Faculty Bibliography

BACKGROUND: Many elderly men with high-risk nonmetastatic prostate cancer (HRnMPCa) do not receive radical treatment, despite the high mortality associated with conservative management. OBJECTIVE: To investigate how age and comorbidity affect treatment of men with HRnMPCa. DESIGN, SETTING, AND PARTICIPANTS: This was an observational nationwide register study during 2001-2012. We identified 19 190 men of <80 yr of age diagnosed with HRnMPCa in the National Prostate Cancer Register of Sweden and 95 948 age-matched men without prostate cancer in the register of the total population. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The outcome was the proportion of men with HRnMPCa receiving radical treatment (radical prostatectomy or radiotherapy). Vital status and the Charlson comorbidity index (CCI) were obtained from nationwide registers. The 10-yr survival of men without prostate cancer, stratified by age and CCI, was used as a measure of the life expectancy of the men with prostate cancer. RESULTS AND LIMITATIONS: The proportions receiving radical treatment varied with life expectancy among men younger than 70 yr, whereas use of these treatments did not match the long life expectancy of men in their seventies with CCI 0-1. Only 10% of men aged 75-80 yr with CCI 0 received radical treatment despite 52% probability of 10-yr life expectancy, compared with approximately half of the men younger than 70 yr with a similar life expectancy. The use of radical treatment for HRnMPCa increased with time in all Swedish counties, but a threefold difference between counties remained in 2009-2012 for patients aged 70-80 yr with CCI 0-1. Uncertain external validity is a study limitation, and the impact of physician versus patient preferences on treatment selection could not be assessed. CONCLUSIONS: Otherwise healthy men in their seventies with HRnMPCa were less likely to receive radical treatment than younger men with a similar life expectancy, although increasing use of radical treatment was observed during the study period. Our findings highlight the need for improved methods for clinical decision-making, including improved assessment of life expectancy. PATIENT SUMMARY: We performed a nationwide register study that showed that many healthy men in their seventies live for at least another 10 yr. Despite this long life expectancy, men in their seventies with high-risk nonmetastatic prostate cancer were often not treated with radical prostatectomy or radiotherapy, possibly because their life expectancy was underestimated. Our study highlights the need for improved clinical decision-making, which should incorporate an assessment of the patient's life expectancy.

INTRODUCTION & OBJECTIVES: Many elderly men do not receive curative treatment for high risk, non-metastatic prostate cancer (HRnMPCa) despite high mortality with conservative management. We aimed to assess how age and comorbidity affect treatment of men with HRnMPCa. MATERIAL & METHODS: The proportion of men with HRnMPCa treated curatively in Sweden in 2001 to 2012 was assessed in this nationwide, population-based study. 19,190 men with HRnMPCa below age 80 at date of diagnosis were identified in the National Prostate Cancer Register (NPCR) and 95,948 age-matched control men were without prostate cancer retrieved from the Register of the Total Population. 10-year survival in control men, stratified by age and Charlson Comorbidity Index (CCI) was used as a measure of the life expectancy of the men with prostate cancer. RESULTS: The proportion receiving curative treatment co-varied with life expectancy in men below age 70, but not in men in their seventies with CCI 0-1. For example, only 10% of men aged 75-80 years with CCI 0 received curative treatment despite a 52% 10-year survival probability, whereas half of men younger than 70 years with similar life expectancy received curative treatment. The use of curative treatment for HRnMPCa increased during the study period in all counties, but a threefold difference between counties for men aged 70-80 years with CCI 0-1 remained in 2009-2012. CONCLUSIONS: Otherwise healthy men in their seventies with HRnMPCa were less likely to receive treatment than younger men with a similar life expectancy. The disparities in use of curative treatment highlight the need for improved assessment of life expectancy

PURPOSE: Delivering the recommended care is an important quality measure that has been insufficiently studied in urology. Obstructive pyelonephritis is a suitable case study for this focus because many patients do not receive such care, although guidelines advocate decompression. We determined the influence of hospital factors, particularly familiarity with urolithiasis, on the likelihood of decompression in such patients. MATERIALS AND METHODS: We used the NIS from 2002 to 2011 to retrospectively identify patients admitted to community hospitals with severe infection and ureteral calculi. Hospital familiarity with nephrolithiasis was estimated by calculating hospital stone volume (divided into quartiles) and hospital treatment intensity (the decompression rate in patients with ureteral calculi and no infection). After calculating national estimates we performed logistic regression to determine the association between the receipt of decompression and hospital stone volume, controlling for treatment intensity and other covariates thought to be associated with receiving recommended care. RESULTS: Of an estimated 107,848 patients with obstructive pyelonephritis 27.4% failed to undergo decompression. Discrepancies were greatest between hospitals with the highest and lowest stone volumes (76% vs 25%, OR 2.77, 95% CI 1.94-3.96, p <0.01) as well as high and low treatment intensity (78% vs 37%, p <0.01). CONCLUSIONS: High hospital stone volume and treatment intensity were associated with an increased likelihood of receiving decompression. Such findings might be useful to identify hospitals and regions where access to quality urological care should be augmented.

BACKGROUND: Active surveillance (AS) is an important yet underutilized strategy to reduce prostate cancer (PCa) overtreatment. OBJECTIVE: To examine the 5-yr outcomes of AS in a population-based setting. DESIGN, SETTING, AND PARTICIPANTS: From the National Prostate Cancer Register of Sweden, we identified 11 726 men