All-cause Survival Research Articles

Abstract 13379: Cause-specific Mortality by Diffuse Coronary Artery Calcium Phenotypes: Results From the Coronary Artery Calcium Consortium

Objectives: We sought to assess characteristics of diffuse coronary artery calcium (CAC) phenotypes and their associations with cause-specific mortality. Background: CAC is a measure of subclinical atherosclerosis and improves risk stratification. CAC characteristics including vessel involvement, number of vessels, volume, and density have been shown to differentially impact risk. Less is known about clinical predictors of a diffuse CAC phenotype and its impact on cause-specific mortality. Methods: The CAC Consortium is a retrospective, multi-site cohort of 66,636 participants without CHD who underwent CAC scoring. Risk factor data were collected at enrollment or scan. Participants with CAC>0 were included—CAC area, CAC density, and the CAC index of diffusion (the percentage of total CAC in the vessel with the highest CAC score) were calculated and the association between CAC characteristics and CVD- and CHD-specific mortality was assessed. Results: In 28,147 study participants (mean age 58.3 years, 25% female, and 89.6% white), ~66% had ≥2 calcified vessels. Diabetes, hypertension, and hyperlipidemia were predictors of multivessel involvement (p<0.001). After controlling for CAC score, those with 4-vessel CAC had more CAC area involved with less dense calcification compared to those with 1-vessel involvement. After adjustment, those with CAC score 1-299 had a graded increase in CVD- and CHD-specific mortality with increasing vessel number compared with 1-vessel CAC. No difference was seen for individuals with CAC >300. Among those with multivessel CAC involvement, all-cause survival was significantly worse in diffuse compared to other phenotypes. Conclusion: Diffuse CAC involvement was characterized by less dense calcification, more CAC area, multiple coronary vessel involvement, and presence of certain traditional risk factors. Multivessel CAC is associated with increased CVD- and CHD-specific mortality, particularly among CAC scores 1-299.

Postdiagnostic Fruit and Vegetable Consumption and Breast Cancer Survival: Prospective Analyses in the Nurses' Health Studies.

Fruits and vegetables contain many bioactive components that may contribute to improved survival after diagnosis of breast cancer, however, evidence to date is insufficient. We prospectively assessed the associations of postdiagnostic fruit and vegetable consumption with breast cancer-specific and all-cause mortality among 8,927 women with stage I-III breast cancer identified during follow-up of the Nurses' Health Study (NHS; 1980-2010) and NHSII (1991-2011), using a validated food frequency questionnaire completed every 4 years after diagnosis. We prospectively documented 2,521 deaths, including 1,070 from breast cancer through follow-up until 2014 in the NHS and 2015 in the NHSII. Total fruit and vegetable and total vegetable consumption was related to lower all-cause [HRQ5vsQ1, 0.82; 95% confidence interval (CI), 0.71-0.94; P trend = 0.004, and HRQ5vsQ1, 0.84; 95% CI, 0.72-0.97; P trend = 0.001, respectively], but not breast cancer-specific mortality. Total fruit consumption was not related to breast cancer-specific or all-cause mortality. Greater intake of green leafy and cruciferous vegetables was associated with lower all-cause mortality. Each 2 servings/week of blueberries was associated with a 25% (HR, 0.75; 95% CI, 0.60-0.94) lower breast cancer-specific and a 17% (HR, 0.83; 95% CI, 0.72-0.96) lower all-cause mortality. In contrast, higher fruit juice consumption was associated with higher breast cancer-specific (HRQ5vsQ1, 1.33; 95% CI, 1.09-1.63; P trend = 0.002) and all-cause mortality (HRQ5vsQ1, 1.19; 95% CI, 1.04-1.36; P trend = 0.003). Apple juice largely accounted for these higher risks and orange juice was not associated with risk. Higher postdiagnostic fruit and vegetable consumption among breast cancer survivors was not associated with breast cancer-specific mortality. However, our findings suggest that higher vegetable consumption, particularly green leafy and cruciferous vegetables, was associated with better overall survival among patients with breast cancer. Higher fruit juice consumption, but not orange juice, was associated with poorer breast cancer-specific and all-cause survival. SIGNIFICANCE: A large-scale study shows that high fruit and vegetable consumption may be associated with better overall survival among breast cancer patients, while high fruit juice consumption may be associated with poorer porgnosis.

Survival following abdominal aortic aneurysm repair in North Queensland is not associated with remoteness of place of residence.

