Prostate Cancer Center Research Articles

Dose Escalation Using a Hydrogel Spacer for Intensity Modulated Radiation Therapy in Prostate Cancer

Dose Escalation Using a Hydrogel Spacer for Intensity Modulated Radiation Therapy in Prostate Cancer W.R. Bosch, W. Straube, T.A. DeWees, N.F. Mariados, J.E. Sylvester, D.K. Shah, S. Kurtzman, S.H. Zimberg, and J.M. Michalski; Washington University School of Medicine, St. Louis, MO, Associated Medical Professionals of NY PLLC, Syracuse, NY, 21st Century Oncology, Fort Myers, FL, Cancer Care of Western New York, Cheektowaga, NY, Northern California Prostate Cancer Center, Campbell, CA, Advanced Radiation Centers of New York, Hauppauge, NY

Requirements for organ-specific oncology centers

The interdisciplinary, interprofessional, and transsectoral cooperation of partners in a network is prerequisite for the certification of a prostate cancer center. The network reflects all phases and aspects of the disease from the patient's point of view. On the basis of quality indicators that are audited annually, the qualified partners of the network ensure quality of care. Quality indicators reflect the quality of the cooperation in the network, the treatment according to the evidence-based guideline, and the specific expertise of the partners. The results of the quality indicators are evaluated annually and summarized in individual and general reports. The system of the quality indicators is an important tool for quality management and to improve daily oncological care. In the future, this system will be extended to include patient-reported outcomes in combination with the OncoBox. The ongoing quantitative and qualitative improvement makes the certification system a relevant instrument for health policy institutions and is useful in political discussions regarding quality assurance and improvement.

Quality assessment in prostate cancer centers certified by the German Cancer Society.

In 2008, the German Cancer Society certification program for prostate cancer centers (PCCs) was introduced, fostering multidisciplinary and interprofessional cooperation. Since then, 97 PCCs have been certified. This paper describes the PCC certification program, quality indicators (QI) that are reported during certification, as well as changes over time and correlates of QI fulfillment. Observational data from 70,683 primary prostate cancer (PCa) cases treated between 2010 and 2013 in certified PCC sites are analyzed using descriptive and correlation analyses. Fulfillment of the requirements is high with over 80% of the sites fulfilling the requirements for most of the presented QIs with defined target values. Fulfillment increased slightly over time, with significant improvements in conducting multidisciplinary tumor conferences (increasing proportion of cases presented pre- and post-treatment, increasing participation of specialists), psycho-oncologic care, social service counseling and research participation. Bivariate associations between hospital characteristics and QIs observed were most distinct for time since first certification. Results suggest that the PCC certification program presented contributes to establishing multidisciplinary teams over time and assures the provision of high-quality PCa care. However, differences in fulfillment of the requirements exist with regard to hospital characteristics beyond the scope of the certification system.

Gleason Score 3 + 5 or 5 + 3 versus 4 + 4 Prostate Cancer: The Risk of Death

The International Society of Urological Pathology recommends that Gleason score (GS) 8 prostate cancer (PC) is one prognostic category, yet heterogeneity in cancer control potentially exists amongst men with GS 3+5/5+3 versus GS 4+4 PC. We compared PC-specific mortality (PCSM) and all-cause mortality (ACM) risk among men with GS 3+5/5+3 versus GS 4+4 PC using competing-risks and Cox regression analyses, adjusting for age, known PC prognostic factors, treatment, and a treatment propensity score. Between 1998 and 2012, 462 men with GS 8 PC were treated using brachytherapy with supplemental external-beam radiation therapy and/or androgen deprivation therapy at the Chicago Prostate Cancer Center. After a median follow-up of 7.6 yr, 118 men died, 26 of PC. PCSM (adjusted hazard ratio [AHR] 2.77, 95% confidence interval [CI] 1.13–6.80; p=0.026) and ACM (AHR 1.75, 95% CI 1.06–2.87; p=0.028) were significantly higher for men with GS 3+5/5+3 PC than for men with GS 4+4 PC. Subcategorizing GS 8 into PC with or without grade 5 should be considered as a stratification factor in randomized trials. Patient summaryLong-term success rates for men with Gleason score 8 prostate cancer vary depending on whether the most aggressive type of cancer (grade 5) is present at biopsy.

