other endpoints varied by race(p>0.1). CONCLUSIONS Prostate Prognostic Grade Groups predicted multiple perioperative oncologic endpoints after prostatectomy in a large, multiracial cohort of men. In this cohort, African American men had lower rates of pathologic upgrading at surgery. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e204 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Ariel Schulman More articles by this author Lauren Howard More articles by this author Kae Jack Tay More articles by this author Rajan Gupta More articles by this author Efrat Tsivian More articles by this author Christopher Amling More articles by this author William Aronson More articles by this author Matthew Cooperberg More articles by this author Christopher Kane More articles by this author Martha Terris More articles by this author Stephen Freedland More articles by this author Thomas Polascik More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD03-10 VALIDATION OF THE 2015 PROSTATE CANCER PROGNOSTIC GRADE GROUPS FOR PREDICTING LONG-TERM ONCOLOGIC OUTCOMES IN A SHARED EQUAL ACCESS HEALTH SYSTEM.

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History I1 Apr 2017PD03-10 VALIDATION OF THE 2015 PROSTATE CANCER PROGNOSTIC GRADE GROUPS FOR PREDICTING LONG-TERM ONCOLOGIC OUTCOMES IN A SHARED EQUAL ACCESS HEALTH SYSTEM. Ariel Schulman, Lauren Howard, Kae Jack Tay, Rajan Gupta, Efrat Tsivian, Christopher Amling, William Aronson, Matthew Cooperberg, Christopher Kane, Martha Terris, Stephen Freedland, and Thomas Polascik Ariel SchulmanAriel Schulman More articles by this author , Lauren HowardLauren Howard More articles by this author , Kae Jack TayKae Jack Tay More articles by this author , Rajan GuptaRajan Gupta More articles by this author , Efrat TsivianEfrat Tsivian More articles by this author , Christopher AmlingChristopher Amling More articles by this author , William AronsonWilliam Aronson More articles by this author , Matthew CooperbergMatthew Cooperberg More articles by this author , Christopher KaneChristopher Kane More articles by this author , Martha TerrisMartha Terris More articles by this author , Stephen FreedlandStephen Freedland More articles by this author , and Thomas PolascikThomas Polascik More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.216AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The 2015 prostate cancer grading system was introduced to simplify pathologic stratification. We examine the performance of the Prognostic Grade Groups (PGG) in the Shared Equal Access Regional Cancer Hospital (SEARCH) database with respect to long term prostate cancer outcomes and whether associations vary by race within an equal access healthcare system. METHODS We performed a retrospective review of men undergoing radical prostatectomy at one of six Veterans Affairs hospitals between 1988 and 2015. We identified 4,325 men with available data. The prognostic ability of PGG for multiple long term clinical endpoints was examined using Cox models. Interactions between PGG and race were tested. RESULTS The cohort consisted of PGG 1 through 5, respectively: 2,077(48%), 1,171(27%), 521(12%), 409(10%), 147(3%). 1,596(38%) were African American. Median follow up was 86(IQR: 45 to 135) months. Higher PGG was associated with higher stage, older age, more recent year of surgery and surgical center (p<0.02). African American men had a lower PGG distribution (p=0.028). Higher PGG was associated with increased risk of all clinical endpoints on univariable and multivariable regression including biochemical recurrence (BCR), adjuvant therapy, castrate resistant prostate cancer (CRPC) [Figure 1, left], metastases, prostate cancer specific mortality (PCSM) and overall survival (OS) [Figure 1, right] (all p<0.001).We found no significant interactions with race in predicting any of the measured outcomes. (BCR: p=0.78, adjuvant therapy: p=0.60, CRPC: p=0.91, metastases: p=0.61, PCSM: p=0.83, OS: p=0.21). CONCLUSIONS The 2015 Prognostic Grade Groups predicted multiple long term clinical endpoints after prostatectomy in a large, multiracial cohort of men. The predictive value for survival endpoints was similar in Caucasian and African American men. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e60-e61 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Ariel Schulman More articles by this author Lauren Howard More articles by this author Kae Jack Tay More articles by this author Rajan Gupta More articles by this author Efrat Tsivian More articles by this author Christopher Amling More articles by this author William Aronson More articles by this author Matthew Cooperberg More articles by this author Christopher Kane More articles by this author Martha Terris More articles by this author Stephen Freedland More articles by this author Thomas Polascik More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Obesity and prostate cancer-specific mortality after radical prostatectomy: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database