ObjectiveTo assess whether survival and clinical events following elective abdominal aortic aneurysm (AAA) repair were associated with remoteness of residence in North Queensland, Australia.MethodsThis retrospective cohort study included participants undergoing elective AAA repair between February 2002 and April 2020 at two hospitals in Townsville, North Queensland, Australia. Outcomes were all-cause survival and AAA-related events, defined as requirement for repeat AAA repair or AAA-related mortality. Remoteness of participant’s place of residence was assessed by the Modified Monash Model classifications and estimated distance from the participants’ home to the tertiary vascular centre. Cox proportional hazard analysis examined the association of remoteness with outcome.ResultsThe study included 526 participants undergoing elective repair by open (n = 204) or endovascular (n = 322) surgery. Fifty-four (10.2%) participants had a place of residence at a remote or very remote location. Participants' were followed for a median of 5.2 (inter-quartile range 2.5–8.3) years, during which time there were 252 (47.9%) deaths. Survival was not associated with either measure of remoteness. Fifty (9.5%) participants had at least one AAA-related event, including 30 (5.7%) that underwent at least one repeat AAA surgery and 23 (4.4%) that had AAA-related mortality. AAA-related events were more common in participants resident in the most remote areas (adjusted hazard ratio 2.83, 95% confidence intervals 1.40, 5.70) but not associated with distance from the participants’ residence to the tertiary vascular centreConclusionsThe current study found that participants living in more remote locations were more likely to have AAA-related events but had no increased mortality following AAA surgery. The findings emphasize the need for careful follow-up after AAA surgery. Further studies are needed to examine the generalisability of the findings.

Outcome of Nodular Lymphocyte Predominant Hodgkin Lymphoma: A Finnish Nationwide Population-Based Study

Background Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) is a rare subtype of Hodgkin lymphoma (HL) with typically indolent clinical course. Although NLPHL is associated with favorable prognosis, late relapses, and a tendency to undergo transformation to aggressive lymphoma is seen in a substantial proportion of cases. Population-based long-term data on outcomes is limited. Aims We aimed to assess outcomes of the patients diagnosed with NLPHL in Finland. Methods We retrieved NLPHL patients diagnosed between 1995-2016 from the Finnish Cancer Registry (FCR) with complete follow-up to end of 2018. The Registry has an excellent coverage and provides accurate population-based nationwide data for all histologically verified cancers in Finland. Gender and events such as histologically verified progression and transformation were obtained from the FCR. Date of death or emigration was verified from the Population Register and underlying cause of death (COD) from Statistics Finland. COD was categorized into three groups: lymphoma, solid cancer, or other cause. Patients were categorized into diagnostic calendar periods (1995-2002, 2003-2010, 2011-2016), gender, according to relapse, transformation, and patient status (alive, dead, emigrated) by end of 2018. Standard descriptive statistical analyses were performed. Progression free survival (PFS) and all-cause overall survival (OS) was estimated via Kaplan-Meier method. Analysis of risk factors for OS and transformation was performed using the Cox proportional hazard model. Risk factors included diagnostic calendar period, age at diagnosis as a continuous variable (year), gender, relapse, and transformation. Multivariate analysis was performed including only factors with a p value < 0.05 from the univariate model. Two-tailed p-values < 0.05 were considered statistically significant. All statistical analyses were performed using R, version 4.0.2. Results We retrieved 414 patients with newly diagnosed NLPHL. Majority of the patients were males (n=320; 77%). Median age was 47 years (range 5 - 87), females being significantly older than males at diagnosis (59 vs 44 years; p < 0.001). We did not observe any statistically significant differences in age at diagnosis, gender distribution, progression, or transformation rates between the calendar periods. Five- and 10-year OS for the entire patient cohort were 89% and 84%, and 5- and 10-year PFS 77% and 64%, respectively (Fig. 1, 2). Eighty-six (21%) patients had at least one histologically verified progression (range 1 - 4). During the 11.1 years (range 0.7 - 23.9) follow-up, 81 (20%) patients died. The underlying COD was any lymphoma in 34 (42%), solid cancer in 14 (17%) and other cause in 33 (41%) patients. Gender, age at diagnosis, and transformation were included in the multivariate model with respect to OS. Age at diagnosis (HR 1.07; 95% CI 1.05 - 1.09), and transformation (HR 2.6; 95% CI 1.5 - 4.7), but not gender, remained independent. We found histologically verified transformation to large B cell lymphoma in 25 (7.4%) patients with ≥ 5-year follow-up from NLHPL diagnosis. Transformation was the first event in 15 (60%) patients, and 10 (40%) patients had one or more NLPHL progressions prior to transformation. The median age at the time of transformation was 57 years (range 20 - 87) and 17 (68%) of patients were males. The transformation free proportion over 5 years of follow-up was 96% and 93% over 10 years (Fig. 3). In multivariate analysis, gender, and age at diagnosis were not significantly associated with the risk of transformation. The 5-year OS after transformation was 50% which was significantly lower compared to the nontransformed patients with 5-year OS of 90%. Fourteen (56%) of the transformed patients died during follow-up, 13 from lymphoma and 1 from other cause. Conclusion In this large nationwide population-based study, females were 15 years older than males at the time of diagnosis. Twenty-five patients (7.4%) developed transformation to large B cell lymphoma. Age and transformation were independent risk factors for poor survival, whereas progression of NLPHL and gender were not associated with adverse outcome. We did not observe any survival difference between diagnostic calendar periods. Lymphoma was the main cause of death. Figure Disclosures Malila: Cancer Society of Finland: Current Employment. Jyrkkio:Hospital District of Southwest Finland: Current Employment.

