Publications by authors named "Steven Canfield"

61 Publications

The role of testosterone replacement therapy and statin use, and their combination, in prostate cancer.

Cancer Causes Control 2021 May 26. Epub 2021 May 26.

Deparment of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA.

Purpose: Previous studies have reported conflicting results in the associations of testosterone replacement therapy (TTh) and statins use with prostate cancer (PCa). However, the combination of these treatments with PCa stage and grade at diagnosis and prostate cancer-specific mortality (PCSM) and by race/ethnicity remains unclear.

Methods: We identified non-Hispanic White (NHW, N = 58,576), non-Hispanic Black (NHB, n = 9,703) and Hispanic (n = 4,898) men diagnosed with PCa in SEER-Medicare data 2007-2011. Pre-diagnostic prescription of TTh and statins was ascertained for this analysis. Multivariable-adjusted logistic and Cox proportional hazards models were used to evaluate the association of TTh and statins use with PCa stage and grade and PCSM.

Results: 22.5% used statins alone, 1.2% used TTh alone, and 0.8% used both. TTh and statins were independently, inversely associated with PCa advanced stage and high grade. TTh plus statins was associated with 44% lower odds of advanced stage PCa (OR 0.56, 95% CI 0.35-0.91). As expected, similar inverse associations were present in NHWs as the overall cohort is mostly comprised NHW men. In Hispanic men, statin use with or without TTh was inversely associated with aggressive PCa.

Conclusions: Pre-diagnostic use of TTh or statins, independent or in combination, was inversely associated with aggressive PCa, including in NHW and Hispanics men, but was not with PCSM. The findings for use of statins with aggressive PCa are consistent with cohort studies. Future prospective studies are needed to explore the independent inverse association of TTh and the combined inverse association of TTh plus statins on fatal PCa.
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http://dx.doi.org/10.1007/s10552-021-01450-0DOI Listing
May 2021

Independent and joint effects of testosterone replacement therapy and statins use on the risk of prostate cancer among White, Black and Hispanic men.

Cancer Prev Res (Phila) 2021 Apr 20. Epub 2021 Apr 20.

University of Texas McGovern Medical School.

The associations of testosterone therapy (TTh) and statins use with prostate cancer (PCa) remain conflicted. However, the joint effects of TTh and statins use on the incidence of PCa, stage and grade at diagnosis, and PCa-specific mortality (PCSM) have not been studied. We identified White (N=74181), Black (N=9157) and Hispanic (N=3313) men diagnosed with PCa in SEER-Medicare 2007-2016. Pre-diagnostic prescription of TTh and statins was ascertained for this analysis. Weighted multivariable-adjusted conditional logistic and Cox proportional hazards models evaluated the association of TTh and statins with PCa, including statistical interactions between TTh and statins. We found that TTh (OR = 0.74, 95% CI: 0.68 - 0.81) and statins (OR = 0.77, 95% CI: 0.0.75 - 0.88) were inversely associated with incident PCa. Similar inverse associations were observed with high-grade and advanced PCa in relation to TTh and statins use. TTh plus statins was inversely associated with incident PCa (OR = 0.53, 95% CI: 0.48 - 0.60), high-grade (OR = 0.43, 95% CI: 0.37 - 0.49) and advanced PCa (OR = 0.44, 95% CI: 0.35 - 0.55). Similar associations were present in White and Black men, but among Hispanics statins were associated with PCSM. Pre-diagnostic use of TTh or statins, independent or combined, was inversely associated with incident and aggressive PCa overall and in NHW and NHB men. Findings for statins and aggressive PCa are consistent with previous studies. Future studies need to confirm the independent inverse association of TTh and the joint inverse association of TTh plus statins on risk of PCa in understudied populations.
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http://dx.doi.org/10.1158/1940-6207.CAPR-21-0040DOI Listing
April 2021

Cultural Adaptation of Evidence-Based Lifestyle Interventions for African American Men With Prostate Cancer: A Dyadic Approach.