Heterogeneity in D׳Amico classification–based low-risk prostate cancer: Differences in upgrading and upstaging according to active surveillance eligibility

BackgroundTo date, no study has examined clinical, pathological, and surgical characteristics of D׳Amico low-risk patients according to active surveillance (AS) eligibility. Material and methodsWe relied on patients with low-risk prostate cancer, who were classified based on the D׳Amico classification, treated with radical prostatectomy (RP) between 2008 and 2013 at the Martini-Clinic Prostate Cancer Center. We assessed differences in clinical, pathological, and surgical characteristics in D׳Amico low-risk patients according to AS eligibility (prostate-specific antigen [PSA]≤10ng/ml, Gleason score≤3+3, ≤2 positive cores,≤50% tumor content per core, and≤cT1-2a). Multivariable logistic regression analyses targeted 2 end points: (1) presence of either intermediate- or high-risk characteristics (Gleason score≥3+4 or≥pT3 or pN1) or (2) exclusive presence of high-risk characteristics (Gleason score≥4+4 or≥pT3 or pN1) at RP. ResultsOf 1,331 patients low-risk prostate cancer classified based on the D׳Amico classification, 825 (62%) men were eligible for AS. AS candidates were less frequently either upgraded (55% vs. 78%, P<0.001) or upstaged (8% vs. 15%, P<0.001). Similarly, at final pathology, AS candidates less frequently harbored either intermediate- or high-risk (56% vs. 78%, P<0.001), or exclusive high-risk characteristics (9% vs. 16%, P<0.001). Tumor involvement per core (>50%) (most powerful), number of positive cores, PSA values, and age were independent predictors for either intermediate- or high-risk characteristics at RP. Tumor involvement per core and PSA values were independent predictors for exclusive high-risk characteristics at RP. ConclusionsD׳Amico low-risk patients did not have a homogeneous histology at RP. Especially, non-AS candidates were at a higher risk of either upgrading or upstaging at final pathology. Tumor involvement greater than 50% per core was the most powerful indicator of adverse pathology. Therefore, DʼAmico low-risk criteria are not safe enough to identify AS candidates.

New treatment options in castration-resistant prostate cancer.

Most of the updates in the 2015 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer center on the systemic therapy front, with a host of newer agents in the mix. At the NCCN 20th Annual Conference, Dr. Andrew J. Armstrong discussed some of the key developments in metastatic castration-resistant and castration-sensitive prostate cancer, particularly the conflicting results on repurposing docetaxel in castration-sensitive disease, the specific population who may experience greater survival benefit from immunotherapy in castration-resistant disease, updated data on the use of androgen receptor and biosynthesis inhibitors, and the emerging role of AR-V7 (androgen-receptor splice variant 7 messenger RNA) as a biomarker of treatment response.

Social Service Counseling in Cancer Centers Certified by the German Cancer Society

Social workers are an integral part of care provided in cancer centers that are certified according to the requirements of the German Cancer Society. This article reports on the tasks of social workers in German cancer care and on the proportion of patients that receives social service counseling (SSC) in breast, lung, colorectal, skin, gynecological, prostate, pancreas, neurological, and head and neck cancer centers based on data from 367,297 patients treated between 2009 and 2012. The highest proportions of patients (median >75%) are provided with SSC in breast and colorectal cancer centers, whereas the median is below 30% in skin cancer centers. Variation between centers and center types is high.

