Publications by authors named "Jonathan Aning"

38 Publications

Clinical Impact of the Predict Prostate Risk Communication Tool in Men Newly Diagnosed with Nonmetastatic Prostate Cancer: A Multicentre Randomised Controlled Trial.

Eur Urol 2021 Sep 4. Epub 2021 Sep 4.

Department of Surgery, University of Cambridge School of Clinical Medicine, Cambridge, UK.

Background: Predict Prostate is a freely available online personalised risk communication tool for men with nonmetastatic prostate cancer. Its accuracy has been assessed in multiple validation studies, but its clinical impact among patients has not hitherto been assessed.

Objective: To assess the impact of the tool on patient decision-making and disease perception.

Design, Setting, And Participants: A multicentre randomised controlled trial was performed across eight UK centres among newly diagnosed men considering either active surveillance or radical treatment. A total of 145 patients were included between 2018 and 2020, with median age 67 yr (interquartile range [IQR] 61-72) and prostate-specific antigen 6.8 ng/ml (IQR 5.1-8.8).

Intervention: Participants were randomised to either standard of care (SOC) information or SOC and a structured presentation of the Predict Prostate tool.

Outcome Measurements And Statistical Analysis: Validated questionnaires were completed by assessing the impact of the tool on decisional conflict, uncertainty, anxiety, and perception of survival.

Results And Limitations: Mean Decisional Conflict Scale scores were 26% lower in the Predict Prostate group (mean = 16.1) than in the SOC group (mean = 21.7; p = 0.027). Scores on the "support", "uncertainty", and "value clarity" subscales all favoured Predict Prostate (all p < 0.05). There was no significant difference in anxiety scores or final treatment selection between the two groups. Patient perception of 15-yr prostate cancer-specific mortality (PCSM) and overall survival benefit from radical treatment were considerably lower and more accurate among men in the Predict Prostate group (p < 0.001). In total, 57% of men reported that the Predict Prostate estimates for PCSM were lower than expected, and 36% reported being less likely to select radical treatment. Over 90% of patients in the intervention group found it useful and 94% would recommend it to others.

Conclusions: Predict Prostate reduces decisional conflict and uncertainty, and shifts patient perception around prognosis to be more realistic. This randomised trial demonstrates that Predict Prostate can directly inform the complex decision-making process in prostate cancer and is felt to be useful by patients. Future larger trials are warranted to test its impact upon final treatment decisions.

Patient Summary: In this national study, we assessed the impact of an individualised risk communication tool, called Predict Prostate, on patient decision-making after a diagnosis of localised prostate cancer. Men were randomly assigned to two groups, which received either standard counselling and information, or this in addition to a structured presentation of the Predict Prostate tool. Men who saw the tool were less conflicted and uncertain in their decision-making, and recommended the tool highly. Those who saw the tool had more realistic perception about their long-term survival and the potential impact of treatment upon this.

Take Home Message: The use of an individualised risk communication tool, such as Predict Prostate, reduces patient decisional conflict and uncertainty when deciding about treatment for nonmetastatic prostate cancer. The tool leads to more realistic perceptions about survival outcomes and prognosis.
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http://dx.doi.org/10.1016/j.eururo.2021.08.001DOI Listing
September 2021

Association of age with response to preoperative chemotherapy in patients with muscle-invasive bladder cancer.

World J Urol 2021 Aug 9. Epub 2021 Aug 9.

Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, Baltimore, MD, USA.

Purpose: To assess the association of patient age with response to preoperative chemotherapy in patients with muscle-invasive bladder cancer (MIBC).

Materials And Methods: We analyzed data from 1105 patients with MIBC. Patients age was evaluated as continuous variable and stratified in quartiles. Pathologic objective response (pOR; ypT0-Ta-Tis-T1N0) and pathologic complete response (pCR; ypT0N0), as well survival outcomes were assessed. We used data of 395 patients from The Cancer Genome Atlas (TCGA) to investigate the prevalence of TCGA molecular subtypes and DNA damage repair (DDR) gene alterations according to patient age.

Results: pOR was achieved in 40% of patients. There was no difference in distribution of pOR or pCR between age quartiles. On univariable logistic regression analysis, patient age was not associated with pOR or pCR when evaluated as continuous variables or stratified in quartiles (all p > 0.3). Median follow-up was 18 months (IQR 6-37). On Cox regression and competing risk regression analyses, age was not associated with survival outcomes (all p > 0.05). In the TCGA cohort, patient with age ≤ 60 years has 7% less DDR gene mutations (p = 0.59). We found higher age distribution in patients with luminal (p < 0.001) and luminal infiltrated (p = 0.002) compared to those with luminal papillary subtype.

Conclusions: While younger patients may have less mutational tumor burden, our analysis failed to show an association of age with response to preoperative chemotherapy or survival outcomes. Therefore, the use of preoperative chemotherapy should be considered regardless of patient age.
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http://dx.doi.org/10.1007/s00345-021-03793-4DOI Listing
August 2021

Obesity and low levels of physical activity impact on cardiopulmonary fitness in older men after treatment for prostate cancer.

Eur J Cancer Care (Engl) 2021 Jun 18:e13476. Epub 2021 Jun 18.

Department of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK.

The purpose of this study was to compare fitness parameters and cardiovascular disease risk of older and younger men with prostate cancer (PCa) and explore how men's fitness scores compared to normative age values. 83 men were recruited post-treatment and undertook a cardiopulmonary exercise test (CPET), sit-to-stand, step-and-grip strength tests and provided blood samples for serum lipids and HbA1c. We calculated waist-to-hip ratio, cardiovascular risk (QRISK2), Charlson comorbidity index (CCI) and Godin leisure-time exercise questionnaire [GLTEQ]. Age-group comparisons were made using normative data. Men > 75 years, had lower cardiopulmonary fitness, as measured by VO Peak (ml/kg/min) 15.8 + 3.8 p < 0.001, and lower grip strength(28.6+5.2 kg p < 0.001) than younger men. BMI ≥30kg/m and higher blood pressure all contributed to a QRisk2 score indicative of 20% chance of cardiovascular risk within 10 years (mean: 36.9-6.1) p < 0.001. Age, BMI and perceived physical activity were significantly associated with lower cardiopulmonary fitness. Men with PCa > 75 years had more cardiovascular risk factors compared to normative standards for men of their age. Although ADT was more frequent in older men, this was not found to be associated with cardiopulmonary fitness, but obesity and low levels of physical activity were. Secondary prevention should be addressed in men with PCa to improve men's overall health.
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http://dx.doi.org/10.1111/ecc.13476DOI Listing
June 2021

How reliable are surgeon-reported data? A comparison of the British Association of Urological Surgeons radical prostatectomy audit with the National Prostate Cancer Audit Hospital Episode Statistics-linked database.

