Faculty Bibliography

Introduction: Current guidelines recommend active surveillance (AS) as the preferred strategy for men with low-risk prostate cancer (PCa). AS involves serial testing to monitor the disease, and curative intervention is offered if the disease progresses. Studies show significant heterogeneity regarding testing frequency and when AS is discontinued.
Objective(s): To identify factors clinicians consider when decreasing/stopping AS for PCa.
Method(s): This qualitative study used data from semi-structured interviews with clinicians who monitor men on AS. Purposive sampling was used to ensure geographic variation in the U.S. Data collection continued until thematic saturation was achieved. Audio-recorded interviews with clinicians were transcribed verbatim and imported into Atlas.ti for data management and analysis. Framework analysis guided coding and identification of themes. Two researchers coded all transcripts independently, met to discuss, and reached consensus. Results and
Conclusion(s): Of the 24 clinicians, 83% were urologists representing 11 states, 92% were male, and 62% were white. Clinicians reported their experiences with either decreasing/stopping AS (Fig. 1, overleaf). Life expectancy, considering age and comorbidities, was the dominant theme influencing the decision to decrease/stop AS. Generally, clinicians did not have a specific age for when they would consider decreasing/stopping AS, but one clinician felt that 75 years should be the cut-off. The fear of missing the window of curability or being sued could limit clinicians' willingness to decrease/stop AS. One clinician's patient reported him to the medical board when he refused to do a rectal exam that was not clinically needed. Clinicians also mentioned situations where men stop showing up, due to work or transportation issues, or say they want to stop because of biopsy fatigue. These findings suggest that clinicians make decisions about changing AS in response to both clinical and pragmatic concerns. As AS use increases, additional recommendations are needed to guide decisions about decreasing/stopping AS. Disclosure of interest: None declared
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OBJECTIVE:To systematically review the literature on genomic tests for prostate cancer (PCa) and evaluate the current state of the evidence on their use in patients with newly diagnosed PCa. METHODS:We conducted a systematic review by searching PubMed, Embase, Cochrane Central, and conference abstracts from the American Urological Association published between 2010 and 2018. Studies evaluating Prolaris, Oncotype Dx, and Decipher assays were assessed for inclusion by two authors. Studies were excluded if the results were derived from surgical specimens rather than biopsy specimens. Meta-analysis was not performed owing to significant variations in methodologies, definitions and outcome measures. RESULTS:A total of 729 articles were retrieved in our initial search. After removing duplicates (270) and excluding articles deemed not relevant (432), 21 full-text articles were deemed suitable for inclusion in our analysis. The full-text articles comprised 8 studies on Prolaris, 8 studies on Oncotype Dx, and 5 studies on Decipher. For each genomic test we extracted data regarding the risk of adverse pathology, biochemical recurrence, metastasis, and prostate cancer mortality. CONCLUSION/CONCLUSIONS:The results of genomic tests that use biomarkers derived from prostate biopsy can be used in conjunction with clinicopathologic variables to improve our ability to risk stratify patients with newly diagnosed prostate cancer. Additional data are needed on the impact of using these tests on long-term patient outcomes and their cost-effectiveness. This article is protected by copyright. All rights reserved.

PURPOSE/OBJECTIVE:To define the role of focal laser ablation (FLA) as clinical treatment of prostate cancer (PCa) using the Delphi consensus method. METHODS:A panel of international experts in the field of focal therapy (FT) in PCa conducted a collaborative consensus project using the Delphi method. Experts were invited to online questionnaires focusing on patient selection and treatment of PCa with FLA during four subsequent rounds. After each round, outcomes were displayed, and questionnaires were modified based on the comments provided by panelists. Results were finalized and discussed during face-to-face meetings. RESULTS:Thirty-seven experts agreed to participate, and consensus was achieved on 39/43 topics. Clinically significant PCa (csPCa) was defined as any volume Grade Group 2 [Gleason score (GS) 3+4]. Focal therapy was specified as treatment of all csPCa and can be considered primary treatment as an alternative to radical treatment in carefully selected patients. In patients with intermediate-risk PCa (GS 3+4) as well as patients with MRI-visible and biopsy-confirmed local recurrence, FLA is optimal for targeted ablation of a specific magnetic resonance imaging (MRI)-visible focus. However, FLA should not be applied to candidates for active surveillance and close follow-up is required. Suitability for FLA is based on tumor volume, location to vital structures, GS, MRI-visibility, and biopsy confirmation. CONCLUSION/CONCLUSIONS:Focal laser ablation is a promising technique for treatment of clinically localized PCa and should ideally be performed within approved clinical trials. So far, only few studies have reported on FLA and further validation with longer follow-up is mandatory before widespread clinical implementation is justified.

Prostate cancer screening reduces advanced disease and prostate cancer death but is controversial due to downstream harms including unnecessary biopsies and overtreatment. In 2012 the United States Preventive Services Task Force (USPSTF) recommended against screening men for prostate cancer, a practice common since the early 1990's. This dramatic policy change was opposed by many physicians and patient groups. Our group reported on the Twitter response within 24 hours of these guidelines, showing a missed opportunity for greater advocacy since the majority of tweets did not express an opinion.

PURPOSE/OBJECTIVE:North American studies have reported that ∼3-7% of opioid-naïve surgical patients transition to chronic opioid use after a single prescription. We examined the risk of chronic opioid use following radical prostatectomy (RP) using nationwide Swedish data. MATERIALS AND METHODS/METHODS:For 25,703 men in National Prostate Cancer Register of Sweden who underwent RP, linkage was performed to the Prescribed Drug Register. Opioid use was assessed in three time periods: baseline (13-1 month preoperatively), perioperative (1 month before and after), and postoperative (1-12 months). Multivariable logistic regression was used to identify predictors of new late use (≥1 opioid prescription in three consecutive months >2 months after surgery). RESULTS:Overall, 16,368 (64%) men filled an opioid prescription during the 13 months before or after surgery. Use of strong opioids increased over time and use of weak opioids decreased. 1.9% of men had opioid prescriptions during the baseline period, followed by a spike around surgery (59%), which sharply decreased in the second postoperative month. However, thereafter the proportion of men with opioid prescriptions remained slightly higher (2.2%) compared to the pre-RP baseline. Among chronic late users, 57% were previous users and 43% were new chronic users. Higher cancer risk category, greater comorbidity, unmarried status, and low educational level were associated with risk of new chronic opioid use. CONCLUSIONS:Slightly more than half of Swedish filled an opioid prescription after RP, and <1% became chronic opioid users. These rates are lower than previous studies of postoperative opioid use from North America.