Am J Mens Health 2020 Nov-Dec;14(6):1557988320945449

University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Although a number of lifestyle interventions have been developed for cancer survivors, the extent to which they are effective for African American men with cancer is unclear. Given that African American men have the highest prostate cancer burden and the lack of proven interventions, this study developed a culturally-tailored lifestyle intervention for African American men with prostate cancer and their partners that aimed to improve healthy lifestyle behaviors (physical activity and healthy eating) and quality of life. The aim of the present study is to provide a detailed overview of the model-based process of intervention adaptation. Based on the IM Adapt approach (Highfield et al., 2015) and Typology of Adaptation (Davidson et al., 2013), the present study adapted existing, evidence-based interventions to address African American prostate cancer survivors' and their partners' potential unmet needs including anxiety/uncertainty about cancer progression, communication between partners, cultural sensitivity, and concordance/discordance of motivation and behaviors between partners. The intervention adaptation was a comprehensive and fluid process. To the best knowledge of the author, this is the first couple-based lifestyle intervention specifically developed for African American men with prostate cancer. The present study will be highly informative to future investigators by providing flexible and detailed information regarding lifestyle intervention adaptation for racial/ethnic minority men with prostate cancer and their partners.
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http://dx.doi.org/10.1177/1557988320945449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653295PMC
November 2020

Prostate Cancer Mortality and Use of 5-Alpha Reductase Inhibitors.

World J Mens Health 2020 Apr 15;38(2):139-140. Epub 2019 Oct 15.

Division of Urology, University of Texas McGovern Medical School, Houston, TX, USA.

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http://dx.doi.org/10.5534/wjmh.190129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076307PMC
April 2020

Androgen Receptor Splice Variant, AR-V7, as a Biomarker of Resistance to Androgen Axis-Targeted Therapies in Advanced Prostate Cancer.

Clin Genitourin Cancer 2020 02 26;18(1):1-10. Epub 2019 Sep 26.

Department of Surgery, University of Texas McGovern Medical School, Houston, TX.

Many therapeutic options are now available for men with metastatic castration-resistant prostate cancer (mCRPC), including next-generation androgen receptor axis-targeted therapies (AATTs), immunotherapy, chemotherapy, and radioisotope therapies. No clear consensus has been reached for the optimal sequencing of treatments for patients with mCRPC, and few well-validated molecular markers exist to guide the treatment decisions for individual patients. The androgen receptor splice variant 7 (AR-V7), a splice variant of the androgen receptor mRNA resulting in the truncation of the ligand-binding domain, has emerged as a biomarker for resistance to AATT. AR-V7 expression in circulating tumor cells has been associated with poor outcomes in patients treated with second- and third-line AATTs. Clinically validated assays are now commercially available for the AR-V7 biomarker. In the present review of the current literature, we have summarized the biology of resistance to AATT, with a focus on the AR-V7; and the clinical studies that have validated AR-V7 expression as a strong independent predictor of a lack of clinical benefit from AATTs. Existing evidence has indicated that patients with AR-V7-positive mCRPC will have better outcomes if treated with taxane chemotherapy regimens rather than additional AATTs.
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http://dx.doi.org/10.1016/j.clgc.2019.09.015DOI Listing
February 2020

Gold nanoshell-localized photothermal ablation of prostate tumors in a clinical pilot device study.

Proc Natl Acad Sci U S A 2019 09 26;116(37):18590-18596. Epub 2019 Aug 26.