Integrated prostate cancer centers might cause an overutilization of radiotherapy for low-risk prostate cancer: A comparison of treatment trends in the United States and Germany from 2004 to 2011

IntroductionAim of the study was to analyze changes in primary treatment for low-risk prostate cancer across different healthcare systems. Materials and methodsWe compared “Surveillance Epidemiology and End Results” data (USA) with data from four German federal epidemiological cancer registries, both from 2004 to 2011. We excluded metastatic disease and patients aged ⩾80years. Thereof, we identified 132,506 (USA) and 54,159 (Germany) patients with low-risk according to the 2014 EAU guidelines. We tested treatment trends for statistical significance with a linear regression model. ResultsActive treatment was radical prostatectomy (RP) in 36.1% vs. 66.2% and radiotherapy (RT) in 38.4% vs. 11.8%. No active treatment (NAT) was reported in 24.2% vs. 16.2% (p<0.001 each). Through the study period the use of RP decreased from 37.1% to 34.2% in the USA (p=0.04) and was constant at a mean of 66.2% in Germany (p=0.8). The use of RT in the USA decreased from 42.8% to 31.8% (p<0.001), while it was stable in Germany (p=0.09). The NAT group grew from 18.0% to 33.2% in the USA (p<0.001), while it was stable in Germany until 2009 (p=0.3). From 2009 to 2011 there also was an increase of the NAT group in Germany from 15.2% to 19.4% (p=0.001). ConclusionIn contrast to former evidence we found the relative use of RT for low-risk prostate cancer much higher in the USA compared to Germany. The implementation of integrated prostate cancer centers in the USA might explain this observation. Deferred and defensive treatment strategies showed a steady increase in the USA. This development seems delayed in Germany by several years.

Are men with favorable intermediate-risk prostate cancer candidates for active surveillance?

82 Background: Active surveillance (AS) is considered appropriate for patients with low-risk prostate cancer (PC) and a life expectancy of at least 10 years. However, with grade migration following the 2005 International Society of Urologic Pathology consensus conference, AS may also be an initial option for men with favorable intermediate-risk PC. We estimated and compared the risk of PC-specific mortality (PCSM) following high dose radiation therapy and androgen deprivation therapy as appropriate amongst men with low, favorable intermediate, unfavorable intermediate, and high-risk PC. Methods: The study consisted of 6,595 consecutively treated men (median age: 68 years) with localized or locally advanced PC at the Chicago PC Center between 1997 and 2013. Fine and Gray competing risks regression analyses (table) were used to assess the risk of PCSM in men with favorable intermediate, unfavorable intermediate or high-risk compared to low-risk PC, adjusting for age at and year of treatment. Results: After median follow-up of 7.76 years, 820 men died: 72 of PC. While men with favorable intermediate-risk did not have significantly increased risk of PCSM as compared to low-risk PC (adjusted hazard ratio (HR) 1.28, 0.63-2.62 95% confidence interval (CI), p-value 0.49), men with high (adjusted HR 9.91, 5.48-17.94 95% CI, p-value &lt;0.0001) or unfavorable intermediate-risk PC (adjusted HR 3.17, 1.60-6.30, p-value 0.001) did. Eight-year point estimates of PCSM were low: 0.68% [0.32-1.31% 95% CI] and 0.44% [0.25-0.75% 95% CI] for men with favorable intermediate and low-risk PC, respectively. Conclusions: Men with low and favorable intermediate-risk PC have similar and low estimates of PCSM during the first decade following standard management. These results provide evidence to support AS as an initial approach for men with favorable intermediate-risk PC. [Table: see text]

RNASEL R462Q Mutation in Prostate Cancer

1 Health Sciences Center, Louisiana State University, Shreveport, USA 2 Department of Urologic Surgery and Vanderbilt Prostate Cancer Center, Vanderbilt University Medical Center, Nashville, USA *Corresponding author : Renjie Jin, Department of Urologic Surgery and Vanderbilt Prostate Cancer Center, Vanderbilt University Medical Center, A1329, MCN, 1161 21st Ave. South, Nashville, TN 37232, USA. Tel: +1-6159367849, Fax: +1-6153432447, E-mail: renjie.jin@vanderbilt.edu

'Act on oncology' as a new comprehensive approach to assess prostate cancer centres--method description and results of a pilot study.