BJU Int 2021 Mar 22. Epub 2021 Mar 22.

Christie and Salford Royal NHS Foundation Trusts, Manchester, UK.

Objectives: To evaluate the accuracy and completeness of surgeon-reported radical prostatectomy outcome data across a national health system by comparison with a national dataset gathered independently from clinicians directly involved in patient care.

Patients And Methods: Data submitted by surgeons to the British Association of Urological Surgeons (BAUS) radical prostatectomy audit for all men undergoing radical prostatectomy between 2015 and 2016 were assessed by cross linkage to the National Prostate Cancer Audit (NPCA) database. Specific data items collected in both databases were selected for comparison analysis. Data completeness and agreement were assessed by percentages and Cohen's kappa statistic.

Results: Data from 4707 men in the BAUS and NPCA databases were matched for comparison. Compared with the NPCA, dataset completeness was higher in the BAUS dataset for type of nerve-sparing procedure (92% vs 42%) and postoperative margin status (89% vs 48%) but lower for readmission (87% vs 100%) and Charlson score (80% vs 100%). For all other variables assessed completeness was comparable. Agreement and data reliability were high for most variables. However, despite good agreement, the inter-cohort reliability was poor for readmission, M stage and Charlson score (κ < 0.30).

Conclusions: For the first time in urology we show that surgeon-reported data from the BAUS radical prostatectomy audit can reliably be used to benchmark peri-operative radical prostatectomy outcomes. For comorbidity data, to assist with risk analysis, and longer-term outcomes, NPCA routinely collected data provide a more comprehensive source.
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http://dx.doi.org/10.1111/bju.15399DOI Listing
March 2021

Supported progressive resistance exercise training to counter the adverse side effects of robot-assisted radical prostatectomy: a randomised controlled trial.

Support Care Cancer 2021 Aug 23;29(8):4595-4605. Epub 2021 Jan 23.

Department of Sport, Exercise & Rehabilitation, Faculty of Health & Life Sciences, University of Northumbria at Newcastle, Room 239, Northumberland Building, Newcastle-upon-Tyne, NE1 8ST, UK.

Purpose: To investigate the effects of a supported home-based progressive resistance exercise training (RET) programme on indices of cardiovascular health, muscular strength and health-related quality of life (HR-QoL) in prostate cancer (PCa) patients after treatment with robot-assisted radical prostatectomy (RARP).

Methods: This study was a single-site, two-arm randomised controlled trial, with 40 participants randomised to either the intervention or control group over a 10-month period. In addition to receiving usual care, the intervention group completed three weekly RET sessions using resistance bands for 6 months. Participants performed 3 sets of 12-15 repetitions for each exercise, targeting each major muscle group. The control group received usual care only. Brachial artery flow-mediated dilatation (FMD) was the primary outcome and assessed at baseline, 3 and 6 months. Secondary outcomes included body weight, body fat, aerobic fitness, strength and blood-borne biomarkers associated with cardiometabolic risk.

Results: There was no significant difference between the groups in FMD at 3 or 6 months. However, there were improvements in aerobic exercise capacity (P < 0.01) and upper- (P < 0.01) and lower-limb (P = 0.01) strength in favour of the RET group at 6 months, accompanied by greater weight loss (P = 0.04) and a reduction in body fat (P = 0.02). Improvements in HRQoL were evident in the RET group at 3 and 6 months via the PCa-specific component of the FACT-P questionnaire (both P < 0.01). Five adverse events and one serious adverse event were reported throughout the trial duration.

Conclusion: This study demonstrates that home-based RET is an effective and safe mode of exercise that elicits beneficial effects on aerobic exercise capacity, muscular strength and HR-QoL in men who have undergone RARP.

Trial Registration: ISRCTN10490647.
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http://dx.doi.org/10.1007/s00520-021-06002-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822752PMC
August 2021

NeuroSAFE PROOF Randomised Controlled Feasibility Study: Brief Report of Perioperative Outcomes, Histological Concordance, and Feasibility.

Eur Urol 2020 09 25;78(3):476-478. Epub 2020 Apr 25.

Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, Westmoreland Street Hospital, University College Hospitals London, London, UK.

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http://dx.doi.org/10.1016/j.eururo.2020.03.052DOI Listing
September 2020

Clinical utility and cost modelling of the phi test to triage referrals into image-based diagnostic services for suspected prostate cancer: the PRIM (Phi to RefIne Mri) study.

BMC Med 2020 04 17;18(1):95. Epub 2020 Apr 17.

Department of Urology, Cambridge University Hospitals Trust, Cambridge, UK.

Background: The clinical pathway to detect and diagnose prostate cancer has been revolutionised by the use of multiparametric MRI (mpMRI pre-biopsy). mpMRI however remains a resource-intensive test and is highly operator dependent with variable effectiveness with regard to its negative predictive value. Here we tested the use of the phi assay in standard clinical practice to pre-select men at the highest risk of harbouring significant cancer and hence refine the use of mpMRI and biopsies.

Methods: A prospective five-centre study recruited men being investigated through an mpMRI-based prostate cancer diagnostic pathway. Test statistics for PSA, PSA density (PSAd) and phi were assessed for detecting significant cancers using 2 definitions: ≥ Grade Group (GG2) and ≥ Cambridge Prognostic Groups (CPG) 3. Cost modelling and decision curve analysis (DCA) was simultaneously performed.

