Publications by authors named "Richard M Hoffman"

134 Publications

Rising Use of Multitarget Stool DNA Testing for Colorectal Cancer.

JAMA Netw Open 2021 Sep 1;4(9):e2122328. Epub 2021 Sep 1.

Department of Medicine, University of California, San Francisco, San Francisco.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.22328DOI Listing
September 2021

Trends and practices for managing low-risk prostate cancer: a SEER-Medicare study.

Prostate Cancer Prostatic Dis 2021 Jun 9. Epub 2021 Jun 9.

Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA.

Background: Expectant management (EM) has been widely recommended for men with low-risk prostate cancers (PCa). We evaluated trends in EM and the sociodemographic and clinical factors associated with EM, initiating a National Comprehensive Cancer Network guideline-concordant active surveillance (AS) monitoring protocol, and switching from EM to active treatment (AT).

Methods: We used the SEER-Medicare database to identify men ages 66+ diagnosed with a low-risk PCa (PSA < 10 ng/mL, Gleason ≤ 6, stage ≤ T2a) in 2010-2013 with ≥1 year of follow-up. We used claims data to capture (1) PCa treatments, including surgical procedures, radiotherapy, and hormone therapy, and (2) AS monitoring procedures, including PSA tests and prostate biopsy. We defined EM as receiving no AT within 1 year of diagnosis. We used multivariable regression techniques to identify factors associated with EM, initiating AS monitoring, and switching to AT.

Results: During the study period, EM increased from 29.4% to 49.0%, p < 0.01. Age < 77, being married/partnered, non-Hispanic ethnicity, higher median ZIP code income, lower PSA levels, stage T1c, and more recent year of diagnosis were associated with EM. Nearly 39% of the EM cohort initiated AS monitoring; age <77, White race, being married/partnered, higher median ZIP code income, and lower PSA levels were associated with initiating AS. By three years after diagnosis, 21.3% of the EM cohort had switched to AT, usually after undergoing AS monitoring procedures.

Discussion: We found increasing uptake of EM over time, though over 50% still received AT. About 60% of EM patients did not initiate AS monitoring, even among those with life expectancy >10 years, implying that a substantial proportion was being managed by watchful waiting. AS monitoring was associated with switching to AT, suggesting that treatment decisions likely were based on cancer progression.
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http://dx.doi.org/10.1038/s41391-021-00393-6DOI Listing
June 2021

Comparative effectiveness of five fecal immunochemical tests using colonoscopy as the gold standard: study protocol.

Contemp Clin Trials 2021 07 8;106:106430. Epub 2021 May 8.

Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, United States of America.

Background: There are nearly 50,000 colorectal cancer (CRC) deaths in the United States each year. CRC is curable if detected in its early stages. Fecal immunochemical tests (FITs) can detect precursor lesions and many can be analyzed at the point-of-care (POC) in physician offices. However, there are few data to guide test selection. Broader use of FITs could make CRC screening more accessible, especially in resource-poor settings.

Methods: A total of 3600 racially and ethnically diverse individuals aged 50 to 85 years having either a screening or surveillance colonoscopy will be recruited. Each participant will complete five FITs on a single stool sample. Test characteristics for each FIT for advanced colorectal neoplasia (ACN) will be calculated using colonoscopy as the gold standard.

Results: We have complete data from a total of 2990 individuals. Thirty percent are Latino and 5.3% are black/African American. We will present full results once the study is completed.

Conclusions: Our focus in this study is how well FITs detect ACN, using colonoscopy as the gold standard. Four of the five FITs being used are POC tests. Although FITs have been shown to have acceptable performance, there is little data to guide which ones have the best test characteristics and colonoscopy is the main CRC screening test used in the United States. Use of FITs will allow broader segments of the population to access CRC screening because these tests require no preparation, are inexpensive, and can be collected in the privacy of one's home. Increasing CRC screening uptake will reduce the burden of advanced adenomas and colorectal cancer.
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http://dx.doi.org/10.1016/j.cct.2021.106430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8227954PMC
July 2021

The Centers for Medicare & Medicaid Services Requirement for Shared Decision-making for Lung Cancer Screening.

JAMA 2021 03;325(10):933-934

Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston.

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http://dx.doi.org/10.1001/jama.2021.1817DOI Listing
March 2021

Patient Adherence to Screening for Lung Cancer in the US: A Systematic Review and Meta-analysis.

JAMA Netw Open 2020 11 2;3(11):e2025102. Epub 2020 Nov 2.

Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston.

Importance: To be effective in reducing deaths from lung cancer among high-risk current and former smokers, screening with low-dose computed tomography must be performed periodically.

Objective: To examine lung cancer screening (LCS) adherence rates reported in the US, patient characteristics associated with adherence, and diagnostic testing rates after screening.

Data Sources: Five electronic databases (MEDLINE, Embase, Scopus, CINAHL, and Web of Science) were searched for articles published in the English language from January 1, 2011, through February 28, 2020.

Study Selection: Two reviewers independently selected prospective and retrospective cohort studies from 95 potentially relevant studies reporting patient LCS adherence.

Data Extraction And Synthesis: Quality appraisal and data extraction were performed independently by 2 reviewers using the Newcastle-Ottawa Scale for quality assessment. A random-effects model meta-analysis was conducted when at least 2 studies reported on the same outcome. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guideline.

Main Outcomes And Measures: The primary outcome was LCS adherence after a baseline screening. Secondary measures were the patient characteristics associated with adherence and the rate of diagnostic testing after screening.

Results: Fifteen studies with a total of 16 863 individuals were included in this systematic review and meta-analysis. The pooled LCS adherence rate across all follow-up periods (range, 12-36 months) was 55% (95% CI, 44%-66%). Regarding patient characteristics associated with adherence rates, current smokers were less likely to adhere to LCS than former smokers (odds ratio [OR], 0.70; 95% CI, 0.62-0.80); White patients were more likely to adhere to LCS than patients of races other than White (OR, 2.0; 95% CI, 1.6-2.6); people 65 to 73 years of age were more likely to adhere to LCS than people 50 to 64 years of age (OR, 1.4; 95% CI, 1.0-1.9); and completion of 4 or more years of college was also associated with increased adherence compared with people not completing college (OR, 1.5; 95% CI, 1.1-2.1). Evidence was insufficient to evaluate diagnostic testing rates after abnormal screening scan results. The main source of variation was attributable to the eligibility criteria for screening used across studies.