Racial and ethnic differences in diffuse large B-cell lymphoma survival among an underserved, urban population

Racial/ethnic differences in diffuse large B-cell lymphoma (DLBCL) survival have focused on non-Hispanic Whites (NHW) and non-Hispanic Blacks (NHB), often excluding Hispanics/Latinos. To further assess these racial/ethnic survival differences, we identified incident DLBCL cases diagnosed between 2005 and 2016 (n = 404; NHW = 136, NHB = 106, Hispanic/Latino = 162) at Montefiore Medical Center (Bronx, NY). All-cause mortality survival curves were assessed by the Kaplan-Meier method and log-rank test. Cox proportional hazards regression assessed the association between demographic/clinical factors and all-cause mortality. Hispanic/Latino patients experienced 52% lower risk of mortality compared to NHWs (HR = 0.48, 95%CI = 0.28–0.83), after adjusting for clinical prognostic factors. This reduced risk experienced by Hispanics/Latinos was similarly observed by age at diagnosis (≤60 years, >60 years), stage (I/II, III/IV), and receipt of chemotherapy. NHBs and NHWs experienced similar risk of mortality (HR = 0.85, 95%CI = 0.52–1.40). Overall, among DLBCL patients, Hispanics/Latinos had improved survival compared to NHWs. Additional research should seek to identify the drivers of this survival benefit.

All-cause and cancer-specific overall survival in kidney transplant recipients with pre-transplant malignancies in a German cohort

Kidney insufficiency and immunosuppression are well established contributors of tumor development, both before and after kidney transplantation. Patients with pre-transplant malignancies (PTM) are at risk of tumor recurrence and of the development of an unrelated tumor after transplantation. In this retrospective study of a German patient cohort, we analyzed 1089 patients that underwent kidney transplantation to determine the frequency, recurrence rate and overall survival of patients with pre-existing tumors across a 10-year period. PTM were found in 5.79% of the patients and appeared at a mean time of 7.39 (SD 6.8) years before transplantation. The tumors were most frequently of urologic (41.43%) origin, followed by malignancies of the skin (25.71%) and gynecologic tumors (10%). Tumor recurrence was observed in one case (1.6%) where the patient died of metastatic spinocellular carcinoma. Patients with pre-existing malignancies had a statistically significantly worse overall survival compared to transplant recipients without tumors (HR = 2.71, 95% CI 1.49–4.969). However, these differences could be entirely ascribed to the age (HR = 1.06, 95% CI 1.04–1.08) and gender (HR = 1.67, 95% CI 1.11–2.52) of the patients. We found that there was no difference in cancer-specific mortality or posttransplant cancer rate between patients with and without pre-existing malignancies (HR = 0.94, 95% CI 0.21–4.26).

Arterial calcification and long-term outcome in chronic limb-threatening ischemia patients

PurposeWithin five years after presentation 50–60% of patients with chronic limb-threatening ischemia (CLI) have died or had an amputation. We assessed the predictive value of lower extremity arterial calcification on computed tomography (CT) characteristics on both 7-years amputation-free survival and 10-years all-cause mortality in patients with CLI. MethodIncluded were 89 CLI patients (mean age 73.1 ± 11.6 years) who underwent a CT angiography of the lower extremities. In the femoropopliteal and crural arteries based on a CT score the following calcification characteristics were assessed: severity, annularity, thickness and continuity. The predictive value of different arterial calcification characteristics was analysed by age- and sex-adjusted multivariate Cox regression analysis. ResultsComplete annular calcifications were common (femoropopliteal 43.7%, n = 38; crural, 63.2%, n = 55). Mean survival was 278.4 weeks (95% CI 238.77–318.0 weeks). Patients with complete annular calcifications had a higher all-cause 10-year mortality (femoropopliteal unadjusted HR 1.64, p = 0.04 and adjusted for age and sex HR 1.68, p = 0.04; crural unadjusted HR 1.92, p = 0.02, adjusted for age and sex HR 2.29, p = 0.006) than patients with other calcification characteristics. ConclusionsAnnularity of calcification of both femoropopliteal and crural arteries is a predictor for 10-year all-cause survival, its hazard being even higher than the traditional prognostic risk factors for CLI and therefore could be involved in the poor survival of these patients.

Temporal Assessment of Prognostic Factors in Patients With Pancreatic Ductal Adenocarcinoma Undergoing Neoadjuvant Treatment and Resection