Results: A total of 545 men were recruited and studied with a median age, PSA and phi of 66 years, 8.0 ng/ml and 44 respectively. Overall, ≥ GG2 and ≥ CPG3 cancer detection rates were 64% (349/545), 47% (256/545) and 32% (174/545) respectively. There was no difference across centres for patient demographics or cancer detection rates. The overall area under the curve (AUC) for predicting ≥ GG2 cancers was 0.70 for PSA and 0.82 for phi. AUCs for ≥ CPG3 cancers were 0.81 and 0.87 for PSA and phi respectively. AUC values for phi did not differ between centres suggesting reliability of the test in different diagnostic settings. Pre-referral phi cut-offs between 20 and 30 had NPVs of 0.85-0.90 for ≥ GG2 cancers and 0.94-1.0 for ≥ CPG3 cancers. A strategy of mpMRI in all and biopsy only positive lesions reduced unnecessary biopsies by 35% but missed 9% of ≥ GG2 and 5% of ≥ CPG3 cancers. Using PH ≥ 30 to rule out referrals missed 8% and 5% of ≥ GG2 and ≥ CPG3 cancers (and reduced unnecessary biopsies by 40%). This was achieved however with 25% fewer mpMRI. Pathways incorporating PSAd missed fewer cancers but necessitated more unnecessary biopsies. The phi strategy had the lowest mean costs with DCA demonstrating net clinical benefit over a range of thresholds.

Conclusion: phi as a triaging test may be an effective way to reduce mpMRI and biopsies without compromising detection of significant prostate cancers.
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http://dx.doi.org/10.1186/s12916-020-01548-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164355PMC
April 2020

Impact of sex on response to neoadjuvant chemotherapy in patients with bladder cancer.

Urol Oncol 2020 07 11;38(7):639.e1-639.e9. Epub 2020 Feb 11.

Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins School of Medicine, Baltimore, MD.

Objective: To assess the effect of patient's sex on response to neoadjuvant chemotherapy (NAC) in patients with clinically nonmetastatic muscle-invasive bladder cancer (MIBC).

Methods: Complete pathologic response, defined as ypT0N0 at radical cystectomy, and downstaging were evaluated using sex-adjusted univariable and multivariable logistic regression modeling. We used interaction terms to account for age of menopause and smoking status. The association of sex with overall survival and cancer-specific survival was evaluated using Cox regression analyses.

Results: A total of 1,031 patients were included in the analysis, 227 (22%) of whom were female. Female patients had a higher rate of extravesical disease extension (P = 0.01). After the administration of NAC, ypT stage was equally distributed between sexes (P = 0.39). On multivariable logistic regression analyses, there was no difference between the sexes or age of menopause with regards to ypT0N0 rates or downstaging (all P > 0.5). On Cox regression analyses, sex was associated with neither overall survival (hazard ratio 1.04, 95% confidence interval 0.75-1.45, P = 0.81) nor cancer-specific survival (hazard ratio 1.06, 95% confidence interval 0.71-1.58, P = 0.77).

Conclusion: Our study generates the hypothesis that NAC equalizes the preoperative disparity in pathologic stage between males and females suggesting a possible differential response between sexes. This might be the explanation underlying the comparable survival outcomes between sexes despite females presenting with more advanced tumor stage.
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http://dx.doi.org/10.1016/j.urolonc.2020.01.010DOI Listing
July 2020

The prognostic value of the neutrophil-to-lymphocyte ratio in patients with muscle-invasive bladder cancer treated with neoadjuvant chemotherapy and radical cystectomy.

Urol Oncol 2020 01 31;38(1):3.e17-3.e27. Epub 2019 Oct 31.

Cross Cancer Institute, Edmonton, AB, Canada; Department of Oncology, University of Alberta, AB, Canada.

Introduction: The neutrophil-to-lymphocyte ratio (NLR) is an attractive marker because it is derived from routine bloodwork. NLR has shown promise as a prognostic factor in muscle invasive bladder cancer (MIBC) but its value in patients receiving neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) is not yet established. Since NLR is related to an oncogenic environment and poor antitumor host response, we hypothesized that a high NLR would be associated with a poor response to NAC and would remain a poor prognostic indicator in patients receiving NAC.

Methods: A retrospective analysis was performed on patients with nonmetastatic MIBC (cT2-4aN0M0) who received NAC prior to RC between 2000 and 2013 at 1 of 19 centers across Europe and North America. The pre-NAC NLR was used to split patients into a low (NLR ≤ 3) and high (NLR > 3) group. Demographic and clinical parameters were compared between the groups using Student's t test, chi-squared, or Fisher's exact test. Putative risk factors for disease-specific and overall survival were analyzed using Cox regression, while predictors of response to NAC (defined as absence of MIBC in RC specimen) were investigated using logistic regression.

Results: Data were available for 340 patients (199 NLR ≤ 3, 141 NLR > 3). Other than age and rate of lymphovascular invasion, demographic and pretreatment characteristics did not differ significantly. More patients in the NLR > 3 group had residual MIBC after NAC than the NLR ≤ 3 group (70.8% vs. 58.3%, P = 0.049). NLR was the only significant predictor of response (odds ratio: 0.36, P = 0.003) in logistic regression. NLR was a significant risk factor for both disease-specific (hazard ratio (HR): 2.4, P = 0.006) and overall survival (HR:1.8, P = 0.02).

Conclusion: NLR > 3 was associated with a decreased response to NAC and shorter disease-specific and overall survival. This suggests that NLR is a simple tool that can aid in MIBC risk stratification in clinical practice.
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http://dx.doi.org/10.1016/j.urolonc.2019.09.023DOI Listing
January 2020

Patient-reported outcomes and urodynamic findings in men with persistent lower urinary tract symptoms following robot-assisted radical prostatectomy.

Neurourol Urodyn 2019 06 13;38(5):1353-1362. Epub 2019 Apr 13.

Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.

Aims: To evaluate the patient-reported outcome measures (PROMs) and urodynamic findings in men seeking intervention for lower urinary tract symptoms (LUTS) after robotic-assisted radical prostatectomy (RARP) in a regional referral center for continence surgery.

Methods: Consecutive men with post-RARP LUTS, who were referred for specialist evaluation and urodynamics between December 2012 and October 2017, were evaluated. Men were invited to complete the International Consultation on Incontinence Questionnaire on Male Lower Urinary Tract Symptoms Long Form (ICIQ-MLUTS) pre-operatively and at 6, 12 and 18 months post-RARP.

Results: In total 64/860 (7.4%) men post-RARP were referred for specialist evaluation. There was a significant increase in total ICIQ-MLUTS and bother scores at 6, 12 and 18 months compared with the baseline in these men (P < 0.001 and P < 0.05, respectively). Urodynamics identified 41/64 (64%) had urodynamic stress incontinence (USI) only, 2/64 (3%) had detrusor overactivity (DO) only and 11/64 (17%) had a combination of USI and DO. Of those referred to a continence specialist 29/64 (45%) underwent a continence procedure.