Laboratory for Nanophotonics, Rice University, Houston, TX 77005

Biocompatible gold nanoparticles designed to absorb light at wavelengths of high tissue transparency have been of particular interest for biomedical applications. The ability of such nanoparticles to convert absorbed near-infrared light to heat and induce highly localized hyperthermia has been shown to be highly effective for photothermal cancer therapy, resulting in cell death and tumor remission in a multitude of preclinical animal models. Here we report the initial results of a clinical trial in which laser-excited gold-silica nanoshells (GSNs) were used in combination with magnetic resonance-ultrasound fusion imaging to focally ablate low-intermediate-grade tumors within the prostate. The overall goal is to provide highly localized regional control of prostate cancer that also results in greatly reduced patient morbidity and improved functional outcomes. This pilot device study reports feasibility and safety data from 16 cases of patients diagnosed with low- or intermediate-risk localized prostate cancer. After GSN infusion and high-precision laser ablation, patients underwent multiparametric MRI of the prostate at 48 to 72 h, followed by postprocedure mpMRI/ultrasound targeted fusion biopsies at 3 and 12 mo, as well as a standard 12-core systematic biopsy at 12 mo. GSN-mediated focal laser ablation was successfully achieved in 94% (15/16) of patients, with no significant difference in International Prostate Symptom Score or Sexual Health Inventory for Men observed after treatment. This treatment protocol appears to be feasible and safe in men with low- or intermediate-risk localized prostate cancer without serious complications or deleterious changes in genitourinary function.
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http://dx.doi.org/10.1073/pnas.1906929116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6744844PMC
September 2019

Imaging in Suspected Renal-Cell Carcinoma: Systematic Review.

Clin Genitourin Cancer 2019 04 11;17(2):e345-e355. Epub 2018 Aug 11.

Department of Urology, Ludwig-Maximilians University, Munich, Germany. Electronic address:

Objective: To systematically assessed the diagnostic performance of contrast-enhanced computed tomography (CT) compared to other imaging modalities for diagnosing and staging renal-cell carcinoma in adults.

Methods: A comprehensive literature search was conducted through various electronic databases. Data from the selected studies were extracted and pooled, and median sensitivity and specificity were calculated wherever possible. Forty studies analyzing data of 4354 patients were included. They examined CT, magnetic resonance imaging (MRI), positron emission tomography-CT, and ultrasound (US).

Results: For CT, median sensitivity and specificity were 88% (interquartile range [IQR] 81%-94%) and 75% (IQR 51%-90%), and for MRI they were 87.5% (IQR 75.25%-100%) and 89% (IQR 75%-96%). Staging sensitivity and specificity for CT were 87% and 74.5%, while MRI showed a median sensitivity of 90% and specificity of 75%. For US, the results varied greatly depending on the corresponding technique. Contrast-enhanced US had a median diagnostic sensitivity of 93% (IQR 88.75%-98.25%) combined with mediocre specificity. The diagnostic performance of unenhanced US was poor. For positron emission tomography-CT, diagnostic accuracy values were good but were based on only a small amount of data. Limitations include the strong heterogeneity of data due to the large variety in imaging techniques and tumor histotypes. Contrast-enhanced CT and MRI remain the diagnostic mainstay for renal-cell carcinoma, with almost equally high diagnostic and staging accuracy.

Conclusion: For specific questions, a combination of different imaging techniques such as CT or MRI and contrast-enhanced US may be useful. There is a need for future large prospective studies to further increase the quality of evidence.
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http://dx.doi.org/10.1016/j.clgc.2018.07.024DOI Listing
April 2019

Balancing Confounding and Generalizability Using Observational, Real-world Data: 17-gene Genomic Prostate Score Assay Effect on Active Surveillance.

Rev Urol 2018 ;20(2):69-76

Genomic Health, Inc. Redwood City, CA.