Conclusions And Relevance: In this study, the pooled LCS adherence rate after a baseline screening was far lower than those observed in large randomized clinical trials of screening. Interventions to promote adherence to screening should prioritize current smokers and smokers from minority populations.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.25102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670313PMC
November 2020

Applying a Text-Search Algorithm to Radiology Reports Can Find More Patients With Pulmonary Nodules Than Radiology Coding Alone.

Fed Pract 2020 May;37(Suppl 2):S32-S37

is a Clinical Assistant Professor of Pulmonary and Critical Care Medicine; is a Professor of Internal Medicine; and is a Professor of Internal Medicine, all at the University of Iowa Carver College of Medicine in Iowa City. is a Research Data Manager; is a Registered Nurse and Research Coordinator; and Peter Kaboli is an Associate Investigator, all in the Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System. is a Research Professor of Public Health at the Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System and the University of Washington School of Public Health in Seattle.

Introduction: Chest imaging often incidentally finds indeterminate nodules that need to be monitored to ensure early detection of lung cancers. Health care systems need effective approaches for identifying these lung nodules. We compared the diagnostic performance of 2 approaches for identifying patients with lung nodules on imaging studies (chest/abdomen): (1) relying on radiologists to code imaging studies with lung nodules; and (2) applying a text search algorithm to identify references to lung nodules in radiology reports.

Methods: We assessed all radiology studies performed between January 1, 2016 and November 30, 2016 in a single Veterans Health Administration hospital. We first identified imaging reports with a diagnostic code for a pulmonary nodule. We then applied a text search algorithm to identify imaging reports with key words associated with lung nodules. We reviewed medical records for all patients with a suspicious radiology report based on either search strategy to confirm the presence of a lung nodule. We calculated the yield and the positive predictive value (PPV) of each search strategy for finding pulmonary nodules.

Results: We identified 12,983 imaging studies with a potential lung nodule. Chart review confirmed 8,516 imaging studies with lung nodules, representing 2,912 unique patients. The text search algorithm identified all the patients with lung nodules identified by the radiology coding (n = 1,251) as well as an additional 1,661 patients. The PPV of the text search was 72% (2,912/4,071) and the PPV of the radiology code was 92% (1,251/1,363). Among the patients with nodules missed by radiology coding but identified by the text search algorithm, 130 had lung nodules > 8 mm in diameter.

Conclusions: The text search algorithm can identify additional patients with lung nodules compared to the radiology coding; however, this strategy requires substantial clinical review time to confirm nodules. Health care systems adopting nodule-tracking approaches should recognize that relying only on radiology coding might miss clinically important nodules.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7497875PMC
May 2020

Lung Cancer Screening with Low-Dose CT: a Meta-Analysis.

J Gen Intern Med 2020 10 24;35(10):3015-3025. Epub 2020 Jun 24.

The University of Kansas School of Medicine-Wichita, Wichita, KS, USA.

Background: Randomized controlled trials have evaluated the efficacy of low-dose CT (LDCT) lung cancer screening on lung cancer (LC) outcomes.

Objective: Meta-analyze LDCT lung cancer screening trials.

Methods: We identified studies by searching PubMed, Google Scholar, the Cochrane Registry, ClinicalTrials.gov , and reference lists from retrieved publications. We abstracted data on study design features, stage I LC diagnoses, LC and overall mortality, false positive results, harm from invasive diagnostic procedures, overdiagnosis, and significant incidental findings. We assessed study quality using the Cochrane risk-of-bias tool. We used random-effects models to calculate relative risks and assessed effect modulators with subgroup analyses and meta-regression.

Results: We identified 9 studies that enrolled 96,559 subjects. The risk of bias across studies was judged to be low. Overall, LDCT screening significantly increased the detection of stage I LC, RR = 2.93 (95% CI, 2.16-3.98), I = 19%, and reduced LC mortality, RR = 0.84 (95% CI, 0.75-0.93), I = 0%. The number needed to screen to prevent an LC death was 265. Women had a lower risk of LC death (RR = 0.69, 95% CI, 0.40-1.21) than men (RR = 0.86, 95% CI, 0.66-1.13), p value for interaction = 0.11. LDCT screening did not reduce overall mortality, RR = 0.96 (95% CI, 0.91-1.01), I = 0%. The pooled false positive rate was 8% (95% CI, 4-18); subjects with false positive results had < 1 in 1000 risk of major complications following invasive diagnostic procedures. The most valid estimates for overdiagnosis and significant incidental findings were 8.9% and 7.5%, respectively.

Discussion: LDCT screening significantly reduced LC mortality, though not overall mortality, with women appearing to benefit more than men. The estimated risks for false positive results, screening complications, overdiagnosis, and incidental findings were low. Long-term survival data were available only for North American and European studies limiting generalizability.
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http://dx.doi.org/10.1007/s11606-020-05951-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573097PMC
October 2020

Lung Cancer Staging at Diagnosis in the Veterans Health Administration: Is Rurality an Influencing Factor? A Cross-Sectional Study.

J Rural Health 2020 09 30;36(4):484-495. Epub 2020 May 30.

Veterans Rural Health Resource Center-Iowa City, Veterans Health Administration (VHA), Office of Rural Health, and the Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VHA, Iowa City, Iowa.

Purpose: To evaluate the association between rurality and lung cancer stage at diagnosis.

Methods: We conducted a cross-sectional study using Veterans Health Administration (VHA) data to identify veterans newly diagnosed with lung cancer between October 1, 2011 and September 30, 2015. We defined rurality, based on place of residence, using Rural-Urban Commuting Area (RUCA) codes with the subcategories of urban, large rural, small rural, and isolated. We used multivariable logistic regression models to determine associations between rurality and stage at diagnosis, adjusting for sociodemographic and clinical characteristics. We also analyzed data using the RUCA code for patients' assigned primary care sites and driving distances to primary care clinics and medical centers.