Conclusions: Patients with bothersome LUTS post-RARP have higher baseline ICIQ-MLUTs scores and significant worsening of total scores at all time points compared with the baseline. Routine use of PROMs may identify patients at risk of bothersome symptoms after RARP and prompt earlier referral for further management of their LUTS. Urodynamic evaluation revealed that the most common finding was pure stress incontinence but the range of urodynamic diagnoses highlights the need to perform urodynamics before making treatment decisions for men with LUTS post-RARP.
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http://dx.doi.org/10.1002/nau.23986DOI Listing
June 2019

Cross-sectional study of patient-reported fatigue, physical activity and cardiovascular status in men after robotic-assisted radical prostatectomy.

Support Care Cancer 2019 Dec 10;27(12):4763-4770. Epub 2019 Apr 10.

Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK.

Purpose: Patient-reported fatigue after robotic-assisted radical prostatectomy (RARP) has not been characterised to date. Fatigue after other prostate cancer (PCa) treatments is known to impact on patient-reported quality of life. The aim of this study was to characterise fatigue, physical activity levels and cardiovascular status post-RARP.

Methods: Between October 2016 and March 2017, men post-RARP or on androgen deprivation therapy (ADT) were invited into the study. Participants were asked to complete the Brief Fatigue Inventory (BFI) and Stage of Change and Scottish Physical Activity Questionnaires (SPAQ) over a 2-week period. Outcome measures were patient-reported fatigue, physical activity levels and the 10-year risk of cardiovascular disease (Q-Risk). Data were analysed in SPSS.

Results: 96/117 (82%) men approached consented to participate; of these, 62/96 (65%) returned complete questionnaire data (RARP n = 42, ADT n = 20). All men reported fatigue with 9/42 (21%) post-RARP reporting clinically significant fatigue. Physical activity did not correlate with fatigue. On average, both groups were overweight (BMI 27.0 ± 3.9 kg/m and 27.8 ± 12.3 kg/m for RARP and ADT, respectively) and the post-RARP group had an 18.1% ± 7.4% Q-Risk2 score.

Conclusions: A proportion of men is at increased risk of cardiovascular disease within 10 years post-RARP and have substantial levels of fatigue; therefore, clinicians should consider including these factors when counselling patients about RARP. Additionally, men post-RARP did not meet the recommended guidelines for resistance-based exercise. Future research is needed to establish whether interventions including resistance-based exercise can improve health and fatigue levels in this population.
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http://dx.doi.org/10.1007/s00520-019-04794-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6825227PMC
December 2019

Perioperative and oncological outcomes of radical prostatectomy for high-risk prostate cancer in the UK: an analysis of surgeon-reported data.

BJU Int 2019 09 10;124(3):441-448. Epub 2019 Jun 10.

University College London Hospital NHS Foundation Trust, London, UK.

Objectives: To analyse the perioperative and oncological outcomes of all radical prostatectomies (RPs) performed for high-risk prostate cancer in the British Association of Urological Surgeons (BAUS) national registry from 2014 to 2015.

Patients And Methods: We identified and analysed outcomes of all RPs performed for high-risk prostate cancer (clinical stage >T2 and/or biopsy Gleason grade >7 and/or preoperative prostate-specific antigen level ≥20 ng/mL) in the national registry for 2014 and 2015. Surgeon reporting of data was mandated during this period. Institution and individual surgeon volume-outcome relationships were assessed.

Results: In total, 3671/13 947 (26.3%) patients underwent RP for high-risk prostate cancer over the 2-year period. Robot-assisted RP was the most prevalent approach (60.7%). In all, 39% of men received an extended pelvic lymph node dissection (LND), but over one-third (33.8%) had no LND. Minimally invasive techniques were associated with a significantly shorter length of stay. The reported rates of Clavien-Dindo ≥III complications within the dataset were low (2.0%), regardless of surgical modality or surgeon volume. No statistically significant surgeon volume-outcome relationships were identified when surgeon volume was stratified into tertiles.

Conclusion: RP for high-risk prostate cancer in the UK appears safe, regardless of modality used or surgeon volume. No clear evidence that surgeon volume impacts on early perioperative outcomes was seen. Quality assurance of the surgeon-reported BAUS dataset is now required to drive quality improvement in national practice.
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http://dx.doi.org/10.1111/bju.14687DOI Listing
September 2019

The Siconolfi step test: a valid and reliable assessment of cardiopulmonary fitness in older men with prostate cancer.

Eur Rev Aging Phys Act 2019 10;16. Epub 2019 Jan 10.

1Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK.

Background: Assessing fitness and promoting regular physical activity can improve health outcomes and early recovery in prostate cancer. This is however, underutilised in clinical practice. The cardiopulmonary exercise test (CPET) is increasingly being used pre-treatment to measure aerobic capacity and peak oxygen consumption (VOpeak - a gold standard in cardiopulmonary fitness assessment). However, CPET requires expensive equipment and may not always be appropriate. The Siconolfi step test (SST) is simpler and cheaper, and could provide an alternative.The aim of this study was to evaluate the validity and reliability of SST for predicting cardiopulmonary fitness in men with prostate cancer. Men were recruited to this two-centre study (Surrey and Newcastle, United Kingdom) after treatment for locally advanced prostate cancer. They had one or more of three risk factors: elevated blood pressure, overweight (BMI > 25), or androgen deprivation therapy (ADT). Cardiopulmonary fitness was measured using SST and cycle ergometry CPET, at two visits three months apart. The validity of SST was assessed by comparing it to CPET. The VOpeak predicted from SST was compared to the VOpeak directly measured with CPET. The reliability of SST was assessed by comparing repeated measures. Bland-Altman analysis was used to derive limits of agreement in validity and reliability analysis.

Results: Sixty-six men provided data for both SST and CPET. These data were used for validity analysis. 56 men provided SST data on both visits. These data were used for reliability analysis. SST provided valid prediction of the cardiopulmonary fitness in men > 60 years old. The average difference between CPET and SST was 0.64 ml/kg/min with non-significant positive bias towards CPET ( = 0.217). Bland-Altman 95% limits of agreement of SST with CPET were ± 7.62 ml/kg/min. SST was reliable across the whole age range. Predicted VOpeak was on average 0.53 ml/kg/min higher at Visit 2 than at Visit 1 ( = 0.181). Bland-Altman 95% limits of agreement between repeated SST measures were ± 5.84 ml/kg/min.