Randomized, controlled trials can provide high-quality, unbiased evidence for therapeutic interventions but are not always a practical or viable study design for certain healthcare decisions, such as those involving prognostic or predictive testing. Studies using large, real-world databases may be more appropriate and more generalizable to the intended target population of physicians and patients to answer these questions but carry potential for hidden bias. We illustrate several emerging methods of analyzing observational studies using propensity score matching (PSM) and coarsened exact matching (CEM). These advanced statistical methods are intended to reveal a "hidden experiment" within an observational database, and so refute or confirm a potential causal effect of assignment to an intervention and study outcome. We applied these methods to the Optum™ Research Database (ORD; Eden Prairie, MN) of electronic health records and administrative claims data to assess the effect of the 17-gene Genomic Prostate Score® (GPS™; Genomic Health, Redwood City, CA) assay on use of active surveillance (AS). In a traditional multivariable logistic regression, the GPS assay increased the use of AS by 29% (95% CI, 24%-33%). Upon applying the matching methods, the effect of the GPS assay on AS use varied between 27% and 80% and the matched data were significant among all algorithms. All matching algorithms performed well in identifying matched data that improved the imbalance in baseline covariates. By using different matching methods to assess causal inference in an observational database, we provide further confidence that the effect of the GPS assay on AS use is statistically significant and unlikely to be a result of confounding due to differences in baseline characteristics of the patients or the settings in which they were seen.
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http://dx.doi.org/10.3909/riu0799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6168323PMC
January 2018

Can bone scans guide therapy with radium-223 dichloride for prostate cancer bone metastases?

Cancer Manag Res 2018 7;10:3317-3324. Epub 2018 Sep 7.

Division of Oncology, Department of Internal Medicine, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA.

Background: Radium-223 dichloride (Ra-223 Xofigo) has recently been approved as an addition to the host of available therapies in the USA as a treatment option for metastatic castrate-resistant prostate cancer (mCRPC) with bone metastases. This study describes our initial experience in patients treated with Ra-223 dichloride. It attempts to optimize patients' selection for the best outcome from Ra-223 dichloride therapy.

Methods: Consecutive patients who were referred for treatment with Ra-223 dichloride were prospectively followed. Patients' demographics, functional status per the Eastern Cooperative Oncology Group (ECOG) performance score, pain level per the numeric rating score (NRS), prostate-specific antigen (PSA), creatinine, and hematological values were compared at baseline and at the end of therapy. Patients also had a bone scan before starting therapy and at the end of therapy. Patients were divided into the favorable response (FR) group if their pain and/or functional status improved and the unfavorable response (UR) group if they did not improve, deteriorated, or deceased. Bone scan findings before and after Ra-223 dichloride therapy were compared in both the FR and UR groups.

Results: Twenty patients were treated with Ra-223 dichloride. Twelve patients had innumerable bone metastases, three patients had super scans, and three patients had two to seven bone lesions. Two patients were lost to follow-up after the first injection. There were eight patients in the FR group and 10 patients in the UR group. Patients with UR had mean ECOG and NRS pain scores of 1.3 and 5.0 versus 0.8 and 4.4 in the FR group. The mean PSA and creatinine levels in the UR group were 445.2 ng/mL and 1.2 mg/dL versus 22.7 ng/mL and 1.1 mg/dL in the FR group. The mean hemoglobin, platelets, and absolute neutrophil values were 11.2 g/dL, 314.9 K/cmm, and 7.3 K/cmm in the UR group versus 11.6 g/dL, 207.0 K/cmm, and 6.2 K/cmm in the FR group. Seven of the eight patients with FR had a bone scan at the end of therapy showing improvement in five patients, a mixed response in one patient, and progression in another patient. Five patients in the UR group completed five or six injections and had bone scans showing flare of bone metastases in three patients, progression in one patient, and improvement in the fifth patient. Three patients in the UR group died after the first or second injections. Two of these patients had baseline super scans and the third one had widespread bone metastases.

Conclusion: mCRPC patients with lower PSA levels at baseline and fewer bone lesions are more likely to respond favorably to Ra-223 dichloride therapy.
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http://dx.doi.org/10.2147/CMAR.S166218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6135075PMC
September 2018

Caffeine intake is not associated with serum testosterone levels in adult men: cross-sectional findings from the NHANES 1999-2004 and 2011-2012.

