Urology Practice最新文献

Introduction: With rising incarceration and cancer diagnosis rates in the United States, understanding the relationship between incarceration status and cancer outcomes is critical. Our study examined prostate cancer (PCa)-specific mortality (PCSM) disparities in incarcerated patients (IP) vs nonincarcerated patients (NP) in Michigan.

Methods: The Michigan Department of Health & Human Services Database was screened for PCa (histology = 8140)-diagnosed patients between 2004 and 2015. IP and NP were cross-analyzed with demographic and clinical covariates. The cumulative incidence function and competing risks multivariable regression were used to examine incarceration impact on PCSM after accounting for all covariates.

Results: In our cohort of 76,045 patients, 152 were IP. Compared with NP, IP were more likely to be younger (median 58.0 vs 67.0 years) and non-Hispanic Black (65.8% vs 16.0%), both P < .0001. IP had higher probability to be diagnosed with ≤ cT2 PCa (95.3% vs 88.5%; P < .0001), cN0 PCa (94.1% vs 86.8%; P < .01), and undergo surgery as first-course treatment (31.6% vs 24.4%; P = .02). Compared with NP, no difference was found in Gleason grade ≥ 8 (52.6% vs 51.4%; P = .9) and PSA (median 7.5 vs 5.9 ng/mL; P = .6). At 10 years, PCSM was 14.7% (95% CI: 7.0%-25.0%) in IP vs 11.4% (95% CI: 11.1%-11.7%) in NP (P = .2). At the multivariable analysis, IP had a 2.44-fold (95% CI: 1.53-3.88; P < .001) higher PCSM risk than NP.

Conclusions: Despite being diagnosed with PCa at a younger age and an earlier stage, IP showed a higher PCSM risk than NP. Further research is warranted to examine this difference.

Introduction: Understanding the impact of innovative models to improve health care management for underserved populations can help to develop care pathways that maximize our ability to deliver high-quality care at a lower cost. Our objective was to utilize time-driven activity-based costing to compare patient burden and cost of benign prostatic hyperplasia (BPH) diagnosis, workup, and management with clinical integration vs traditional care pathways, and to evaluate the relative cost-effectiveness of various care models.

Methods: In this quality improvement effort at the Los Angeles County Department of Health Services, clinical care was integrated between specialists and primary care providers (PCPs), allowing comanagement for common conditions. We analyzed cost and patient burden using space, personnel cost, and time data from the 2024 fiscal year to compare care with the integrated care model and through traditional care pathways. We constructed workflow and process maps to capture the full patient journey from initial encounter to surgical intervention. We then used time-driven activity-based costing to quantify costs, time, and process steps in both care models.

Results: Without the use of clinical integration, urologist time needed to manage a patient with BPH was 66 minutes, while total urologist time with clinical integration was 36 minutes. PCP times were 66 and 36 minutes with and without integration, respectively. Cost difference between integrated and nonintegrated pathways was greatest when presenting to the PCP with concerns for BPH with a cost difference of 12.3% ($336.03 vs $383.23). Significant but lower cost differences were found when presenting to the emergency department not in urinary retention (10.7% difference, $393.05 vs $440.25) and when presenting to the emergency department in urinary retention (5.0% difference, $327.05 vs $344.23).

Conclusions: The integrated model showed cost savings, particularly through initial management by PCPs and with streamlined transitions from PCPs to specialists. Clinical integration resulted in more cost-effective BPH care for the patient, providers, and health system. The integrated approach may enhance access to specialty care while minimizing treatment burden and health care expenditures.

Introduction: Socioeconomic status contributes to disparities in kidney cancer outcomes. We examined the association between Area Deprivation Index (ADI) and overall mortality (OM) and cancer-specific mortality (CSM) in a North American statewide cohort.

Methods: By using the Michigan Department of Health and Human Services database, we included patients diagnosed with renal cell carcinoma between 2004 and 2019. ADI was assigned based on residential census block group, ranked as a percentile of deprivation relative to the national level. Individuals were categorized into quartiles, based on national quartile value, where the fourth (ADI: 75-100) represented those in the most deprived areas. Cumulative incidence function was used to compare CSM and OM with ADI quartile. Competing-risk regression and Cox regression analysis tested the association of ADI on CSM and OM, respectively.