Conclusions: SST provides a valid and reliable alternative to CPET for the assessment of cardiopulmonary fitness in older men with prostate cancer. Caution is advised when assessing men 60 years old or younger because the VOpeak predicted with SST was significantly lower than that measured with CPET.
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http://dx.doi.org/10.1186/s11556-018-0207-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6327593PMC
January 2019

Effects of short-term, medium-term and long-term resistance exercise training on cardiometabolic health outcomes in adults: systematic review with meta-analysis.

Br J Sports Med 2020 Mar 22;54(6):341-348. Epub 2018 Jun 22.

Department of Sport, Exercise and Rehabilitation, University of Northumbria at Newcastle, Newcastle upon Tyne, UK.

Objective: To examine the effects of short-term, medium-term and long-term resistance exercise training (RET) on measures of cardiometabolic health in adults.

Design: Intervention systematic review.

Data Sources: MEDLINE and Cochrane Library databases were searched from inception to February 2018. The search strategy included the following keywords: resistance exercise, strength training and randomised controlled trial.

Eligibility Criteria For Selecting Studies: Randomised controlled trials published in English comparing RET≥2 weeks in duration with a non-exercising control or usual care group. Participants were non-athletic and aged ≥18 years.

Results: A total of 173 trials were included. Medium-term and long-term RET reduced systolic blood pressure (-4.02 (95% CI -5.92 to -2.11) mm Hg, p<0.0001 and -5.08 (-10.04 to -0.13) mm Hg, p=0.04, respectively) and diastolic blood pressure (-1.73 (-2.88 to -0.57) mm Hg, p=0.003 and -4.93 (-8.58 to -1.28) mm Hg, p=0.008, respectively) versus control. Medium-term RET elicited reductions in fasted insulin and insulin resistance (-0.59 (-0.97 to -0.21) µU/mL, p=0.002 and -1.22 (-2.29 to -0.15) µU/mL, p=0.02, respectively). The effects were greater in those with elevated cardiometabolic risk or disease compared with younger healthy adults. The quality of evidence was low or very low for all outcomes. There was limited evidence of adverse events.

Conclusions: RET may be effective for inducing improvements in cardio metabolic health outcomes in healthy adults and those with an adverse cardio metabolic risk profile.

Prospero Registration Number: CRD42016037946.
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http://dx.doi.org/10.1136/bjsports-2017-098970DOI Listing
March 2020

Detailed analysis of patient-reported lower urinary tract symptoms and effect on quality of life after robotic radical prostatectomy.

Urol Oncol 2018 Aug 9;36(8):364.e15-364.e22. Epub 2018 Jun 9.

Department of Urology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.

Objective: To prospectively evaluate short- to medium-term patient-reported lower urinary tract symptoms (LUTS) and their effect on health-related quality of life (HRQoL) using validated questionnaires in a large cohort of patients following robotic-assisted radical prostatectomy (RARP) for prostate cancer.

Materials And Methods: HRQoL and LUTS outcomes were prospectively assessed in 357 consecutive men undergoing RARP at a single center from 2012 to 2015 using the functional assessment of cancer therapy-prostate (FACT-P) and the international consultation on incontinence modular questionnaire-male LUTS (ICIQ-MLUTS). Questionnaires were administered at baseline, 6, 12, and 18 months. Data were analyzed using paired t-tests and ANOVA.

Results: Questionnaire completion rates were high (over 60% of eligible men completed 18-month follow-up). Mean Total FACT-P did not significantly change after RARP: 125.95 (standard deviation [SD] = 19.82) at baseline and 125.86 (SD = 21.14) at 18-months (P = 0.55). Mean total ICIQ-MLUTS also remained unchanged: 18.69 (SD = 10.70) at baseline and 18.76 (SD = 11.33) at 18-months (P = 0.11). Mean voiding score significantly reduced from 10.34 (SD = 5.78) at baseline to 6.33 (SD = 3.99) at 6 months after RARP (P<0.001). A reciprocal significant increase in storage score was observed: 5.34 (SD = 4.26) at baseline, 9.65 (SD = 5.71) at 6 months (P<0.001). Subanalyses of ICIQ-MLUTS scores revealed increases in storage symptoms were exclusively within urinary incontinence domains and included significant increases in both urge and stress urinary incontinence scores.

Conclusion: Overall, patient-reported outcome measures evaluating HRQoL and LUTS do not significantly change after RARP. Detailed analysis reveals significant changes within LUTS domains do occur after surgery which could be overlooked if only total LUTS scores are reported.
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http://dx.doi.org/10.1016/j.urolonc.2018.05.017DOI Listing
August 2018

A prospective randomized pilot study evaluating an ERAS protocol versus a standard protocol for patients treated with radical cystectomy and urinary diversion for bladder cancer.

World J Urol 2018 Feb 7;36(2):215-220. Epub 2017 Nov 7.

Department of Urologic Sciences, Vancouver Prostate Centre, University of British Columbia, Vancouver, Canada.

Purpose: There is a lack of evidence demonstrating the benefits of using enhanced recovery after surgery protocols (ERAS). Here, we propose to use a randomized clinical pilot study to demonstrate the benefits and feasibility of implementing ERAS versus standard protocols (SP) in patients undergoing radical cystectomy (RC) and urinary diversion.

Methods: 27 consecutive patients undergoing RC were included in the study. 12 patients were prospectively randomized to follow an ERAS protocol and 15 patients followed an SP. Duration of hospital stay, time to first flatulence and bowel movement, complications and 30 day readmission rates, as well as subjective outcomes such as postoperative pain, nausea, bowel symptoms, quality of life (QoL), and patient experience and satisfaction were evaluated.

Results: Patients following ERAS had a significantly shorter: hospital stay, time to flatulence, and time to bowel movement than patients following SP. No major complications were reported. Only one patient in the ERAS group was readmitted for bowel obstruction, and no patients were readmitted in the SP group. Patients under ERAS reported lower postoperative pain scores. Mean Functional Assessment of Cancer Therapy Bladder Cancer score decreased and mean Expanded Prostate Cancer Index Composite, bowel symptom score increased in the SP group at the time of discharge compared to prior to surgery.

Conclusions: This study shows the feasibility of a randomized pilot study assessing ERAS compared to SP post RC. ERAS protocol provided evidence of significant benefits over SP with similar complication rates. This study suggests the need for a clinical trial of assessing ERAS protocols after RC.
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http://dx.doi.org/10.1007/s00345-017-2109-2DOI Listing
February 2018

Diagnosing and managing androgen deficiency in men.