Aging Male 2019 Mar 25;22(1):45-54. Epub 2018 Apr 25.

b Division of Urology , UTHealth McGovern Medical School , Houston , TX , USA.

Objective: The association of caffeine intake with testosterone remains unclear. We evaluated the association of caffeine intake with serum testosterone among American men and determined whether this association varied by race/ethnicity and measurements of adiposity.

Methods: Data were analyzed for 2581 men (≥20 years old) who participated in the cycles of the NHANES 1999-2004 and 2011-2012, a cross-sectional study. Testosterone (ng/mL) was measured by immunoassay among men who participated in the morning examination session. We analyzed 24-h dietary recall data to estimate caffeine intake (mg/day). Multivariable weighted linear regression models were conducted.

Results: We identified no linear relationship between caffeine intake and testosterone levels in the total population, but there was a non-linear association (p < .01). Similarly, stratified analysis showed nonlinear associations among Mexican-American and Non-Hispanic White men (p ≤ .03 both) and only among men with waist circumference <102 cm and body mass index <25 kg/m (p < .01, both).

Conclusion: No linear association was identified between levels of caffeine intake and testosterone in US men, but we observed a non-linear association, including among racial/ethnic groups and measurements of adiposity in this cross-sectional study. These associations are warranted to be investigated in larger prospective studies.
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http://dx.doi.org/10.1080/13685538.2018.1465912DOI Listing
March 2019

Active Surveillance Use Among a Low-risk Prostate Cancer Population in a Large US Payer System: 17-Gene Genomic Prostate Score Versus Other Risk Stratification Methods.

Rev Urol 2017 ;19(4):203-212

Genomic Health, Inc. Redwood City, CA.

Many men with low-risk prostate cancer (PCa) receive definitive treatment despite recommendations that have been informed by two large, randomized trials encouraging active surveillance (AS). We conducted a retrospective cohort study using the Optum™ Research Database (Eden Prairie, MN) of electronic health records and administrative claims data to assess AS use for patients tested with a 17-gene Genomic Prostate Score™ (GPS; Genomic Health, Redwood City, CA) assay and/or prostate magnetic resonance imaging (MRI). De-identified records were extracted on health plan members enrolled from June 2013 to June 2016 who had ≥1 record of PCa (n 5 291,876). Inclusion criteria included age ≥18 years, new diagnosis, American Urological Association low-risk PCa (stage T1-T2a, prostate-specific antigen ≤10 ng/mL, Gleason score 5 6), and clinical activity for at least 12 months before and after diagnosis. Data included baseline characteristics, use of GPS testing and/or MRI, and definitive procedures. GPS or MRI testing was performed in 17% of men (GPS, n 5 375, 4%; MRI, n 5 1174, 13%). AS use varied from a low of 43% for men who only underwent MRI to 89% for GPStested men who did not undergo MRI ( <.001). At 6-month follow-up, AS use was 31.0% higher (95% CI, 27.6%-34.5%; <.001) for men receiving the GPS test only versus men who did not undergo GPS testing or MRI; the difference was 30.5% at 12-month follow-up. In a large US payer system, the GPS assay was associated with significantly higher AS use at 6 and 12 months compared with men who had MRI only, or no GPS or MRI testing.
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http://dx.doi.org/10.3909/riu0786DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5811877PMC
January 2017

Coffee Intake and Incidence of Erectile Dysfunction.