Results: We included 9210 patients with a median age of 60 (IQR: 52-67) years. Among those, 35.6%, 31.2%, 25.4%, and 7.8% were from the fourth, third, second, and first ADI quartile, respectively. Compared with the first ADI quartile, those in the fourth were younger (median age: 59 vs 60) and diagnosed more often with clear cell and papillary renal cell carcinoma (respectively, 70% vs 67% and 23.1% vs 20.9%; all-P < .0001). At 10 years, CSM hazard was 25.6% vs 26.4% (P = .02) and OM hazard was 60.7% vs 72.8% (P < .0001) for patients in the first vs fourth ADI quartiles. Multivariable analysis showed that, comparing with the first ADI quartile, patients in the second, third, and fourth had, respectively, 1.62-, 1.45-, and 1.38-fold higher CSM hazard (P = .03) and 1.32-, 1.41-, and 1.58-fold higher OM hazard (P < .001).

Conclusions: The ADI was significantly associated with kidney cancer outcomes, with patients in more deprived areas exhibiting a higher mortality risk.

Introduction: The United States has a high incarceration rate, with documented racial and socioeconomic disparities in incarceration. Cancer is the leading cause of death in prisons, accounting for nearly a third of deaths. Previous studies suggest that incarcerated patients may present with more advanced disease and worse cancer-specific outcomes. We aimed to assess the association between incarceration status and stage at presentation in bladder cancer.

Methods: We used the Michigan Cancer Surveillance Program, a statewide, population-based registry. We included patients diagnosed with bladder cancer between 2004 and 2019. Advanced stage was defined as pathological T stage ≥ 2, nodal involvement (N+), or distant metastasis (M+). Demographic and clinicopathological variables included were age, sex, race/ethnicity, year of diagnosis, smoking history, histological grade, and tumor stage. Patients were stratified by incarceration status. Univariable and multivariable logistic regression analyses were performed to assess the association between incarceration status and advanced disease at the diagnosis, after adjusting for relevant covariates.

Results: Among 29,429 patients with bladder cancer, 31 (0.1%) were incarcerated at diagnosis. Incarcerated patients were younger (median age 58 vs 72 years, P < .001), more frequently Black (16.1% vs 6.2%), and had a higher proportion of ≥T2 stage disease (32.3% vs 20.4%). In unadjusted analysis, incarceration was not significantly associated with advanced disease (odds ratio [OR] 1.82, 95% CI: 0.82-3.77; P = .12). However, in multivariable analysis adjusting for age, sex, race, smoking, and grade, incarceration was associated with higher odds of advanced stage at presentation (OR 2.46, 95% CI: 1.01-5.82; P = .04). Female sex, Black race, smoking status, and high-grade tumors were also independently associated with advanced disease.

Conclusions: Incarceration at the time of diagnosis was independently associated with higher odds of presenting with advanced-stage bladder cancer. These findings highlight incarceration status as a marker of clinical vulnerability, not fully explained by known risk factors such as smoking or race. Addressing this disparity will require both preventive strategies targeting modifiable risk factors and structural interventions to ensure timely access to cancer diagnosis and care within correctional settings.

Introduction: Immune checkpoint inhibitors targeting programmed death-1 (PD-1) in combination with tyrosine kinase inhibitors have reshaped the first-line treatment landscape of advanced renal cell carcinoma (RCC). However, the relative efficacy and safety of different PD-1-based regimens remain unclear. This meta-analysis aims to evaluate the efficacy and safety of first-line anti-PD-1-based combinations with tyrosine kinase inhibitors compared with sunitinib in metastatic RCC and to explore whether clinical outcomes differ according to the PD-1 inhibitor subtype.

Methods: We performed a systematic review and meta-analysis of phase III randomized controlled trials comparing anti-PD-1-based combinations (pembrolizumab + axitinib, pembrolizumab + lenvatinib, nivolumab + cabozantinib) vs sunitinib in treatment-naïve advanced RCC. HRs for overall survival (OS) and progression-free survival (PFS) were pooled using random-effects models. Subgroup analyses were conducted according to PD-L1 status.

Results: Three pivotal trials enrolling 2224 patients were included. Anti-PD-1-based regimens significantly improved OS (pooled HR = 0.66, 95% CI 0.53-0.83) and progression-free survival (pooled HR = 0.56, 95% CI 0.47-0.67) compared with sunitinib, with consistent gains in objective response rate. Subgroup analyses showed benefit irrespective of PD-L1 status: pooled HRs for OS were 0.54 (95% CI 0.42-0.68) in PD-L1-negative and 0.53 (95% CI 0.38-0.74) in PD-L1-positive tumors.

Conclusions: First-line anti-PD-1-based immunotherapy combinations significantly improve survival and response outcomes over sunitinib in advanced RCC, with consistent efficacy across PD-1 subtypes and PD-L1 expression groups.