BackgroundThe clinicopathologic factors associated with the survival of patients with pancreatic ductal adenocarcinoma (PDAC) during the different phases of neoadjuvant treatment (NT)—at diagnosis, restaging, or postoperatively—remain unclear. MethodsData of patients with PDAC who underwent pancreatic resection after NT between 2008 and 2018 were retrospectively collected. Clinicopathologic characteristics and outcomes were compared stratified by resection margin status. Three multivariable regression models (at diagnosis, restaging, and postoperatively) were constructed to assess the temporal impact of different prognostic factors on all-cause survival (ACS) and disease-free survival (DFS). ResultsAll patients were diagnosed with a nonmetastatic PDAC and were appropriate candidates for NT according to the current National Comprehensive Cancer Network guidelines. From a total of 83 patients, 57 (68.7%) had a negative resection margin >1 mm (R0), whereas 26 patients (31.3%) had a positive resection margin (R1). At diagnosis, planned procedure (P = 0.017) and CA19-9 >100 U/mL (P = 0.047) were independent prognostic factors of decreased ACS. At restaging, planned procedure (P = 0.017), FOLFIRINOX (P = 0.026), and tumor size >30 mm (P = 0.030) were independent prognostic factors for increased and decreased ACS, respectively. Postoperatively, R0 was an independent prognostic factor for improved ACS (P = 0.005) and DFS (P = 0.002), whereas adjuvant therapy (P = 0.006) was associated with increased ACS. Lymph node involvement (P = 0.019) was associated with decreased DFS. ConclusionsAt diagnosis, restaging, and postoperatively, different, relevant clinicopathologic factors significantly impact the survival of patients with nonmetastatic PDAC undergoing NT. An R0 resection remains the most important prognostic factor and therefore should be the primary goal of surgical treatment in the neoadjuvant setting.

How long does a shoulder replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 10 years of follow-up.

Shoulder replacement is an increasingly common treatment for end-stage degenerative shoulder conditions. Some shoulder replacements are unsuccessful and additional operations might be required. It is important for patients and clinicians to know how long shoulder replacements last and how effectively they reduce pain and improve function. This study aims to determine the longevity and long-term efficacy of shoulder replacements. In this systematic review and meta-analysis, we searched MEDLINE and Embase from their inception to Sept 24, 2019, for case series and registry data reporting 10-year or longer survival of total shoulder replacements, humeral hemiarthroplasties, and reverse total shoulder replacements of a specific brand of implant. Survival, implant, and patient-reported outcome measures data were extracted. The primary outcome was implant survival. We reviewed and analysed national joint replacement registries separately. We weighted each series by SE and calculated a pooled survival estimate at years 10, 15, and 20. For patient-reported outcome measures we pooled the standardised mean difference at 10 years. This study is registered with PROSPERO, CRD42019140221. 927 non-duplicate articles were identified by our search, nine articles (reporting ten series) were eligible for analysis of survival and six articles were eligible for analysis of patient reported outcomes. The ten series reported all-cause survival of 529 total shoulder replacements and 364 humeral hemiarthroplasties; no series for reverse total shoulder replacement met the inclusion criteria. The estimated 10-year survival for total shoulder replacement was 94·6% (95% CI 93·6-97·6) and humeral hemiarthroplasties was 90·4% (87·0-94·0). A single registry contributed 7651 total shoulder replacements, 1395 humeral hemiarthroplasties, and 7953 reverse total shoulder replacements. The pooled registry 10-year survival was 92·0% (95% CI 91·0-93·0) for total shoulder replacement, 85·5% (83·3-87·7) for humeral hemiarthroplasties, and 94·4% (93·4-95·7) for patients with osteoarthritis who had reverse total shoulder replacement and 93·6% (91·1-95·8) for patients with rotator cuff arthropathy who had reverse total shoulder replacement. Pooled 10-year patient-reported outcome measures showed a substantial improvement from baseline scores, with a standardised mean difference of 2·13 (95% CI 1·93-2·34). Our data show that approximately 90% of shoulder replacements last for longer than 10 years and patient-reported benefits are sustained. Our findings will be of use to surgeons and patients in the informed consent process and to health-care providers for resource planning. The National Institute for Health Research, the National Joint Registry for England, Wales, Northern Ireland, and Isle of Man, and the Royal College of Surgeons of England.

Reference-adjusted and standardized all-cause and crude probabilities as an alternative to net survival in population-based cancer studies.

In population-based cancer survival studies, the most common measure to compare population groups is age-standardized marginal relative survival, which under assumptions can be interpreted as marginal net survival; the probability of surviving if it was not possible to die of causes other than the cancer under study (if the age distribution was that of a common reference population). The hypothetical nature of this definition has led to confusion and incorrect interpretation. For any measure to be fair in terms of comparing cancer survival, then differences between population groups should depend only on differences in excess mortality rates due to the cancer and not differences in other-cause mortality rates or differences in the age distribution. We propose using crude probabilities of death and all-cause survival which incorporate reference expected mortality rates. This makes it possible to obtain marginal crude probabilities and all-cause probability of death that only differ between population groups due to excess mortality rate differences. Choices have to be made regarding what reference mortality rates to use and what age distribution to standardize to. We illustrate the method and some potential choices using data from England for men diagnosed with melanoma. Various marginal measures are presented and compared. The new measures help enhance understanding of cancer survival and are a complement to the more commonly used measures.

Effect of Patient Demographics and Tracheostomy Timing and Technique on Patient Survival.