BackgroundMultidisciplinary care of prostate cancer is increasingly offered in specialised cancer centres. It requires the optimisation of medical and operational processes and the integration of the different medical and non-medical stakeholders.ObjectiveTo develop a standardised operational process assessment tool basing on the capability maturity model integration (CMMI) able to implement multidisciplinary care and improve process quality and efficiency.Design, Setting, and ParticipantsInformation for model development was derived from medical experts, clinical guidelines, best practice elements of renowned cancer centres, and scientific literature. Data were organised in a hierarchically structured model, consisting of 5 categories, 30 key process areas, 172 requirements, and more than 1500 criteria. Compliance with requirements was assessed through structured on-site surveys covering all relevant clinical and management processes. Comparison with best practice standards allowed to recommend improvements. ‘Act On Oncology’(AoO) was applied in a pilot study on a prostate cancer unit in Europe.Results and LimitationsSeveral best practice elements such as multidisciplinary clinics or advanced organisational measures for patient scheduling were observed. Substantial opportunities were found in other areas such as centre management and infrastructure. As first improvements the evaluated centre administration described and formalised the organisation of the prostate cancer unit with defined personnel assignments and clinical activities and a formal agreement is being worked on to have structured access to First-Aid Posts.ConclusionsIn the pilot study, the AoO approach was feasible to identify opportunities for process improvements. Measures were derived that might increase the operational process quality and efficiency.

Does HistoScanning™ predict positive results in prostate biopsy? A retrospective analysis of 1,188 sextants of the prostate

The role of HistoScanning™ (HS) in prostate biopsy is still indeterminate. Existing literature is sparse and controversial. To provide more evidence according to that important clinical topic, we analyzed institutional data from the Martini-Clinic, Prostate Cancer Center, Hamburg. Patients who received prostate biopsy and who also received HS were included in the study cohort. A single examiner, blinded to pathological results, re-analyzed all HS data in accordance with sextants of the prostate. Each sextant was considered as an individual case. Corresponding results from biopsy and HS were analyzed. The area under the receiver-operating characteristic curve (AUC) for the prediction of a positive biopsy by HS was calculated. Furthermore, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were assessed according to different HS signal volume cutoffs (>0, >0.2 and >0.5 ml). Overall, 198 men were identified and 1,188 sextants were analyzed. The AUC to predict positive biopsy results by HS was 0.58. Sensitivity, specificity, PPV and NPV for HS to predict positive biopsy results per sextant, depending on different HS signal volume cutoffs (>0, >0.2 and >0.5 ml) were 84.1, 27.7, 29.5 and 82.9 %, 60.9, 50.6, 28.8 and 79.7 %, and 40.1, 73.3, 33.1 and 78.8 %, respectively. Positive HS signals do not accurately predict positive prostate biopsy results according to sextant analysis. We cannot recommend a variation of well-established random biopsy patterns or reduction of biopsy cores in accordance with HS signals at the moment.

“Act on Oncology” as a new comprehensive approach to assess prostate cancer centers.

e16095 Background: Multidisciplinary care (MDC) of prostate cancer (PC) is increasingly accepted. Key elements are well organized clinical processes and integration of clinical disciplines and stak...

MP58-09 INCIDENCE OF INSIGNIFICANT PROSTATE CANCER: A REPORT OF 955 CONSECUTIVE PATIENTS UNDERGOING RADICAL PROSTATECTOMY IN A HIGH VOLUME PROSTATE CANCER CENTER