Practitioner 2017 04;261(1803):19-22

Androgens play a crucial role in bone, muscle and fat metabolism, erythropoiesis and cognitive health. In men aged 40-79 years the incidence of biochemical deficiency and symptomatic hypogonadism is 2.1-5.7%. Decreased libido or reduced frequency and quality of erections, fatigue, irritability, infertility or a diminished feeling of wellbeing may be presenting complaints. However, a significant proportion of men with androgen deficiency will be identified when they present for unrelated concerns. Important factors to elicit from the history in addition to the presenting complaint include: a medical history of obesity, type 2 diabetes, systemic diseases or metabolic syndrome which all impact on testosterone physiology. A comprehensive medical review will identify agents which can cause low testosterone levels such as statins, steroids, opioids, dopamine antagonists and 5-alpha reductase inhibitors. Alcohol, anabolic steroids and illicit substance use such as marihuana can impact on testosterone levels and non-prescribed drug use should be routinely discussed. The mainstay of treatment in persisting androgen deficiency is to restore normal physiological levels of testosterone by using exogenous testosterone. It may take at least three to six weeks to notice any clinical improvement in symptoms. Men receiving testosterone supplementation should be followed closely and have their testosterone, haematocrit and PSA levels checked at three, six and twelve months after initiation of testosterone replacement therapy. Men should then be reviewed at least annually thereafter.
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April 2017

Acceptability of dietary and physical activity lifestyle modification for men following radiotherapy or radical prostatectomy for localised prostate cancer: a qualitative investigation.

BMC Urol 2017 Oct 10;17(1):94. Epub 2017 Oct 10.

University of Bristol, NIHR Biomedical Research Centre - Nutrition, Diet and Lifestyle Theme, Level 3, University Hospitals Bristol Education Centre, Upper Maudlin Street, Bristol, BS2 8AE, England, UK.

Background: The experience and acceptability of lifestyle interventions for men with localised prostate cancer are not well understood, yet lifestyle interventions are increasingly promoted for cancer survivors. We explored the opinions, experiences and perceived acceptability of taking part in nutritional and physical activity interventions amongst men with prostate cancer and their partners; with the ultimate plan to use such information to inform the development of nutritional and physical activity interventions for men with prostate cancer.

Methods: Semi-structured interviews with 16 men, and seven partners, undergoing curative surgery or radiotherapy for prostate cancer. Interviews explored experiences of lifestyle interventions, acceptable changes participants would make and perceived barriers and facilitators to change. Interviews were thematically analysed using the framework approach.

Results: Men were frequently open to lifestyle modification and family support was considered vital to facilitate change. Health beneficial, clinician endorsed, understandable, enjoyable interventions were perceived as attractive. Barriers included 'modern' digital technology, poor weather, competing commitments or physical limitations, most notably incontinence following radical prostatectomy. Men were keen to participate in research, with few negative aspects identified.

Conclusions: Men are willing to change behaviour but this needs to be supported by clinicians and health professionals facilitating lifestyle change. An 'intention-behaviour gap', when an intended behaviour does not materialise, may exist. Digital technology for data collection and lifestyle measurement may not be suitable for all, and post-surgery urinary incontinence is a barrier to physical activity. These novel findings should be incorporated into lifestyle intervention development, and implemented clinically.
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http://dx.doi.org/10.1186/s12894-017-0284-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5633894PMC
October 2017

Positive surgical margins and biochemical recurrence following minimally-invasive radical prostatectomy - An analysis of outcomes from a UK tertiary referral centre.

BMC Urol 2017 Oct 2;17(1):91. Epub 2017 Oct 2.

Department of Urology, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK.

Background: Positive surgical margins are a strong prognostic marker of disease outcome following radical prostatectomy, though prior evidence is largely from a PSA-screened population. We therefore aim to evaluate the biochemical recurrence in men with positive surgical margins (PSM) after minimally-invasive radical prostatectomy (MIRP) in a UK tertiary centre.

Methods: Retrospective study of men undergoing laparoscopic or robotic-assisted radical prostatectomy between 2002 and 2014. Men with positive surgical margins (PSM) were identified and their biochemical recurrence (BCR) rate compared with men without PSM. The primary outcome measures were BCR rates and time to BCR. Cox regression was used to estimate adjusted hazard ratios for biochemical recurrence rate (BCR), accounting for potential confounders.

Results: Five hundred ninety-two men were included for analysis. Pre-operative D'Amico risk stratification showed 37.5%, 53.3% and 9.3% of patients in the low, intermediate and high-risk groups, respectively. On final pathological analysis, the proportion of patients with local staging pT2, pT3a and pT3b was 68.8%, 25.2% and 6.1% respectively. Overall positive margin rate was 30.6%. On multivariate analysis, the only pre-operative factor associated with PSM was age >65years. Patients with PSM were more likely to have higher tumour volume and more advanced pathological local stage. The BCR rate was 10.7% in margin-positive patients and 5.1% in margin-negative patients, at median 4.4-year follow-up. Upon multivariate analysis, high pre-operative PSA and high Gleason group were the only significant predictors of BCR (P<0.05).

Conclusions: In comparison to patients with negative surgical margins, those with PSM do not translate into worse medium-term oncological outcomes in the majority of cases amongst our cohort. We found that high pre-operative PSA and high Gleason group were the only significant predictors of BCR.
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http://dx.doi.org/10.1186/s12894-017-0262-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5625596PMC
October 2017

Identifying intermediate-risk candidates for active surveillance of prostate cancer.

Urol Oncol 2017 10 20;35(10):605.e1-605.e8. Epub 2017 Jul 20.

Department of Urological Sciences, The Vancouver Prostate Centre, University of British Columbia, Vancouver, Canada.

Purpose: Although already established for very-low and low-risk (LR) prostate cancer (PCa), controversy remains around offering active surveillance (AS) to men with intermediate-risk (IR) PCa. As IR represents a broad spectrum of disease biology, there is a critical need to define eligibility criteria that will enable both patient and physician to accept AS as the best balance of competing risks. In this study, we aimed to identify predictors of progression to enable optimal patient selection.

Materials And Methods: In our AS cohort, men were assigned to risk categories according to the National Comprehensive Cancer Network (NCCN favorable and NCCN unfavorable) and the CAPRA classifications. Clinical, biochemical and pathological characteristics, progression to definitive invasive treatment, and pathologic progression on follow-up biopsies were compared among these groups. A multivariate Cox regression model was used to identify independent predictors of progression on AS.