The ideal timing and technique of tracheostomy vary among patients and may impact outcomes. We aim to examine the association between tracheostomy timing, placement technique, and patient demographics on survival. Retrospective cohort study. A retrospective review was performed for all patients who underwent tracheostomy in 2016 and 2017 at one urban academic tertiary-care hospital. Kaplan-Meier curves were created based on combinations of tracheostomy timing and technique (early percutaneous, early non-percutaneous, late percutaneous, and late non-percutaneous). Cox proportional hazard models were used to determine multivariable effects of timing, technique, and other demographic factors. Primary outcome measures were tracheostomy-related mortality and overall survival. Secondary outcomes were in-hospital, 30-day, and 90-day mortality. Our study included 523 patients. There were six tracheostomy-related deaths, with hemorrhage and tracheoesophageal fistula being the most common causes. Tracheostomy timing and technique combinations were not associated with differences in all-cause mortality or survival following discharge. Cox proportional hazard models showed that Charlson Comorbidity Index (CCI) and unknown partner status were associated with a decrease in survival (P < .01 and P=.05, respectively). Additionally, patient age, gender, race, CCI, and body mass index were not independently associated with changes in survival. Late and non-percutaneous tracheostomies were associated with more tracheostomy-related deaths, but timing and technique were not associated with differences in patient survival. Multiple regression analysis showed that increased patient comorbidities, measured via CCI, and unknown partner status were independently associated with decreased survival. Proceduralists should discuss timing, technique, and patient social factors together with the medical care team when constructing plans for postdischarge management. 4 Laryngoscope, 131:1468-1473, 2021.

Synergistic effects of histologic subtype, T-stage, and M-stage in the prognosis of differentiated thyroid cancer: a retrospective observational study.

BackgroundThe incidence of differentiated thyroid cancer has increased in many countries during the past few decades. This study aimed to investigate the synergistic effect of clinicopathological factors, including histologic subtype, T stage, and M stage, on the prognosis of differentiated thyroid cancer (DTC).MethodsWe collected data on 86,302 patients with DTC from 2004 to 2013 from the SEER database. We extracted multiple variables from the selected object of study. Demographic characteristics consisted of age at diagnosis, sex, year of diagnosis, and race. Pathological characteristics included T stage, N stage, M stage, multifocality, histologic subtype and extrathyroidal extension. Treatment characteristics included radiation therapy and surgery. Univariate and multivariate analyses were conducted to evaluate the correlation between clinicopathological factors and prognosis. The relative excess risk of synergistic effect (RERI), attributable proportion (AP) of synergistic effect, and synergy index (SI) were used to explore the synergistic effect of these factors on prognosis.ResultsHistologic subtype, T-stage, and M-stage were found to be risk factors for cancer-specific survival and all-cause survival in multivariate analysis. The cancer-specific mortality (CSM) rates per 1,000 person-years for patients were found to be higher in follicular thyroid carcinoma (FTC) patients and patients with T3–T4, M1 status disease. In addition, CSM and all-cause mortality (ACM) were also associated with age, sex, race, N- stage, extension, radiation treatment, and surgical approach (all, P<0.001). We also found that histologic subtype had a synergistic effect with both T and M status stage on the prognosis (RERI =7.431, AP =0.278, SI =1.407; RERI =37.889, AP =0.430, SI =1.771, respectively). Synergy was also noted between T- stage and M- stage (RERI =134.125, AP =0.537, SI =2.168).ConclusionsHistologic subtype, T-stage, and M-stage in different combinations were risk factors for poor prognosis in DTC, and had synergistic effects.

Synergic effects of histology subtype, lymph node metastasis, and distant metastasis on prognosis in differentiated thyroid carcinoma using the SEER database.

Differentiated thyroid carcinoma (DTC) is the most common clinical type of thyroid carcinoma. There are rare reports on the synergic effects of the different clinicopathological risk factors on the prognosis of it. We retrospectively reviewed data on 86,032 DTC patients from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox regression analyses were conducted to evaluate the correlation between clinicopathological factors and the prognosis of DTC. Relative excess risk (RERI) of synergic effect, attributable proportion (AP) of synergic effect, and synergy index (SI) were calculated to assess synergic effects. Kaplan-Meier analyses with log-rank tests was used to plot the survival curve affected by different risk factors. Histology subtype, lymph node metastasis (LNM) status, and distant metastasis (DM) were independent risk factors for cancer-specific survival (CSS) and all-cause survival (ACS) in the multivariate analysis (all, P<0.001). Patients' age at diagnosis, sex, extrathyroidal extension, and radiation also influenced prognosis (all, P<0.001). The cancer-specific mortality (CSM) and all-cause mortality (ACM) rates per 1,000 person-years were higher in patients with follicular thyroid carcinoma (FTC) and in those with N1 stage and M1 stage disease. Furthermore, we observed a significant synergic effect between histology subtype and N stage, as well as histology subtype and M stage for the CSM of DTC (RERI =48.806, AP =0.853, SI =7.565; RERI =37.889, AP =0.430, SI =1.771, respectively). However, no synergic effect was observed in the case of the N stage and M stage for the CSM of DTC (RERI =7.928, AP =0.084, SI =1.093). Patients with histology subtype of FTC and N1 stage, histology subtype of FTC and M1 stage had significant additive synergic effects on DTC prognosis for CSM.

Re: Radiation Dose Escalation or Longer Androgen Suppression to Prevent Distant Progression in Men with Locally Advanced Prostate Cancer: 10-Year Data from the TROG 03.04 RADAR Trial.