You have accessJournal of UrologyProstate Cancer: Localized VI1 Apr 2014MP58-09 INCIDENCE OF INSIGNIFICANT PROSTATE CANCER: A REPORT OF 955 CONSECUTIVE PATIENTS UNDERGOING RADICAL PROSTATECTOMY IN A HIGH VOLUME PROSTATE CANCER CENTER Jonas Schiffmann, Georg Salomon, Thorsten Schlomm, Guido Sauter, Markus Graefen, and Hartwig Huland Jonas SchiffmannJonas Schiffmann More articles by this author , Georg SalomonGeorg Salomon More articles by this author , Thorsten SchlommThorsten Schlomm More articles by this author , Guido SauterGuido Sauter More articles by this author , Markus GraefenMarkus Graefen More articles by this author , and Hartwig HulandHartwig Huland More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1825AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Overtreatment of insignificant prostate cancer (iPCa) by radical prostatectomy (RP) and undertreatment in patients undergoing Active surveillance (AS) are still subject of a vital discussion. Considering an increasing use of AS within low risk patients and an inverse stage migration among patients treated by RP these days, contemporary reflections of the incidence of iPCa in men undergoing RP in a high volume prostate cancer center are required. METHODS Consecutive patients from our institutional database who were scheduled for RP between October 2012 and March 2013 were included into our study. We investigated retrospectively the incidence of iPCa according to different definitions (tumor volume < 0.2ml, < 0.5ml or < 2.5ml and an organ-confined tumor, no Gleason 4 or 5). RESULTS Overall, 955 patients were identified and according to different definitions of iPCa (see above) 0.9%, 2.7% and 8.8%, respectively were harboring iPCa. CONCLUSIONS The contemporary incidence of iPCa in patients scheduled for RP in a high volume prostate cancer center has decreased successfully. The patient selection has significantly improved and an overtreatment in current patients undergoing RP in our institution is strictly reduced. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e661 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Jonas Schiffmann More articles by this author Georg Salomon More articles by this author Thorsten Schlomm More articles by this author Guido Sauter More articles by this author Markus Graefen More articles by this author Hartwig Huland More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Erreichbarkeit von Organkrebszentren: Existiert bereits ein flächendeckendes Angebot in Deutschland?

For several years, health care providers and health policy have been establishing certified cancer treatment centres. Although certification is not required by law, a comprehensive and close to home medical care in certified centres is required for all patients with cancer. We analysed whether Germany already provides a spatially inclusive and comprehensive supply with certified centres for the most common cancers for women and men. Based on the central place concept "coverage" is defined as accessibility within 30 min by car for over 90% of the population. Using a software-supported route searching procedure we calculated 30- and 60-minutes-driving time zones around all breast and prostate cancre centers. We aggregated the population shares of all 5 digit postcode areas within the defined driving time zone and compared these areas to those outside the radius. The results are depicted as cartographic information. Nationwide 84% of the female populations over 18 years can reach the next breast centre within 30 min by car. In particular in the states of Mecklenburg-Western Pomerania and Brandenburg several areas do not provide sufficient access to breast centres. Using a travel time threshold of 60 min leads to an accessibility rate of 99%. 56% of the male population have access to a prostate cancer centre within half an hour by car. Again, the biggest coverage problems exist especially in eastern Germany. Within a radius of 60 min, the accessibility of prostate cancer centres increases to 94%. In Germany, some regions do not provide a spatially inclusive and comprehensive supply with organ cancer centers. However, it must be remembered that comprehensive access to care cannot be pursued as the only goal of health policy. Instead, the trade-off between justice, health and patients' interests and economic performance and adequate funding must be considered.

Interdisciplinary decision making in prostate cancer therapy – 5-years’ time trends at the Interdisciplinary Prostate Cancer Center (IPC) of the Charité Berlin