Results: AS was the initial management option for 651 men, including 144 with IR PCa. During the median follow-up of 4.5 years (range: 0.6-19.1), 259 patients (39.7%) underwent definitive treatment. Further, 5- and 10-year predicted rates of intervention for IR patients were 50% and 66%, respectively. Treatment rates were no different between the NCCN LR and NCCN IR groups, but were higher in CAPRA IR compared to CAPRA LR groups (P = 0.025). NCCN unfavorable IR patients had a twofold increased risk of definitive intervention compared to favorable IR (hazard ratio [HR] = 2.07; 95% CI: 1.17-3.65; P = 0.01). In the entire cohort, the percentage of biopsy cores positive (continuous variable; P = 0.006) and ISUP grade 2 or higher on initial biopsy (P = 0.027) were independent predictors of cessation of AS on multivariate analysis. In the intermediate group, only the percentage of positive biopsy cores was an independent predictor (P = 0.021) of AS cessation. Only 1 IR patient developed metastatic disease (0.7%). Actuarial overall survival at 5 and 10 years was 98.6% and 94.1%, respectively. There were 2 PCa deaths at 18.7 and 19.1 years of follow-up.

Conclusion: In all AS, increasing percentage of core involvement and presence of Gleason pattern 4 are predictors of increased risk of progression. For IR patients, the NCCN favorable criteria and CAPRA score predict those more likely to remain on AS.
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http://dx.doi.org/10.1016/j.urolonc.2017.06.048DOI Listing
October 2017

The provision of dietary and physical activity advice for men diagnosed with prostate cancer: a qualitative study of the experiences and views of health care professionals, patients and partners.

Cancer Causes Control 2017 04 20;28(4):319-329. Epub 2017 Feb 20.

The NIHR Biomedical Research Unit in Nutrition, Diet and Lifestyle at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Upper Maudlin Street, Bristol, BS2 8AE, UK.

Purpose: To explore the views and experiences of health care professionals (HCPs), men diagnosed with localised prostate cancer and their partners about the provision of advice on diet and physical activity after diagnosis and treatment for localised prostate cancer.

Methods: Semi-structured in-depth interviews with ten HCPs (Consultant Urological Surgeons, Uro-Oncology Clinical Nurse Specialists and Allied Health Professionals: see Table 1) and sixteen men diagnosed with localised prostate cancer and seven of their partners. Data from interviews were thematically analysed using the Framework Approach.

Results: The men and their partners provided differing accounts to the HCPs and sometimes to each other concerning the provision of advice on diet and physical activity. Some men were unable to recall receiving such advice from HCPs. Factors impacting upon advice-giving included the perceived lack of an evidence base to support dietary and physical activity advice and the credibility of advice providers. The timing of advice provision was a contentious issue as some HCPs believed that patients might not be willing to receive dietary and physical activity advice at the time of diagnosis, whilst others viewed this an opportune time to provide behaviour change information. Patients concurred with the latter opinion.

Conclusions: Men and their partners would value nutritional and physical activity advice from their HCP, after a localised prostate cancer diagnosis. Men would prefer to receive this advice at an early stage in their cancer journey and may implement behaviour change if the received advice is clear and evidence-based. HCPs should receive suitable training regarding what information to provide to men and how best to deliver this information.
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http://dx.doi.org/10.1007/s10552-017-0861-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5357268PMC
April 2017

Practical survivorship in prostate cancer.

Authors:
Jonathan Aning

Br J Nurs 2016 Oct;25(18):S32-S34

Consultant Urological Surgeon, Department of Urology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, looks at addressing unmet supportive care needs for men treated for localised prostate cancer.

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http://dx.doi.org/10.12968/bjon.2016.25.18.S32DOI Listing
October 2016

Erratum to: Defining competency in flexible cystoscopy: a novel approach using cumulative Sum analysis.

BMC Urol 2016 Sep 12;16(1):57. Epub 2016 Sep 12.

Department of Urology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN, UK.

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http://dx.doi.org/10.1186/s12894-016-0175-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5018934PMC
September 2016

Managing lower urinary tract symptoms in men.

Practitioner 2016 Apr;260(1792):11-6, 2

Male lower urinary tract symptoms (LUTS) are common and increase in prevalence with age. Up to 90% of men aged 50 to 80 may suffer from troublesome LUTS. Men may attend expressing direct concern about micturition, describing one or more LUTS and the related impact on their quality of life. Frequently men may present for other medical or urological reasons such as concern regarding their risk of having prostate cancer or erectile dysfunction but on taking a history bothersome LUTS are identified. Men may present late in the community with urinary retention: the inability to pass urine. A thorough urological history is essential to inform management. It is important to determine whether men have storage or voiding LUTS or both. All patients must have a systematic comprehensive examination including genitalia and a digital rectal examination. Investigations performed in primary care should be guided by the history and examination findings, taking into account the impact of the LUTS on the individual's quality of life. Current NICE guidelines recommend the following to be performed at initial assessment: frequency volume chart (FVC); urine dipstick to detect blood, glucose, protein, leucocytes and nitrites; and prostate specific antigen. Men should be referred for urological review if they have: bothersome LUTS which have not responded to conservative management or medical therapy; LUTS in association with recurrent or persistent UTIs; urinary retention; renal impairment suspected to be secondary to lower urinary tract dysfunction; or suspected urological malignancy. All patients not meeting criteria for immediate referral to urology can be managed initially in primary care. Based on history, examination and investigation findings an individualised management plan should be formulated. Basic lifestyle advice should be given regarding reduction or avoidance of caffeinated products and alcohol. The FVC should guide advice regarding fluid intake management and all medications should be reviewed.
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April 2016

Defining competency in flexible cystoscopy: a novel approach using cumulative Sum analysis.

BMC Urol 2016 Jun 13;16(1):31. Epub 2016 Jun 13.

Department of Urology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN, UK.

Background: Flexible cystoscopy (FC) is one of the most frequently performed urological intervention. Cumulative sum analysis (CUSUM) allows objective assessment of a proceduralist's performance to ensure acceptable outcomes. This study investigated the application of CUSUM to assess a trainee's learning curve and maintenance of competence in performing FC.

Methods: A single urology trainee, with no previous experience of FC, performed FCs between August 2013 and February 2014. For assessment FC was divided into 5 steps. Each step was assigned a CUSUM completion score. The primary outcome measure was successful performance of a complete FC. Prospective data were collected and analysed using CUSUM.