No AccessJournal of UrologyUrological Survey1 Oct 2020Re: Radiation Dose Escalation or Longer Androgen Suppression to Prevent Distant Progression in Men with Locally Advanced Prostate Cancer: 10-Year Data from the TROG 03.04 RADAR Trial Samir S. TanejaMD Samir S. TanejaSamir S. Taneja More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001220.02AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Re: Radiation Dose Escalation or Longer Androgen Suppression to Prevent Distant Progression in Men with Locally Advanced Prostate Cancer: 10-Year Data from the TROG 03.04 RADAR Trial." The Journal of Urology, 204(4), pp. 879–880 Suggested Reading : Survival outcomes of dose-escalated external beam radiotherapy versus combined brachytherapy for intermediate and high risk prostate cancer using the National Cancer Data Base. J Urol 2016; 195: 1453. Link, Google Scholar : Impact of hormonal therapy on intermediate risk prostate cancer treated with combination brachytherapy and external beam irradiation. J Urol 2010; 183: 546. Link, Google Scholar : 15-Year cause specific and all-cause survival following brachytherapy for prostate cancer: negative impact of long-term hormonal therapy. J Urol 2014; 192: 754. Link, Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 204Issue 4October 2020Page: 879-880 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samir S. Taneja More articles by this author Expand All Advertisement Loading ...

Long-term stroke risk with carotid endarterectomy in patients with severe carotid stenosis

ObjectiveInformed debate regarding the optimal use of carotid endarterectomy (CEA) for stroke risk reduction requires contemporary assessment of both long-term risk and periprocedural risk. In this study, we report long-term stroke and death risk after CEA in a large integrated health care system. MethodsAll patients with documented severe (70%-99%) stenosis from 2008 to 2012 who underwent CEA were identified and stratified by asymptomatic or symptomatic indication. Those with prior ipsilateral interventions were excluded. Patients were followed up through 2017 for the primary outcomes of any stroke/death within 30 days of intervention and long-term ipsilateral ischemic stroke; secondary outcomes were any stroke and overall survival. ResultsOverall, 1949 patients (63.2% male; mean age, 71.3 ± 8.9 years) underwent 2078 primary CEAs, 1196 (58%) for asymptomatic stenosis and 882 (42%) for symptomatic stenosis. Mean follow-up was 5.5 ± 2.7 years. Median time to surgery was 72.0 (interquartile range, 38.5-198.0) days for asymptomatic patients and 21.0 (interquartile range, 5.0-55.0) days for symptomatic patients (P < .001). Most of the patients' demographics and characteristics were similar in both groups. Controlled blood pressure rates were similar at the time of CEA. Baseline statin use was seen in 60.5% of the asymptomatic group compared with 39.9% in the symptomatic group (P < .001), and statin adherence by 80% medication possession ratio was 19.3% asymptomatic vs 12.4% symptomatic (P < .001). The crude overall 30-day any stroke/death rates were 0.9% and 1.5% for the asymptomatic group and the symptomatic group, respectively. The 5-year risk of ipsilateral stroke and a combined end point of any stroke/death by Kaplan-Meier survival analysis were 2.5% and 28.7% for the asymptomatic group and 4.0% and 31.4% for the symptomatic group, respectively. Unadjusted cumulative all-cause survival was 74.2% for the asymptomatic group and 71.8% for the symptomatic group at 5 years. ConclusionsIn a contemporary review of CEA, outcomes for either operative indication show low adverse events perioperatively and low long-term stroke risk up to 5 years. These results are well within consensus guidelines and published trial outcomes and should help inform the discussion around optimal CEA use for severe carotid stenosis.

Outcomes of Older Patients in the Recent Era of Heart Kidney Transplantation

Background and ObjectiveVariable age thresholds are often used at transplant centers for simultaneous heart and kidney transplantation (HKT). We hypothesize that selected older recipients enjoy comparable outcome to younger recipients in the current era of HKT. MethodsWe performed a retrospective analysis of HKT outcomes in the United Network for Organ Sharing (UNOS) registry from 2006 to 2018, classifying patients by age at transplant as ≥ 65 or < 65 years. The primary outcome was patient death. Secondary outcomes included all-cause kidney graft failure and death-censored kidney allograft failure. ResultsOf 973 patients, 774 (80%) were younger than 65 years (mean 52 ± 10 years) and 199 (20%) were 65 years or older (mean 67 ± 2 years). The older HKT cohort had fewer blacks (22% vs 35%, P = .01) and women (12 vs 18%, P = .04). Fewer older patients received dialysis (30% vs 54%, P < .001) and mechanical support (36% vs 45%, P = .03) before HKT. Older recipients received organs from slightly older donors. The median follow-up time was shorter for patients 65 years or older than for the younger group (2.3 vs 3.3 years, P < .001). Patient survival was similar between the groups (mean 8.8 vs 9.8 years, P = .3), with the most common causes of death being cardiovascular (29%) and infectious complications (28%). There was no difference in all-cause kidney graft survival (mean 8.7 vs 9.3 years, P = .8). Most commonly, recipients died with a functional renal allograft (59.8%), and this occurred more commonly in older patients (81.4% vs 54.8%, P = .001). Cox proportional hazard modeling showed that higher donor age (hazard ratio [HR] 1.015, P = .01; HR 1.022, P = .02) and use of pre-transplant dialysis (HR 1.5, P = .004; HR 1.8, P = .006) increased the risk for both all-cause and death-censored kidney allograft failure, respectively. ConclusionsOur study showed that carefully selected older patients have outcomes similar to those of a younger cohort and argues for comprehensive evaluation of the recipients with age as part of comorbidity assessment rather than use of an arbitrary age threshold for candidacy.