Findings: We identified 4,220 veterans with small cell lung cancer (SCLC) and 25,978 with non-small cell lung cancer (NSCLC). Large rural residence (compared to urban) was associated with early-stage diagnosis of NSCLC (OR = 1.12; 95% CI: 1.00-1.24) and SCLC (OR = 1.73; 95% CI: 1.18-1.55). However, the finding was significant only in the southern and western regions of the country. White race, female sex, chronic lung disease, higher comorbidity, receiving primary care, being a former tobacco user, and more recent year of diagnosis were also associated with diagnosing early-stage NSCLC. Driving distance to medical centers was inversely associated with late-stage NSCLC diagnoses, particularly for large rural areas.

Conclusions: We did not find clear associations between rurality and lung cancer stage at diagnosis. These findings highlight the complex relationship between rurality and lung cancer within VHA, suggesting access to care cannot be fully captured by current rurality codes.
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http://dx.doi.org/10.1111/jrh.12429DOI Listing
September 2020

Why men with a low-risk prostate cancer select and stay on active surveillance: A qualitative study.

PLoS One 2019 20;14(11):e0225134. Epub 2019 Nov 20.

Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States of America.

Objective: Active surveillance (AS) is an increasingly utilized strategy for monitoring men with low-risk prostate cancer (PCa) that allows them to defer active treatment (AT) in the absence of cancer progression. Studies have explored reasons for selecting AS and for then switching to AT, but less is known about men's experiences being on AS. We interviewed men to determine the clinical and psychological factors associated with selecting and adhering to AS protocols.

Methods: We conducted semi-structured interviews with men with a low-risk PCa at two academic medical centers. Subjects had either been on AS for ≥ 1 year or had opted for AT after a period of AS. We used an iterative, content-driven approach to analyze the interviews and to identify themes.

Results: We enrolled 21 subjects, mean age 70.4 years, 3 racial/ethnic minorities, and 16 still on AS. Men recognized the favorable prognosis of their cancer (some had sought second opinions when initially offered AT), valued avoiding treatment complications, were reassured that close monitoring would identify progression early enough to be successfully treated, and trusted their urologists. Although men reported feeling anxious around the time of surveillance testing, those who switched to AT did so based only on evidence of cancer progression.

Conclusions: Our selected sample was comfortable being on AS because they understood and valued the rationale for this approach. However, this highlights the importance of ensuring that men newly diagnosed with a low-risk PCa are provided sufficient information about prognosis and treatment options to make informed decisions.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0225134PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6867634PMC
March 2020

Selecting Active Surveillance: Decision Making Factors for Men with a Low-Risk Prostate Cancer.

Med Decis Making 2019 11 21;39(8):962-974. Epub 2019 Oct 21.

Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA.

Men with a low-risk prostate cancer (PCa) should consider observation, particularly active surveillance (AS), a monitoring strategy that avoids active treatment (AT) in the absence of disease progression. To determine clinical and decision-making factors predicting treatment selection. Prospective cohort study. Kaiser Permanente Northern California (KPNC). Men newly diagnosed with low-risk PCa between 2012 and 2014 who remained enrolled in KPNC for 12 months following diagnosis. We used surveys and medical record abstractions to measure sociodemographic and clinical characteristics and psychological and decision-making factors. Men were classified as being on observation if they did not undergo AT within 12 months of diagnosis. We performed multivariable logistic regression analyses. The average age of the 1171 subjects was 61.5 years ( = 7.2 years), and 81% were white. Overall, 639 (57%) were managed with observation; in adjusted analyses, significant predictors of observation included awareness of low-risk status (odds ratio 1.75; 95% confidence interval 1.04-2.94), knowing that observation was an option (3.62; 1.62-8.09), having concerns about treatment-related quality of life (1.21, 1.09-1.34), reporting a urologist recommendation for observation (8.20; 4.68-14.4), and having a lower clinical stage (T1c v. T2a, 2.11; 1.16-3.84). Conversely, valuing cancer control (1.54; 1.37-1.72) and greater decisional certainty (1.66; 1.18-2.35) were predictive of AT. Results may be less generalizable to other types of health care systems and to more diverse populations. Many participants selected observation, and this was associated with tumor characteristics. However, nonclinical decisional factors also independently predicted treatment selection. Efforts to provide early decision support, particularly targeting knowledge deficits, and reassurance to men with low-risk cancers may facilitate better decision making and increase uptake of observation, particularly AS.
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http://dx.doi.org/10.1177/0272989X19883242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6895433PMC
November 2019

Attitudes of Clinicians about Screening Head and Neck Cancer Survivors for Lung Cancer Using Low-Dose Computed Tomography.

Ann Otol Rhinol Laryngol 2020 Jan 13;129(1):23-31. Epub 2019 Aug 13.

Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA.

Objective: National guidelines recommend lung cancer screening (LCS) using low-dose computed tomography (LDCT) for high-risk patients, including survivors of other tobacco-related cancers like head and neck cancer (HNC). This qualitative study investigated clinicians' practices and attitudes toward LCS with LDCT with patients who have survived HNC, in the context of mandated requirements for shared decision making (SDM) using decision aids.

Methods: Thematic analysis of transcribed semi-structured clinician interviews and focus group.

Results: Clinicians recognized LCS' utility for some HNC survivors with smoking histories. However, they identified many challenges to SDM in diverse clinic settings, including time, workflow, uncertainty about guidelines and reimbursement, decision aids, competing patient priorities, unclear evidence, potentially heightened patient receptivity and stress, and the complexity of discussions. They also identified challenges to LCS implementation.

Conclusions: While clinicians feel that LDCT LCS may benefit some HNC survivors, there are barriers both to implementing LCS SDM for these patients in primary care as currently recommended and to integrating it into cancer clinics. Challenges for SDM across settings include a lack of decision aids tailored to patients with cancer histories. Given recommendations to broaden LCS eligibility criteria, more research may be required before refinement of current guidelines.
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http://dx.doi.org/10.1177/0003489419868245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945809PMC
January 2020

Post-imaging pulmonary nodule mathematical prediction models: are they clinically relevant?