Background:At the population level, obesity is associated with prostate cancer (PC) mortality. However, few studies analyzed the associations between obesity and long-term PC-specific outcomes after initial treatment.Methods:We conducted a retrospective analysis of 4268 radical prostatectomy patients within the Shared Equal Access Regional Cancer Hospital (SEARCH) database. Cox models accounting for known risk factors were used to examine the associations between body mass index (BMI) and PC-specific mortality (PCSM; primary outcome). Secondary outcomes included biochemical recurrence (BCR) and castration-resistant PC (CRPC). BMI was used as a continuous and categorical variable (normal <25 kg/m2, overweight 25–29.9 kg/m2 and obese ⩾30 kg/m2). Median follow-up among all men who were alive at last follow-up was 6.8 years (interquartile range=3.5–11.0). During this time, 1384 men developed BCR, 117 developed CRPC and 84 died from PC. Hazard ratios were analyzed using competing-risks regression analysis accounting for non-PC death as a competing risk.Results:On crude analysis, higher BMI was not associated with risk of PCSM (P=0.112), BCR (0.259) and CRPC (P=0.277). However, when BMI was categorized, overweight (hazard ratio (HR) 1.99, P=0.034) and obesity (HR 1.97, P=0.048) were significantly associated with PCSM. Obesity and overweight were not associated with BCR or CRPC (all P⩾0.189). On multivariable analysis adjusting for both clinical and pathological features, results were little changed in that obesity (HR=2.05, P=0.039) and overweight (HR=1.88, P=0.061) were associated with higher risk of PCSM, but not with BCR or CRPC (all P⩾0.114) with the exception that the association for overweight was no longer statistical significant.Conclusions:Overweight and obesity were associated with increased risk of PCSM after radical prostatectomy. If validated in larger studies with longer follow-up, obesity may be established as a potentially modifiable risk factor for PCSM.

In Men with Castration-Resistant Prostate Cancer, Visceral Metastases Predict Shorter Overall Survival: What Predicts Visceral Metastases? Results from the SEARCH Database

BackgroundAlthough visceral metastases (VMs) are widely recognized to portend worse prognoses compared with bone and lymph metastases in men with metastatic castration-resistant prostate cancer (mCRPC), little is known about what predicts VMs and the extent to which men with VMs do worse. ObjectiveTo determine whether men with VMs at initial mCRPC diagnosis have worse overall survival (OS) and identify predictors of VMs. Design, setting, and participantsWe analyzed 494 men diagnosed with castration-resistant prostate cancer post-1999 and no known metastases from five Veterans Affairs hospitals of the Shared Equal Access Regional Cancer Hospital (SEARCH) database who later developed metastases. Radiology scans within 30 d of initial metastasis diagnosis were reviewed to collect information on bone, visceral, and lymph node metastases. We analyzed the 236 men who had a computed tomography scan performed. Outcome measurements and statistical analysisPredictors of VMs and OS were evaluated using logistic regression and Cox models, respectively. Results and limitationsOf the 236 mCRPC patients, 38 (16%) had VMs. Regarding VMs, 19 patients (50%), 8 patients (21%), and 16 patients (42%) had metastases in the liver, lungs, and other locations, respectively. VMs were a predictor of OS on crude analysis (hazard ratio [HR]: 1.88; 95% confidence interval [CI], 1.30–2.72; p=0.001) and after risk adjustment (HR: 1.84; 95% CI, 1.24–2.72; p=0.002). Age, year, treatment center, prostate-specific antigen (PSA), and time from CRPC to metastases were significant in predicting OS (all p<0.05). None of the variables tested were associated with having VMs (all p > 0.09). Prospective studies and larger cohorts are needed to validate our findings. ConclusionsDemographic, tumor, and PSA kinetic characteristics were not predictive of having VMs, but VMs predicted worse OS. Patient summaryBecause patients with VMs have worse overall survival, further research is needed to develop better biomarkers and thus diagnose those with VMs at earlier stages in their disease course.