Am J Epidemiol 2018 05;187(5):951-959

Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Coffee intake is suggested to have a positive impact on chronic diseases, yet its role in urological diseases such as erectile dysfunction (ED) remains unclear. We investigated the association of coffee intake with incidence of ED by conducting the Health Professionals Follow-Up Study, a prospective analysis of 21,403 men aged 40-75 years old. Total, regular, and decaffeinated coffee intakes were self-reported on food frequency questionnaires. ED was assessed by mean values of questionnaires in 2000, 2004 and 2008. Multivariable adjusted Cox proportional hazards models were used to compute hazard ratios for patients with incident ED (n = 7,298). No significant differences were identified for patients with incident ED after comparing highest (≥4 cups/day) with lowest (0 cups/day) categories of total (hazard ratio (HR) = 1.00, 95% confidence interval (CI): 0.90, 1.11) and regular coffee intakes (HR = 1.00, 95% CI: 0.89, 1.13). When comparing the highest category with lowest category of decaffeinated coffee intake, we found a 37% increased risk of ED (HR = 1.37, 95% CI: 1.08, 1.73), with a significant trend (P trend = 0.02). Stratified analyses also showed an association among current smokers (P trend = 0.005). Overall, long-term coffee intake was not associated with risk of ED in a prospective cohort study.
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http://dx.doi.org/10.1093/aje/kwx304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5928455PMC
May 2018

Creation of a Novel Digital Rectal Examination Evaluation Instrument to Teach and Assess Prostate Examination Proficiency.

J Surg Educ 2018 Mar - Apr;75(2):434-441. Epub 2017 Oct 12.

Department of Urology, University of Virginia, Charlottesville, Virginia.

Objective: To create a validated tool to measure digital rectal examination proficiency and aid with teaching of the examination.

Design: The Digital Rectal Examination Clinical Tool was created using a modified Delphi method with 5 urologists and 5 radiation oncologists. The instrument was then validated in a population of preclinical medical students examining male urological teaching associates, and clinical trainees (third- and fourth-year medical students and urology resident physicians) examining prospectively enrolled subjects. Trainees completed paired examinations with an attending urologist, and responses were scored with reference to the attending responses.

Setting: The instrument was validated at the University of Virginia in the urology clinic, endoscopic operating room, and main operating room settings.

Participants: We tested the instrument on consenting subjects consisting of male urologic teaching associates (n = 12), clinic patients (n = 4), and operating room patients (n = 64). The participants were undergraduate (n = 302) and graduate (n = 9) medical trainees.

Results: In preclerkship trainees, improved scores in subjects without abnormal compared to those with abnormal findings demonstrated validity. In clinical trainees, scores on the Digital Rectal Examination Clinical Tool increased by 2% for each additional year of training, demonstrating construct validity.

Conclusions: We used an expert panel to create a novel instrument for measuring digital rectal examination proficiency and validated it with preclinical and clinical trainee cohorts at our institution.
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http://dx.doi.org/10.1016/j.jsurg.2017.08.012DOI Listing
December 2018

Key Steps in Conducting Systematic Reviews for Underpinning Clinical Practice Guidelines: Methodology of the European Association of Urology.

Eur Urol 2018 02 13;73(2):290-300. Epub 2017 Sep 13.

EAU Guidelines Office, Brussels, Belgium.

Context: The findings of systematic reviews (SRs) and meta-analyses (MAs) are used for clinical decision making. The European Association of Urology has committed increasing resources into the development of high quality clinical guidelines based on such SRs and MAs.

Objective: In this paper, we have summarised the process of conducting SRs for underpinning clinical practice guidelines under the auspices of the European Association of Urology Guidelines Office.

Evidence Acquisition: The process involves explicit methods and the findings should be reproducible. When conducting a SR, the essential first step is to formulate a clear and answerable research question. An extensive literature search lays the foundation for evidence synthesis. Data are extracted independently by two reviewers and any disagreements are resolved by discussion or arbitration by a third reviewer.

Evidence Synthesis: In SRs, data for particular outcomes in individual randomised controlled trials may be combined statistically in a meta-analysis to increase power when the studies are similar enough. Biases in studies included in a SR/MA can lead to either an over estimation or an under estimation of true intervention effect size, resulting in heterogeneity in outcome between studies. A number of different tools are available such as Cochrane Risk of Bias assessment tool for randomised controlled trials. In circumstances where there is too much heterogeneity, or when a review has included nonrandomised comparative studies, it is more appropriate to conduct a narrative synthesis. The GRADE tool for assessing quality of evidence strives to be a structured and transparent system, which can be applied to all evidence, regardless of quality. A SR not only identifies, evaluates, and summarises the best available evidence, but also the gaps to be targeted by future studies.