Evaluation of Racial, Ethnic, and Socioeconomic Associations With Treatment and Survival in Uveal Melanoma, 2004-2014

Identifying disparities in uveal melanoma (UM) treatment patterns and survival across racial, ethnic, and socioeconomic (SES) groups reveals possible inequities in ophthalmologic health care. To examine the association of race, ethnicity, and SES with UM treatment and survival. A retrospective cohort analysis of 28% of the US population using the Surveillance, Epidemiology, and End Results (SEER) 18 registries from January 1, 2004, to December 31, 2014, was conducted. Data analysis was performed from April to July 2018. SEER identified 4475 individuals using International Classification of Diseases for Oncology, Third Edition site and morphology codes. Race, ethnicity, and SES estimated by tertile using Yost Index composite scores. Treatment odds ratios (ORs), 1-year and 5-year survival estimates, mortality hazard ratios (HRs), and Kaplan-Meier survival curves. Hypothesis was formulated before data collection. Multivariate analyses of 4475 individuals (2315 [51.7%] men; non-Hispanic white, 4130 [92.3%]; nonwhite, 345 [7.7%]) showed that patients who were nonwhite (OR, 1.45; 95% CI, 1.12-1.88) and socioeconomically disadvantaged (lower SES: OR, 2.21; 95% CI, 1.82-2.68; middle SES: OR, 1.86; 95% CI, 1.56-2.21) were more likely to receive primary enucleation. No interactions were observed between race/ethnicity, SES, and stage at diagnosis. From 2004 to 2014, rates of primary enucleation decreased across all racial/ethnic and SES groups, but disparities persisted. Socioeconomically disadvantaged patients had lower 5-year all-cause survival rates (lower SES: 69.2%; middle SES: 68.1%; and upper SES: 73.8%), although disease-specific survival did not vary significantly by racial/ethnic or SES strata. Mortality risk was associated with older age at diagnosis (56-68 years: HR, 1.70; 95% CI, 1.44-2.01; ≥69 years: HR, 3.32; 95% CI, 2.85-3.86), advanced stage of UM (stage 2: HR, 1.40; 95% CI, 1.19-1.65; stage 3: HR, 2.26; 95% CI, 1.87-2.73; and stage 4: HR, 10.09; 95% CI, 7.39-13.77), and treatment with primary enucleation (HR, 2.14; 95% CI, 1.88-2.44) with no racial/ethnic or SES variation. In this study, SEER data from 2004 to 2014 suggest that nonwhite and socioeconomically disadvantaged patients with UM are more likely to be treated with primary enucleation, although no such variation appears to exist in disease-specific survival. These differences reveal opportunities to address issues regarding treatment choice in UM.

Why pathologists and oncologists should know about tumour-infiltrating lymphocytes (TILs) in triple-negative breast cancer: an Australian experience of 139 cases

The presence of increased tumour infiltrating lymphocytes (TILs) is established as a positive prognostic factor in triple-negative breast cancer (TNBC). The majority of studies have examined the role of TILs in predicting response to chemotherapy, but their role as a general prognostic marker in TNBC is unclear. Moreover, there is a lack of consensus in the literature regarding a suitable cut-off point by which to stratify patients into prognostic groups. Therefore, we sought to confirm the prognostic value of TILs in an independent cohort of unselected TNBCs, and to determine an appropriate cut-off point by which to stratify TIL scores into prognostically significant categories. We used the International TILs Working Group (ITWG) methodology to assess the density of stromal TILs in our cohort of 139 TNBC patients undergoing curative resection at our institution. The percentage TILs scores were categorised first into three groups: low (0-10%), intermediate (15-50%), and high (55-100%). A second binary variable was also created by separating cases into low TILs (≤50%) and high TILs (>50%) groups. Using the three-tiered system, mean disease-free survival was 156, 99 and 94 months for the high, intermediate and low TILs groups, respectively (p=0.030). However, no statistically significant improvement was observed for overall survival. Using the two-tiered system, statistically significant improvements in both overall survival (p=0.030) and disease-free survival (p=0.010) were observed. This survival benefit remained statistically significant in multivariate analyses (p=0.010, p=0.014). We conclude that TILs scored using the ITWG system and dichotomised at a cut-off score of 50%, are a powerful predictor of all-cause and disease-free survival in TNBC regardless of chemotherapy treatment.

P1166DOES PERITONEAL PROTEIN LOSS AFFECT CARDIOVASCULAR MORTALITY OF PERITONEAL DIALYSIS PATIENTS ?