Racial Differences in the Association Between Preoperative Serum Cholesterol and Prostate Cancer Recurrence: Results from the SEARCH Database.

Black men are disproportionately affected by both cardiovascular disease and prostate cancer. Epidemiologic evidence linking dyslipidemia, an established cardiovascular risk factor, and prostate cancer progression is mixed. As existing studies were conducted in predominantly non-black populations, research on black men is lacking. We identified 628 black and 1,020 non-black men who underwent radical prostatectomy and never used statins before surgery in the Shared Equal Access Regional Cancer Hospital (SEARCH) database. Median follow-up was 2.9 years. The impact of preoperative hypercholesterolemia on risk of biochemical recurrence was examined using multivariable, race-stratified proportional hazards. In secondary analysis, we examined associations with low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides, overall and among men with dyslipidemia. High cholesterol was associated with increased risk of recurrence in black [HR(per10 mg/dL) 1.06; 95% confidence interval (CI), 1.02-1.11] but not non-black men (HR(per10 mg/dL) 0.99; 95% CI, 0.95-1.03; P(interaction) = 0.011). Elevated triglycerides were associated with increased risk in both black and non-black men (HR(per10 mg/dL) 1.02; 95% CI, 1.00-1.03 and 1.02; 95% CI, 1.00-1.02, respectively; P(interaction) = 0.458). There were no significant associations between LDL or HDL and recurrence risk in either race. Associations with cholesterol, LDL, and triglycerides were similar among men with dyslipidemia, but low HDL was associated with increased risk of recurrence in black, but not non-black men with dyslipidemia (P(interaction) = 0.047). Elevated cholesterol was a risk factor for recurrence in black but not non-black men, whereas high triglycerides were associated with increased risk regardless of race. Significantly contrasting associations by race may provide insight into prostate cancer racial disparities.

Pathologic and biochemical outcomes among African American and Caucasian men with low-risk prostate cancer in the search database: Implications for active surveillance candidacy.

76 Background: Racial disparities in the incidence and risk profile of prostate cancer (PCa) at diagnosis among African American (AA) men are well reported, however it remains unclear whether AA race is independently associated with adverse pathological findings among men with clinical low risk disease. Methods: We conducted a retrospective analysis among 895 men, with clinical low risk (Gleason 3+3, clinical stage ≤T2a, PSA≤10 ng/mL) treated with immediate radical prostatectomy within the Shared Equal Access Regional Cancer Hospital (SEARCH) database. We evaluated clinical and demographic characteristics by AA or Caucasian race. Associations between AA versus Caucasian race with pathologic Gleason upgrade (≥3+4), major upgrade (≥4+3), upstage (pT3a or higher), margin status and biochemical recurrence (BCR) were examined using chi-square, logistic regression, log-rank, and Cox proportional hazards analyses. Results: We identified 355 AA and 540 Caucasian men with low-risk tumors within the SEARCH cohort followed for a median of 6.3 (IQR 3.8-8.9). AA men were younger (mean 59.5vs. 62.0 years), and had higher median PSA (5.5 vs. 5.1). Following adjustment for relevant covariates, AA race was not significantly associated with pathological upgrade (OR 1.335, 95% CI 0.936-1.905, p=0.111), major upgrade (OR 0.561, 95% CI 0.300-1.049, p=0.070), upstaging (OR 1.111, 95% CI 0.670-1.844, p=0.683), or positive surgical margins (OR 1.046, 95% CI 0.732-1.494, p=0.806). The 5-year recurrence-free survival rates were 73.4% and 78.4% for AA and Caucasian men, respectively (log-rank p=0.178). After adjustment for clinical and pathological characteristics, AA race was not significantly associated with BCR (HR 1.1.054, 95% CI 0.814-1.501, p=0.521). Conclusions: In a cohort of low-risk men treated with prostatectomy within an equal access health system with a high representation of AA men, no significant differences were observed in the rates of pathologic upgrading, upstaging or biochemical recurrence. These data support continued use of AS in AA. Upgrading and upstaging remain concerning possibilities for all men regardless of race.