Results: In total, 419 FCs were performed. Acceptable performance of FC was achieved by the 122(nd) procedure. Complete assessment of the ureteric orifices and trigone was the most difficult step of FC to achieve consistently. Competence for complete FC was achieved following 289 procedures.

Conclusion: CUSUM analysis objectively assesses acquisition of competence in flexible cystoscopy. Recommended indicative numbers may underestimate the number of FCs trainees require to achieve, and maintain, competency. Validation of CUSUM method in a larger cohort of trainees should be considered.
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http://dx.doi.org/10.1186/s12894-016-0143-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907277PMC
June 2016

Careful assessment key in managing prostatitis.

Practitioner 2015 Apr;259(1781):15-9, 2

Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, it is most prevalent in men aged between 35 and 50. Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain and asymptomatic inflammatory prostatitis. Acute bacterial prostatitis presents with acute onset pelvic pain which may or may not be related to voiding, lower urinary tract symptoms, sometimes haematuria or haematospermia and systemic symptoms such as fever and rigors. A documented history of recurrent urinary tract infections is the key feature of chronic bacterial prostatitis. Duration of symptoms > 3 months defines chronicity. The key symptom of chronic pelvic pain syndrome is pain. Patients may describe pain during or after ejaculation as their predominant symptom. Clinical assessment includes a thorough history and examination. A digital rectal examination should be performed after a midstream urine (MSU) sample has been collected for urine dipstick, microscopy and culture. The prostate should be checked for nodules. In acute bacterial prostatitis the MSU is the only laboratory investigation required. Chronic pelvic pain syndrome may be multifactorial and part of a more generalised pain disorder. Pelvic floor muscle abnormalities, altered neuroendocrine pathways, chemically induced inflammation, bacterial infection, autoimmune processes, dysfunctional voiding as well intraprostatic ductal reflux mechanisms have all been identified in men with chronic pelvic pain syndrome.
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April 2015

Prostate cancer survivorship: a nurse-led service model.

Br J Nurs 2015 Oct 8-21;24(18):S14-21

Consultant Urological Surgeon, Department of Urology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust.

A significant proportion of men suffer side effects and are acknowledged to have unmet physical, functional and psychological needs after prostate cancer treatment. A nurse-led survivorship programme was implemented at Newcastle upon Tyne Hospitals NHS Foundation Trust for men with prostate cancer. This article describes implementation of the model and presents the results of an early evaluation to assess its impact. In the first 6 months 169 men (90% of those invited) engaged in the survivorship programme. Holistic needs assessments in particular were found to be invaluable for addressing individual men's needs and signposting them to relevant services. Collaboration between existing organisations and initiatives across primary and secondary care resulted in the establishment of a comprehensive network of services available to men on the programme. The nurse-led Newcastle survivorship model has been able to deliver individualised survivorship care with a high satisfaction rating within routine NHS practice.
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http://dx.doi.org/10.12968/bjon.2015.24.Sup18.S14DOI Listing
February 2016

GPs could play key role in prostate cancer survivorship programmes.

Practitioner 2014 Nov;258(1776):27-31, 3

Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK.

The number of men living with prostate cancer in the UK is predicted to rise from 255,000 to 416,000 in 2020 and 620,000 by 2030. More than 80% of men diagnosed with prostate cancer can expect to survive for at least five years. Up to 87% of men with prostate cancer may have unmet supportive care needs. Patients regularly cite psychological and sexual issues as the most significant. Poor functional outcomes after treatment such as incontinence and erectile dysfunction have a major impact on quality of life. The traditional model of hospital follow-up fails to deliver optimum patient-centred cancer care. Holistic aspects of care such as psychological needs and factors which may facilitate full rehabilitation of patients back into society may be missed. The key elements of a survivorship programme are: education, intervention, surveillance and co-ordination of care. Interventions which may improve immediate care include: structured holistic needs assessment and care planning, treatment summaries and cancer care reviews, patient education and support events and advice about, and access to, physical activity schemes. Urologists and GPs need to collaborate to establish shared care pathways for prostate cancer patients. Elements of these innovative pathways will include clear follow-up protocols for prostate cancer survivors discharged into the community and rapid access arrangements for patients about whom GPs are concerned.
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November 2014

Multicenter assessment of neoadjuvant chemotherapy for muscle-invasive bladder cancer.

Eur Urol 2015 Feb 23;67(2):241-9. Epub 2014 Sep 23.

Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA.

Background: The efficacy of neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (BCa) was established primarily with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC), with complete response rates (pT0) as high as 38%. However, because of the comparable efficacy with better tolerability of gemcitabine and cisplatin (GC) in patients with metastatic disease, GC has become the most commonly used regimen in the neoadjuvant setting.

Objective: We aimed to assess real-world pathologic response rates to NAC with different regimens in a large, multicenter cohort.

Design, Setting, And Participants: Data were collected retrospectively at 19 centers on patients with clinical cT2-4aN0M0 urothelial carcinoma of the bladder who received at least three cycles of NAC, followed by radical cystectomy (RC), between 2000 and 2013.

Intervention: NAC and RC.

Outcome Measurements And Statistical Analysis: The primary outcome was pathologic stage at cystectomy. Univariable and multivariable analyses were used to determine factors predictive of pT0N0 and ≤pT1N0 stages.

Results And Limitations: Data were collected on 935 patients who met inclusion criteria. GC was used in the majority of the patients (n=602; 64.4%), followed by MVAC (n=183; 19.6%) and other regimens (n=144; 15.4%). The rates of pT0N0 and ≤pT1N0 pathologic response were 22.7% and 40.8%, respectively. The rate of pT0N0 disease for patients receiving GC was 23.9%, compared with 24.5% for MVAC (p=0.2). There was no difference between MVAC and GC in pT0N0 on multivariable analysis (odds ratio: 0.89 [95% confidence interval, 0.61-1.34]; p=0.6).

Conclusions: Response rates to NAC were lower than those reported in prospective randomized trials, and we did not discern a difference between MVAC and GC. Without any evidence from randomized prospective trials, the best NAC regimen for invasive BCa remains to be determined.

Patient Summary: There was no apparent difference in the response rates to the two most common presurgical chemotherapy regimens for patients with bladder cancer.
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http://dx.doi.org/10.1016/j.eururo.2014.09.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4840190PMC
February 2015
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