BackgroundPatients with prostate cancer face the difficult decision between a wide range of therapeutic options. These men require elaborate information about their individual risk profile and the therapeutic strategies´ risks and benefits to choose the best possible option. In order to detect time trends and quality improvements between an early patient population (2003/2004) and a later reference group (2007/2008) data was analysed with regards to epidemiologic parameters, differences in diagnostics and the type and ranking of the recommended therapies taking into account changes to Gleason Grading System and implementation of new therapeutic strategies, particularly Active surveillance, in 2005.MethodsData from all 496 consecutive patients who received consultation in 2003/2004 (n = 280) and 2007/2008 (n = 216) was retrospectively evaluated. Categorical variables were compared using the Chi-square test. Dependent variables were analysed using the unpaired Students´ t-test and the Mann–Whitney U-test.ResultsThe cohorts were comparable concerning clinical stage, initial PSA, prostate volume, comorbidities and organ confined disease. Patients in Cohort I were younger (66.44 vs. 69.31y; p < .001) and had a longer life expectancy (17.22 vs. 14.75y; p < .001). 50.9%, 28.2% and 20.9% in Cohort I and 37.2%, 39.6% and 23.2% in Cohort II showed low-, intermediate- and high-risk disease (D´Amico) with a trend towards an increased risk profile in Cohort II (p = .066). The risk-adapted therapy recommended as first option was radical prostatectomy for 91.5% in Cohort I and 69.7% in Cohort II, radiation therapy for 83.7% in Cohort I and 50.7% in Cohort II, and other therapies (brachytherapy, Active surveillance, Watchful waiting, high-intensity focused ultrasound) for 6.5% in Cohort I and 6.9% in Cohort II (p < .001). Radiation therapy was predominant in both cohorts as second treatment option (p < .001). Time trends showing quality improvement involved an increase in biopsy cores (9.95 ± 2.38 vs. 8.43 ± 2.29; p < .001) and an increased recommendation for bilateral nerve sparing (p < .001).ConclusionIn the earlier years, younger patients with a more favourable risk profile presented for interdisciplinary consultation. A unilateral recommendation for radical prostatectomy and radiation therapy was predominant. In the later years, the patient population was considerably older. However, this group may have benefitted from optimised diagnostic possibilities and a wider range of treatment options.

Perioperative Complications after Radical Prostatectomy: Open versus Robot-Assisted Laparoscopic Approach

Background: The best technique of radical prostatectomy - open versus robot-assisted approach - is controversially discussed. In this study, we compared the complication rates of open and robot-assisted radical prostatectomy during the introduction and subsequent routine use of a da Vinci® robotic device while open surgery remained the standard approach. Patients and Methods: Between January 1st, 2006, and June 4th, 2012, 2,754 men underwent radical prostatectomy at our department. Among them, 317 received robot-assisted and 2,438 open surgery. According to the requirements for prostate cancer centers certified by the Deutsche Krebsgesellschaft (German Cancer Society), a prospective database recording perioperative complications was built up. The complication rates of open and robot-assisted radical prostatectomy were compared with the χ² or Fisher exact test. The distributions of quantitative variables were compared with U tests. Results: Whereas the demographic factors favored patients selected for robot-assisted radical prostatectomy, there were no differences between open and robot-assisted surgery concerning length of stay, autologous blood transfusion rates and the incidence of perioperative complications. Conclusions: Open and robot-assisted radical prostatectomy had comparable complication rates. With better patient- and tumor-related parameters as well as decreasing transfusion rates in the robot-assisted subgroup, this observation might reflect the learning curves of the involved robotic surgeons.

Intermediate versus short-course hormone therapy and mortality in men with high-risk prostate cancer treated with radiation therapy.

83 Background: Radiation therapy (RT) plus 28-36 months of hormonal therapy (HT) is standard-of-care for men with high-risk prostate cancer (HRPC) based on randomized trials comparing these HT durations to 4-6 months. However, it is unknown whether shorter durations of HT may also decrease mortality. We evaluate the impact of intermediate-course HT on the risk of all-cause mortality (ACM) in men with HRPC treated with RT. Methods: The study cohort comprised 554 men with HRPC (PSA &gt; 20; Gleason score 8 or higher; or clinical stage T2c or higher) consecutively treated at the Chicago Prostate Cancer Center between 1997 and 2007. All men received brachytherapy with or without external beam RT and HT of intermediate (&gt; 6 to 24; median 12 months) or short (up to 6; median 4 months) duration. A Cox regression multivariable analysis was performed assessing whether intermediate compared to short-course HT was associated with a decreased risk of ACM, adjusting for age, year and type of RT, treatment propensity score, and known PC prognostic factors. Results: After a median follow up of 4.3 years a total of 64 (11.6%) men died. Intermediate compared to short-course HT was associated with a significantly decreased risk of ACM (adjusted hazard ratio 0.44, 95% confidence interval 0.20 - 0.94, P = 0.03). Other significant covariates are shown in the table. The 5-year estimates of ACM for intermediate versus short-course HT were 7.0% and 15.7%, respectively. Conclusions: In men with HRPC treated with RT, a median HT duration of 12 months was associated with a significantly decreased risk of ACM when compared to a median HT duration of 4 months. This raises the hypothesis that HT durations shorter than 28-36 months may be sufficient to decrease mortality in men with HRPC. The ongoing RADAR trial by the Trans Tasman Radiation Oncology Group comparing 18 to 6 months of HT may provide level I evidence to validate this hypothesis. [Table: see text]