Eur Radiol 2019 Oct 1;29(10):5367-5377. Epub 2019 Apr 1.

Department of Radiology, University of Iowa, 200 Hawkins Drive cc704 GH, Iowa City, IA, 52242, USA.

Objectives: Post-imaging mathematical prediction models (MPMs) provide guidance for the management of solid pulmonary nodules by providing a lung cancer risk score from demographic and radiologists-indicated imaging characteristics. We hypothesized calibrating the MPM risk score threshold to a local study cohort would result in improved performance over the original recommended MPM thresholds. We compared the pre- and post-calibration performance of four MPM models and determined if improvement in MPM prediction occurs as nodules are imaged longitudinally.

Materials And Methods: A common cohort of 317 individuals with computed tomography-detected, solid nodules (80 malignant, 237 benign) were used to evaluate the MPM performance. We created a web-based application for this study that allows others to easily calibrate thresholds and analyze the performance of MPMs on their local cohort. Thirty patients with repeated imaging were tested for improved performance longitudinally.

Results: Using calibrated thresholds, Mayo Clinic and Brock University (BU) MPMs performed the best (AUC = 0.63, 0.61) compared to the Veteran's Affairs (0.51) and Peking University (0.55). Only BU had consensus with the original MPM threshold; the other calibrated thresholds improved MPM accuracy. No significant improvements in accuracy were found longitudinally between time points.

Conclusions: Calibration to a common cohort can select the best-performing MPM for your institution. Without calibration, BU has the most stable performance in solid nodules ≥ 8 mm but has only moderate potential to refine subjects into appropriate workup. Application of MPM is recommended only at initial evaluation as no increase in accuracy was achieved over time.

Key Points: • Post-imaging lung cancer risk mathematical predication models (MPMs) perform poorly on local populations without calibration. • An application is provided to facilitate calibration to new study cohorts: the Mayo Clinic model, the U.S. Department of Veteran's Affairs model, the Brock University model, and the Peking University model. • No significant improvement in risk prediction occurred in nodules with repeated imaging sessions, indicating the potential value of risk prediction application is limited to the initial evaluation.
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http://dx.doi.org/10.1007/s00330-019-06168-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717521PMC
October 2019

Implications of the New USPSTF Prostate Cancer Screening Recommendation-Attaining Equipoise.

JAMA Intern Med 2018 07;178(7):889-891

Cancer Epidemiology and Population Science Program, Holden Comprehensive Cancer Center, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City.

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http://dx.doi.org/10.1001/jamainternmed.2018.1982DOI Listing
July 2018

The complicated 'Yes': Decision-making processes and receptivity to lung cancer screening among head and neck cancer survivors.

Patient Educ Couns 2018 10 22;101(10):1741-1747. Epub 2018 Apr 22.

Department of Otolaryngology-Head and Neck Surgery, University of Iowa Carver College of Medicine, Iowa City, USA.

Objective: Shared decision making (SDM) is recommended when offering lung cancer screening (LCS)-which presents challenges with tobacco-related cancer survivors because they were excluded from clinical trials. Our objective was to characterize head and neck cancer (HNC) survivors' knowledge, attitudes, and beliefs toward LCS and SDM.

Methods: Between November 2017 and June 2018, we conducted semi-structured qualitative interviews with 19 HNC survivors, focusing on patients' cancer and smoking history, receptivity to and perceptions of LCS, and decision-making preferences RESULTS: Participants were receptive to LCS, referencing their successful HNC outcomes. They perceived that LCS might reduce uncertainty and emphasized the potential benefits of early diagnosis. Some expressed concern over costs or overdiagnosis, but most minimized potential harms, including false positives and radiation exposure. Participants preferred in-person LCS discussions, often ideally with their cancer specialist.

Conclusion And Practice Implications: HNC survivors may have overly optimistic expectations for LCS, and clinicians need to account for this in SDM discussions. Supporting these patients in making informed decisions will be challenging because we lack clinical data on the potential benefits and harms of LCS for cancer survivors. While some patients prefer discussing LCS with their cancer specialists, the ability of specialists to support high-quality decision making is uncertain.
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http://dx.doi.org/10.1016/j.pec.2018.04.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6119119PMC
October 2018

Challenges Implementing Lung Cancer Screening in Federally Qualified Health Centers.

Am J Prev Med 2018 04 21;54(4):568-575. Epub 2018 Feb 21.

Center for Community Health Integration and the Prevention Research Center for Healthy Neighborhoods, Case Western Reserve University, Cleveland, Ohio; Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio; Cancer Prevention, Control and Population Research, Case Comprehensive Cancer Center, Cleveland, Ohio.

Introduction: The purpose of this study is to identify issues faced by Federally Qualified Health Centers (FQHCs) in implementing lung cancer screening in low-resource settings.

Methods: Medical directors of 258 FQHCs serving communities with tobacco use prevalence above the median of all 1,202 FQHCs nationally were sampled to participate in a web-based survey. Data were collected between August and October 2016. Data analysis was completed in June 2017.

Results: There were 112 (43%) FQHC medical directors or surrogates who responded to the 2016 survey. Overall, 41% of respondents were aware of a lung cancer screening program within 30 miles of their system's largest clinic. Although 43% reported that some providers in their system offer screening, it was typically at a very low volume (less than ten/month). Although FQHCs are required to collect tobacco use data, only 13% indicated that these data can identify patients eligible for screening. Many FQHCs reported important patient financial barriers for screening, including lack of insurance (72%), preauthorization requirements (58%), and out-of-pocket cost burdens for follow-up procedures (73%). Only 51% indicated having adequate access to specialty providers to manage abnormal findings, and few reported that leadership had either committed resources to lung cancer screening (12%) or prioritized lung cancer screening (12%).