Abstract Background and Aims Peritoneal protein loss (PPL) through peritoneal effluent has been a well-recognized detrimental result of peritoneal dialysis (PD). The amount of protein lost will depend on dialysis time, protein size, its serum concentration and other factors including patients’ clinical status. Peritoneal protein loss may be a manifestation of endothelial dysfunction, as with another type of capillary protein leakage, microalbuminuria, a recognized endothelial dysfunction marker. The aim of this study was to retrospectively evaluate the influence of PPL on cardiovascular mortality of peritoneal dialysis patients Method This is a single center retrospective study of 84 PD patients (m=54, f=30) with mean age of 65.2±17 years, mean PD duration of 43.2±24.9 months conducted for the time period from 2006 to 2019 (13 years). The patients were divided into two groups according to the amount of protein excreted during the modified Peritoneal Equilibration Test (PET) procedure using PD solution of 3.86% DW, 2 Lt infusion volume for total time of 4 hours. The total amount of proteins excreted was calculate from PET by multiplying the concentration of proteins at the end of the test with the total volume of PD fluid at the same time. Group A excreted a total amount of proteins &amp;lt; 1.55 gr (median value) at the end of PET test and Group B &amp;gt; 1.55 gr. The cumulative all-cause and cardiovascular survival of the PD patients was calculated by Kaplan Meier while the possible effect of any parameter in survival rates was evaluated by using Cox Regression analysis Results There was not any statistically significant difference between the two groups according to PD duration, age, dialysis adequacy targets, Residual Renal Function(RRF), BMI, ultrafiltration volume during PET and their transport status. The cumulative all-cause survival using Kaplan-Meier analysis revealed no statistically significant deference between the two groups (Log Rank p=0.55) even though mortality risk was adjusted for several factors (Cox Regression). When cardiovascular survival, using Cox Regression analysis, was adjusted for age, sex, Diabetes, PD modality, dialysis Kt/V and RRF we found that Group A (with protein excretion &amp;lt; 1.55 gr) had statistically significant better cardiovascular survival (p=0.029) compared to Group B. We confirm these results while trying to find among the total of our patients the possible risk factors for cardiovascular mortality. Using Cox Regression analysis, the amount of protein excreted during PET procedure and the type of PD solutions (high or low in GDPs) used were statistically significant (p=0.019 and p=0.04 respectively) independent risk factors for cardiovascular survival in our patients. Conclusion These results indicate that protein loss during peritoneal dialysis procedure has negative impact on cardiovascular mortality and survival of PD patients. Additionally, the use of PD solutions with low Glucose Degradation Products (GDPs) and AGEs may improve PD patient’s cardiovascular survival. Randomized interventional studies are encouraged to address the pathological concern of PPL in the future, namely its effects on cardiovascular conditions or its role as marker and effort to reduce PPL using ACE inhibitors or vit D should be considered only if it diminishes cardiovascular morbidity or mortality.

P1174STUDY ON THE RELATIONSHIP BETWEEN HYPOCHLOREMIA AND ALL-CAUSE DEATH IN PATIENTS RECEIVING CONTINUOUS AMBULATORY PERITONEAL DIALYSIS

Abstract Background and Aims To investigate the relationship between hypochloremia on all-cause death in patients receiving continuous ambulatory peritoneal dialysis (CAPD). Method 300 CAPD patients from January 2013 to December 2019 in the Sixth People's Hospital affiliated to Shanghai Jiaotong University. According to the serum chloride level, the patients were divided into two groups: hypochloremia group (serum chlorine ≤ 96mmol / L, n = 135) and normal chloride group (106mmol / L &amp;lt; serum chlorine &amp;gt; 96mmol / L, n = 165). The endpoint was all-cause death. We used the receiver-operating characteristic (ROC) curve to analysis the diagnostic value and logistic regression to assess the predictive value in relation to serum chloride with all-cause death in CAPD patients. Kaplan Meier curve was used to evaluate the effect of serum chloride on all-cause death survival analysis. All statistics were analyzed by SPSS 20.0 software, P &amp;lt; 0.05, indicating significant difference. Results 114 cases of all-cause death occurred in CAPD patients during follow-up (62.1 ± 11.1 months). The results of correlation analysis showed that serum chloride was positively correlated with serum sodium and potassium (r=0.721,0.199, P=0.001) and the negative correlation between serum chloride and dialysis age and serum phosphorus (r=-0.321, - 0.300, P=0.001). ROC curve analysis showed that serum chloride was statistically significant in predicting all-cause death in CAPD patients (AUC = 0.666, 95% Cl = 0.601-0.730, sensitivity / specificity = 64.6% / 59.8%, best threshold = 95.5mmol/l). Kaplan Meier analysis of all-cause death risk curve shows that the incidence of all-cause death in the low chloride group is higher than that in the normal serum chloride group. Logistic regression analysis showed that low chloride level was an independent risk factor for all-cause death in CAPD patients. Conclusion Hypochloremia is an independent risk factor for all-cause death in CAPD patients.