Effect of Practice Integration Between Urologists and Radiation Oncologists on Prostate Cancer Treatment Patterns

National attention has focused on whether urology-radiation oncology practice integration, known as integrated prostate cancer centers, contributes to the use of intensity modulated radiation therapy, a common and expensive prostate cancer treatment. We examined prostate cancer treatment patterns before and after conversion of a urology practice to an integrated prostate cancer center in July 2006. Using the SEER (Statistics, Epidemiology and End Results)-Medicare database, we identified patients 65 years old or older in 1 statewide registry diagnosed with nonmetastatic prostate cancer between 2004 and 2007. We classified patients into 3 groups, including 1--those seen by integrated prostate cancer center physicians (exposure group), 2--those living in the same hospital referral region who were not seen by integrated prostate cancer center physicians (hospital referral region control group) and 3--those living elsewhere in the state (state control group). We compared changes in treatment among the 3 groups, adjusting for patient, clinical and socioeconomic factors. Compared with the 8.1 ppt increase in adjusted intensity modulated radiation therapy use in the state control group, the use of this therapy increased 20.3 ppts (95% CI 13.4, 27.1) in the integrated prostate cancer center group and 19.2 ppts (95% CI 9.6, 28.9) in the hospital referral region control group. Androgen deprivation therapy, for which Medicare reimbursement decreased sharply, similarly decreased in integrated prostate cancer center and hospital referral region controls. Prostatectomy decreased significantly in the integrated prostate cancer center group. Coincident with the conversion of a urology group practice to an integrated prostate cancer center, we observed an increase in intensity modulated radiation therapy and a decrease in androgen deprivation therapy in patients seen by integrated prostate cancer center physicians and those seen in the surrounding health care market that were not observed in the remainder of the state.

Cardiovascular Comorbidity and Mortality in Men With Prostate Cancer Treated With Brachytherapy-Based Radiation With or Without Hormonal Therapy

To assess the impact of coronary artery disease (CAD) risk factors and sequelae on the risk of all-cause mortality (ACM) in men treated for prostate cancer (PC). The study cohort comprised 5077 men with PC consecutively treated with curative intent between 1997 and 2006 at the Chicago Prostate Cancer Center. Cox and Fine and Gray's competing risks regression multivariable analyses were performed, assessing whether cardiovascular comorbidity impacted the risk of ACM and PC-specific mortality, respectively, adjusting for CAD risk factors (diabetes mellitus, hypercholesterolemia, or hypertension) and sequelae (congestive heart failure or myocardial infarction), age, year and type of treatment, and known PC prognostic factors. When compared with men with no comorbidity there was a significantly increased risk of ACM in men with congestive heart failure or myocardial infarction (adjusted hazard ratio [AHR] 1.96, P<.001) and in men with diabetes mellitus (AHR 1.60, P=.03) and hypertension (AHR 1.25, P=.04). In contrast, men with hypercholesterolemia had a similar risk of ACM (AHR 0.68, P=.17) when compared with men with no comorbidity. Other factors associated with a significantly increased risk of ACM included age (AHR 1.09, P<.001), prostate-specific antigen level (AHR 1.25, P=.008), and Gleason score 8-10 disease (AHR 1.71, P=.003). Cardiovascular comorbidity did not impact the risk of PC-specific mortality. In addition to age and unfavorable PC prognostic factors, select CAD risk factors and sequelae are associated with an increased risk of ACM in men treated for PC. These comorbidity prognostic factors predict time courses of mortality from competing causes, which may be factored into the decision-making process when considering management options for PC in a given individual.