Conclusions: FQHCs and other safety-net clinics, which predominantly serve low-socioeconomic populations with high proportions of smokers eligible for lung cancer screening, face significant economic and resource challenges to implementing lung cancer screening. Although these vulnerable patients are at increased risk for lung cancer, reducing patient financial burdens and appropriately managing abnormal findings are critical to ensure that offering screening does not inadvertently lead to harm and increase disparities.
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http://dx.doi.org/10.1016/j.amepre.2018.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483158PMC
April 2018

Quality of life among men with low-risk prostate cancer during the first year following diagnosis: the PREPARE prospective cohort study.

Transl Behav Med 2018 03;8(2):156-165

Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.

As many as 40% of men diagnosed with prostate cancer have low-risk disease, which results in the need to decide whether to undergo active treatment (AT) or active surveillance (AS). The treatment decision can have a significant effect on general and prostate-specific quality of life (QOL). The purpose of this study was to assess the QOL among men with low-risk prostate cancer during the first year following diagnosis. In a prospective cohort study, we conducted pretreatment telephone interviews (N = 1,139; 69.3% response rate) with low-risk PCa patients (PSA ≤ 10, Gleason ≤ 6) and a follow-up assessment 6-10 months postdiagnosis (N = 1057; 93%). We assessed general depression, anxiety, and physical functioning, prostate-specific anxiety, and prostate-specific QOL at both interviews. Clinical variables were obtained from the medical record. Men were 61.7 (SD = 7.2) years old, 82% white, 39% had undergone AT (surgery or radiation), and 61.0% had begun AS. Linear regression analyses revealed that at follow-up, the AS group reported significantly better sexual, bowel, urinary, and general physical function (compared to AT), and no difference in depression. However, the AS group did report greater general anxiety and prostate-specific anxiety at follow-up, compared to AT. Among men with low-risk PCa, adjusting for pretreatment functioning, the AS group reported better prostate-related QOL, but were worse off on general and prostate-specific anxiety compared to men on AT. These results suggest that, within the first year postdiagnosis, men who did not undergo AT may require additional support in order to remain comfortable with this decision and to continue with AS when it is clinically indicated.
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http://dx.doi.org/10.1093/tbm/ibx005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6256951PMC
March 2018

Racial-Ethnic Disparities in Late-Stage Colorectal Cancer Among Hispanics and Non-Hispanic Whites of New Mexico.

Hisp Health Care Int 2017 12;15(4):180-188

2 University of Iowa, Iowa City, IA, USA.

Introduction: Hispanics in New Mexico are diagnosed with more later-stage colorectal cancer (CRC) than non-Hispanic Whites (NHW). Our study evaluated the interaction of race/ethnicity and risk factors for later-stage III and IV CRC among patients in New Mexico.

Method: CRC patients ages 30 to 75 years ( n = 163, 46% Hispanic) completed a survey on key explanatory clinical, lifestyle, preventive health, and demographic variables for CRC risk. Adjusted logistic regression models examined whether these variables differentially contributed to later-stage CRC among NHW versus Hispanics.

Results: Compared with NHW, Hispanics had a higher prevalence of later-stage CRC ( p = .007), diabetes ( p = .006), high alcohol consumption ( p = .002), low education ( p = .003), and CRC diagnosis due to symptoms ( p = .06). Compared with NHW, Hispanics reporting high alcohol consumption (odds ratio [OR] = 7.59; 95% confidence interval [CI] = 1.31-43.92), lower education (OR = 3.5; 95% CI = 1.28-9.65), being nondiabetic (OR = 3.23; 95% CI = 1.46-7.15), or ever smokers (OR = 2.4; 95% CI = 1.03-5.89) were at higher risk for late-stage CRC. Adjusting for CRC screening did not change the direction or intensity of the odds ratios.

Conclusion: The ethnicity-risk factor interactions, identified for late-stage CRC, highlight significant factors for targeted intervention strategies aimed at reducing the burden of later-stage CRC among Hispanics in New Mexico with broad applicability to other Hispanic populations.
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http://dx.doi.org/10.1177/1540415317746317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6211799PMC
December 2017

Making the grade: The newest US Preventive Services Task Force prostate cancer screening recommendation.

Cancer 2017 10 22;123(20):3875-3878. Epub 2017 Aug 22.

Division of Medicine, Geriatrics, and Palliative Care, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia.

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http://dx.doi.org/10.1002/cncr.30941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5756476PMC
October 2017

Decision-making processes among men with low-risk prostate cancer: A survey study.

Psychooncology 2018 01 13;27(1):325-332. Epub 2017 Jul 13.

Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA.

Objective: To characterize decision-making processes and outcomes among men expressing early-treatment preferences for low-risk prostate cancer.

Methods: We conducted telephone surveys of men newly diagnosed with low-risk prostate cancer in 2012 to 2014. We analyzed subjects who had discussed prostate cancer treatment with a clinician and expressed a treatment preference. We asked about decision-making processes, including physician discussions, prostate-cancer knowledge, decision-making styles, treatment preference, and decisional conflict. We compared the responses across treatment groups with χ or ANOVA.

Results: Participants (n = 761) had a median age of 62; 82% were white, 45% had a college education, and 35% had no comorbidities. Surveys were conducted at a median of 25 days (range 9-100) post diagnosis. Overall, 55% preferred active surveillance (AS), 26% preferred surgery, and 19% preferred radiotherapy. Participants reported routinely considering surgery, radiotherapy, and AS. Most were aware of their low-risk status (97%) and the option for AS (96%). However, men preferring active treatment (AT) were often unaware of treatment complications, including sexual dysfunction (23%) and urinary complications (41%). Most men (63%) wanted to make their own decision after considering the doctor's opinion, and about 90% reported being sufficiently involved in the treatment discussion. Men preferring AS had slightly more uncertainty about their decisions than those preferring AT.

Conclusions: Subjects were actively engaged in decision making and considered a range of treatments. However, we found knowledge gaps about treatment complications among those preferring AT and slightly more decisional uncertainty among those preferring AS, suggesting the need for early decision support.
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http://dx.doi.org/10.1002/pon.4469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849389PMC
January 2018

Lung Cancer Screening.

Med Clin North Am 2017 Jul;101(4):769-785

Department of Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive C325 GH, Iowa City, IA 52242, USA.

Lung cancer is the leading cause of cancer death in the United States. More than 80% of these deaths are attributed to tobacco use, and primary prevention can effectively reduce the cancer burden. The National Lung Screening Trial showed that low-dose computed tomography (LDCT) screening could reduce lung cancer mortality in high-risk patients by 20% compared with chest radiography. The US Preventive Services Task Force recommends annual LDCT screening for persons aged 55 to 80 years with a 30-pack-year smoking history, either currently smoking or having quit within 15 years.
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http://dx.doi.org/10.1016/j.mcna.2017.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368999PMC
July 2017

Treatment Decision Regret Among Long-Term Survivors of Localized Prostate Cancer: Results From the Prostate Cancer Outcomes Study.

J Clin Oncol 2017 Jul 11;35(20):2306-2314. Epub 2017 May 11.

Richard M. Hoffman, University of Iowa Carver College of Medicine; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA; Mary Lo and Ann S. Hamilton, Keck School of Medicine of the University of Southern California, Los Angeles, CA; Jack A. Clark, Edith Nourse Rogers Veterans Affairs Memorial Hospital, Bedford; Boston University School of Public Health; Michael J. Barry, Massachusetts General Hospital; Harvard Medical School, Boston, MA; Peter C. Albertsen, University of Connecticut Health Center, Farmington, CT; Michael Goodman, Emory University, Atlanta, GA; David F. Penson, Vanderbilt University, Nashville, TN; Janet L. Stanford, Fred Hutchinson Cancer Research Center, Seattle, WA; and Antoinette M. Stroup, Rutgers School of Public Health, Piscataway; Rutgers Cancer Institute of New Jersey, New Brunswick, NJ.

Purpose To determine the demographic, clinical, decision-making, and quality-of-life factors that are associated with treatment decision regret among long-term survivors of localized prostate cancer. Patients and Methods We evaluated men who were age ≤ 75 years when diagnosed with localized prostate cancer between October 1994 and October 1995 in one of six SEER tumor registries and who completed a 15-year follow-up survey. The survey obtained demographic, socioeconomic, and clinical data and measured treatment decision regret, informed decision making, general- and disease-specific quality of life, health worry, prostate-specific antigen (PSA) concern, and outlook on life. We used multivariable logistic regression analyses to identify factors associated with regret. Results We surveyed 934 participants, 69.3% of known survivors. Among the cohort, 59.1% had low-risk tumor characteristics (PSA < 10 ng/mL and Gleason score < 7), and 89.2% underwent active treatment. Overall, 14.6% expressed treatment decision regret: 8.2% of those whose disease was managed conservatively, 15.0% of those who received surgery, and 16.6% of those who underwent radiotherapy. Factors associated with regret on multivariable analysis included reporting moderate or big sexual function bother (reported by 39.0%; OR, 2.77; 95% CI, 1.51 to 5.0), moderate or big bowel function bother (reported by 7.7%; OR, 2.32; 95% CI, 1.04 to 5.15), and PSA concern (mean score 52.8; OR, 1.01 per point change; 95% CI, 1.00 to 1.02). Increasing age at diagnosis and report of having made an informed treatment decision were inversely associated with regret. Conclusion Regret was a relatively infrequently reported outcome among long-term survivors of localized prostate cancer; however, our results suggest that better informing men about treatment options, in particular, conservative treatment, might help mitigate long-term regret. These findings are timely for men with low-risk cancers who are being encouraged to consider active surveillance.
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http://dx.doi.org/10.1200/JCO.2016.70.6317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5501361PMC
July 2017

Physicians' perspectives on the informational needs of low-risk prostate cancer patients.

Health Educ Res 2017 04;32(2):134-152

Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington DC 20007, USA.

Despite the evidence indicating that decision aids (DA) improve informed treatment decision making for prostate cancer (PCa), physicians do not routinely recommend DAs to their patients. We conducted semi-structured interviews with urologists (n = 11), radiation oncologists (n = 12) and primary care physicians (n = 10) about their methods of educating low-risk PCa patients regarding the treatment decision, their concerns about recommending DAs, and the essential content and format considerations that need to be addressed. Physicians stressed the need for providing comprehensive patient education before the treatment decision is made and expressed concern about the current unevaluated information available on the Internet. They made recommendations for a DA that is brief, applicable to diverse populations, and that fully discloses all treatment options (including active surveillance) and their potential side effects. Echoing previous studies showing that low-risk PCa patients are making rapid and potentially uninformed treatment decisions, these results highlight the importance of providing patient education early in the decision-making process. This need may be fulfilled by a treatment DA, should physicians systematically recommend DAs to their patients. Physicians' recommendations for the inclusion of particular content and presentation methods will be important for designing a high quality DA that will be used in clinical practice.
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http://dx.doi.org/10.1093/her/cyx035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914350PMC
April 2017

Patient Perspectives on Low-Dose Computed Tomography for Lung Cancer Screening, New Mexico, 2014.

Prev Chronic Dis 2016 08 18;13:E108. Epub 2016 Aug 18.

Department of Medicine, University of Iowa Carver College of Medicine, University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA.

Introduction: National guidelines call for annual lung cancer screening for high-risk smokers using low-dose computed tomography (LDCT). The objective of our study was to characterize patient knowledge and attitudes about lung cancer screening, smoking cessation, and shared decision making by patient and health care provider.

Methods: We conducted semistructured qualitative interviews with patients with histories of heavy smoking who received care at a Federally Qualified Health Center (FQHC Clinic) and at a comprehensive cancer center-affiliated chest clinic (Chest Clinic) in Albuquerque, New Mexico. The interviews, conducted from February through September 2014, focused on perceptions about health screening, knowledge and attitudes about LDCT screening, and preferences regarding decision aids. We used a systematic iterative analytic process to identify preliminary and emergent themes and to create a coding structure.

Results: We reached thematic saturation after 22 interviews (10 at the FQHC Clinic, 12 at the Chest Clinic). Most patients were unaware of LDCT screening for lung cancer but were receptive to the test. Some smokers said they would consider quitting smoking if their screening result were positive. Concerns regarding screening were cost, radiation exposure, and transportation issues. To support decision making, most patients said they preferred one-on-one discussions with a provider. They also valued decision support tools (print materials, videos), but raised concerns about readability and Internet access.

Conclusion: Implementing lung cancer screening in sociodemographically diverse populations poses significant challenges. The value of tobacco cessation counseling cannot be overemphasized. Effective interventions for shared decision making to undergo lung cancer screening will need the active engagement of health care providers and will require the use of accessible decision aids designed for people with low health literacy.
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http://dx.doi.org/10.5888/pcd13.160093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4993119PMC
August 2016

Treatment Preferences for Active Surveillance versus Active Treatment among Men with Low-Risk Prostate Cancer.

Cancer Epidemiol Biomarkers Prev 2016 08 2;25(8):1240-50. Epub 2016 Jun 2.

Division of Research, Kaiser Permanente Northern California.

Background: Due to the concerns about the overtreatment of low-risk prostate cancer, active surveillance (AS) is now a recommended alternative to the active treatments (AT) of surgery and radiotherapy. However, AS is not widely utilized, partially due to psychological and decision-making factors associated with treatment preferences.

Methods: In a longitudinal cohort study, we conducted pretreatment telephone interviews (N = 1,140, 69.3% participation) with newly diagnosed, low-risk prostate cancer patients (PSA ≤ 10, Gleason ≤ 6) from Kaiser Permanente Northern California. We assessed psychological and decision-making variables, and treatment preference [AS, AT, and No Preference (NP)].

Results: Men were 61.5 (SD, 7.3) years old, 24 days (median) after diagnosis, and 81.1% white. Treatment preferences were: 39.3% AS, 30.9% AT, and 29.7% NP. Multinomial logistic regression revealed that men preferring AS (vs. AT) were older (OR, 1.64; CI, 1.07-2.51), more educated (OR, 2.05; CI, 1.12-3.74), had greater prostate cancer knowledge (OR, 1.77; CI, 1.43-2.18) and greater awareness of having low-risk cancer (OR, 3.97; CI, 1.96-8.06), but also were less certain about their treatment preference (OR, 0.57; CI, 0.41-0.8), had greater prostate cancer anxiety (OR, 1.22; CI, 1.003-1.48), and preferred a shared treatment decision (OR, 2.34; CI, 1.37-3.99). Similarly, men preferring NP (vs. AT) were less certain about treatment preference, preferred a shared decision, and had greater knowledge.

Conclusions: Although a substantial proportion of men preferred AS, this was associated with anxiety and uncertainty, suggesting that this may be a difficult choice.

Impact: Increasing the appropriate use of AS for low-risk prostate cancer will require additional reassurance and information, and reaching men almost immediately after diagnosis while the decision-making is ongoing. Cancer Epidemiol Biomarkers Prev; 25(8); 1240-50. ©2016 AACR.
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http://dx.doi.org/10.1158/1055-9965.EPI-15-1079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970911PMC
August 2016

Sociodemographic and Clinical Predictors of Switching to Active Treatment among a Large, Ethnically Diverse Cohort of Men with Low Risk Prostate Cancer on Observational Management.

J Urol 2016 Sep 14;196(3):734-40. Epub 2016 Apr 14.

Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, D.C.

Purpose: We determined the clinical and sociodemographic predictors of beginning active treatment in an ethnically diverse population of men with low risk prostate cancer initially on observational treatment.

Materials And Methods: We retrospectively studied men diagnosed with low risk prostate cancer between 2004 and 2012 at Kaiser Permanente Northern California who did not receive any treatment within the first year of diagnosis and had at least 2 years of followup. We used Cox proportional hazards regression models to determine factors associated with time from diagnosis to active treatment.

Results: We identified 2,228 eligible men who were initially on observation, of whom 27% began active treatment during followup at a median of 2.9 years. NonHispanic black men were marginally more likely to begin active treatment than nonHispanic white men independent of baseline and followup clinical measures (HR 1.3, 95% CI 1.0-1.7). Among men who remained on observation nonHispanic black men were rebiopsied within 24 months of diagnosis at a slightly lower rate than nonHispanic white men (HR 0.70, 95% CI 0.6-1.0). Gleason grade progression (HR 3.3, 95% CI 2.7-4.1) and PSA doubling time less than 48 months (HR 2.9, 95% CI 2.3-3.7) were associated with initiation of active treatment independent of race.

Conclusions: Sociodemographic factors such as ethnicity and education may independently influence the patient decision to pursue active treatment and serial biopsies during active surveillance. These factors are important for further studies of prostate cancer treatment decision making.
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http://dx.doi.org/10.1016/j.juro.2016.04.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5094279PMC
September 2016

Screening Coverage Needed to Reduce Mortality from Prostate Cancer: A Living Systematic Review.

PLoS One 2016 12;11(4):e0153417. Epub 2016 Apr 12.

Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States of America.

Introduction: Screening for prostate cancer remains controversial because of conflicting results from the two major trials: The Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) screening trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC).

Objective: Meta-analyze and meta-regress the available PSA screening trials.

Methods: We performed a living systematic review and meta-regression of the reduction in prostate cancer mortality as a function of the duration of screening provided in each trial. We searched PubMed, Web of Science, the Cochrane Registry, and references lists from previous meta-analyses to identify randomized trials of PSA screening. We followed PRISMA guidelines and qualified strength of evidence with a GRADE Profile.

Results: We found 6 trials, but excluded one that also screened with trans-rectal ultrasound. We considered each ERSPC center as a separate trial. When pooling together all 11 trials we found no significant benefit from screening; however, the heterogeneity was 28.2% (95% CI: 0% to 65%). Heterogeneity was explained by variations in the duration of serial screening (I2 0%; 95% CI: 0% to 52%). When we analyzed the subgroup of trials that added more than 3 years of screening (range 3.2 to 3.8) we found a significant benefit for screening with risk ratio 0.78 (95% CI 0.65-0.94; I2 = 0%; 95% CI: 0% to 69%) and a number needed to invite for screening of 1000. We downgraded the quality of evidence to moderate due to our retrospective identification of subgroups and limited data on control group screening.

Conclusions: Adequate duration of screening reduces mortality from prostate cancer. The benefit, while small, compares favorably with screening for other cancers. Our projections are limited by the moderate quality of evidence.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0153417PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4829241PMC
August 2016

Alcohol consumption--the importance of context.

BMJ 2016 Feb 4;352:i580. Epub 2016 Feb 4.

French Food, Environment and Work Safety Agency (ANSES), 94701 Maisons-Alfort Cedex, France.

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http://dx.doi.org/10.1136/bmj.i580DOI Listing
February 2016

Trends in United States Prostate Cancer Incidence Rates by Age and Stage, 1995-2012.

Cancer Epidemiol Biomarkers Prev 2016 Feb 8;25(2):259-63. Epub 2015 Dec 8.

University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico. Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico.

Background: The advent of PSA testing in the late 1980s substantially increased prostate cancer incidence rates. Concerns about overscreening and overdiagnosis subsequently led professional guidelines (circa 2000 and later) to recommend against routine PSA testing. We evaluated trends in prostate cancer incidence, including late-stage diagnoses, from 1995 through 2012.

Methods: We used joinpoint regression analyses to evaluate all-, localized/regional-, and distant-stage prostate cancer incidence trends based on Surveillance, Epidemiology, and End Results (SEER) data. We stratified analyses by age (50-69, 70+). We reported incidence trends as annual percent change (APC).

Results: Overall age-adjusted incidence rates for localized/regional stage prostate cancer have been declining since 2001, sharply from 2010 to 2012 [APC, -13.1; 95% confidence intervals (CI), -23.5 to -1.3]. Distant-stage incidence rates have declined since 1995, with greater declines from 1995 to 1997 (APC, -8.4; 95% CI, -2.3 to -14.1) than from 2003 to 2012 (APC, -1.0; 95% CI, -1.7 to -0.4). Distant-stage incidence rates declined for men ages 70+ from 1995 to 2012, but increased in men ages 50 to 69 years from 2004 to 2012 (APC, 1.7; 95% CI, 0.2 to 3.2).

Conclusions: Guidelines discouraging routine prostate cancer screening were temporally associated with declining localized/regional prostate cancer incidence rates; however, incidence rates of distant-stage disease are now increasing in younger men.

Impact: This trend may adversely affect prostate cancer mortality rates.
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http://dx.doi.org/10.1158/1055-9965.EPI-15-0723DOI Listing
February 2016

Knowledge and values for cancer screening decisions: Results from a national survey.

Patient Educ Couns 2016 Apr 10;99(4):624-630. Epub 2015 Nov 10.

Department of Medicine and Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, United States. Electronic address:

Background: Guidelines recommend shared decision making (SDM) for cancer screening decisions. SDM requires providers to ensure that patients are informed about screening issues and to support decisions that are concordant with patient values. We evaluated decision-quality factors for breast, colorectal, and prostate cancer screening decisions.

Methods: We conducted a national, population-based Internet survey of adults aged 40+ to characterize perceptions about about cancer screening, the importance of information sources, cancer screening knowledge, values and preferences for screening, and the most influential drivers of decisions.

Results: Among 1452 participants who completed the survey, the mean age was 60, and 94% were insured. Most participants reported feeling well informed about cancer screening, though only 21% reported feeling extremely well informed. Most participants correctly answered about 50% of the knowledge questions, with the majority markedly overestimating lifetime risk of cancer diagnoses and mortality. Participants rated health care providers as the most important source of information.

Conclusion: Although respondents considered themselves well informed about cancer they performed poorly on knowledge questions. This discordance suggests the potential for poor-quality decision making.

Practice Implications: To improve the quality of decision making, providers need training to utilize decision support tools and time to carry out SDM.
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http://dx.doi.org/10.1016/j.pec.2015.11.001DOI Listing
April 2016

The Comparative Harms of Open and Robotic Prostatectomy in Population Based Samples.

J Urol 2016 Feb 3;195(2):321-9. Epub 2015 Sep 3.

Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee; Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee.

Purpose: Robotic assisted radical prostatectomy has largely replaced open radical prostatectomy for the surgical management of prostate cancer despite conflicting evidence of superiority with respect to disease control or functional sequelae. Using population cohort data, in this study we examined sexual and urinary function in men undergoing open radical prostatectomy vs those undergoing robotic assisted radical prostatectomy.

Materials And Methods: Subjects surgically treated for prostate cancer were selected from 2 large population based prospective cohort studies, the Prostate Cancer Outcomes Study (enrolled 1994 to 1995) and the Comparative Effectiveness Analysis of Surgery and Radiation (enrolled 2011 to 2012). Subjects completed baseline, 6-month and 12-month standardized patient reported outcome measures. Main outcomes were between-group differences in functional outcome scores at 6 and 12 months using linear regression, and adjusting for baseline function, sociodemographic and clinical characteristics. Sensitivity analyses were used to evaluate outcomes between patients undergoing open radical prostatectomy and robotic assisted radical prostatectomy within and across CEASAR and PCOS.

Results: The combined cohort consisted of 2,438 men, 1,505 of whom underwent open radical prostatectomy and 933 of whom underwent robotic assisted radical prostatectomy. Men treated with robotic assisted radical prostatectomy reported better urinary function at 6 months (mean difference 3.77 points, 95% CI 1.09-6.44) but not at 12 months (1.19, -1.32-3.71). Subjects treated with robotic assisted radical prostatectomy also reported superior sexual function at 6 months (8.31, 6.02-10.56) and at 12 months (7.64, 5.25-10.03). Sensitivity analyses largely supported the sexual function findings with inconsistent support for urinary function results.

Conclusions: This population based study reveals that men undergoing robotic assisted radical prostatectomy likely experience less decline in early urinary continence and sexual function than those undergoing open radical prostatectomy. The clinical meaning of these differences is uncertain and longer followup will be required to establish whether these benefits are durable.
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http://dx.doi.org/10.1016/j.juro.2015.08.092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4916911PMC
February 2016
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