Conclusions: SRs and MAs are integral in developing sound clinical practice guidelines and recommendations.

Patient Summary: Clinical practice guidelines should be evidence based, and systematic reviews and meta-analyses are essential in their production. We have discussed the key steps of conducting systematic reviews and meta-analyses in this paper.
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http://dx.doi.org/10.1016/j.eururo.2017.08.016DOI Listing
February 2018

Racial/Ethnic Differences in the Associations of Overall and Central Body Fatness with Circulating Hormones and Metabolic Factors in US Men.

Int J Endocrinol Metab 2017 Apr 22;15(2):e44926. Epub 2017 Apr 22.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Background: Racial/ethnic disparities in the associations of body fatness with hormones and metabolic factors remain poorly understood. Therefore, we evaluated whether the associations of overall and central body fatness with circulating sex steroid hormones and metabolic factors differ by race/ethnicity.

Methods: Data from 1,243 non-Hispanic white (NHW), non-Hispanic black (NHB) and Mexican-American (MA) adult men in the third national health and nutrition examination survey (NHANES III) were analyzed. Waist circumference (central body fatness) was measured during the physical examination. Percent body fat (overall body fatness) was calculated from bioelectrical impedance. Associations were estimated by using weighted linear regression models to adjust the two measures of body fatness for each other.

Results: Waist circumference, but not percent body fat was inversely associated with total testosterone and SHBG in all three racial/ethnic groups after their mutual adjustment (all P < 0.0001). Percent body fat (P = 0.02), but not waist circumference was positively associated with total estradiol in NHB men; no association was present in NHW and MA men (P-interaction = 0.04). Waist circumference, but not body fat was strongly positively associated with fasting insulin (all P < 0.0001) and inversely associated with HDL cholesterol (all P ≤ 0.003) in all three racial/ethnic groups. Both percent body fat and waist circumference were positively associated with leptin (all P < 0.0001) in all three racial/ethnic groups.

Conclusions: There was no strong evidence in the associations of sex hormones and metabolic factors with body fatness in different racial/ethnic groups. These findings should be further explored in prospective studies to determine their relevance in racial/ethnic disparities of chronic diseases.
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http://dx.doi.org/10.5812/ijem.44926DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556314PMC
April 2017

Endogenous and exogenous testosterone and prostate cancer: decreased-, increased- or null-risk?

Transl Androl Urol 2017 Jun;6(3):566-579

Division of Urology, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA.

For more than 70 years, the contention that high levels of testosterone or that the use of testosterone therapy (TTh) increases the development and progression of prostate cancer (PCa) has been widely accepted and practiced. Yet, the increasing and emerging evidence on testosterone research seems to challenge that contention. To review literature on the associations of endogenous and exogenous testosterone with decreased-, increased-, or null-risk of PCa, and to further evaluate only those studies that reported magnitude of associations from multivariable modeling as it minimizes confounding effects. We conducted a literature search to identify studies that investigated the association of endogenous total testosterone [continuous (per 1 unit increment and 5 nmol/L increment) and categorical (high low)] and use of TTh with PCa events [1990-2016]. Emphasis was given to studies/analyses that reported magnitude of associations [odds ratio (OR), relative risk (RR) and hazard ratios (HRs)] from multivariable analyses to determine risk of PCa and their statistical significance. Most identified studies/analyses included observational and randomized placebo-controlled trials. This review was organized in three parts: (I) association of endogenous total testosterone (per 1 unit increment and 5 nmol/L increment) with PCa; (II) relationship of endogenous total testosterone (categorical high vs. low) with PCa; and (III) association of use of TTh with PCa in meta-analyses of randomized placebo-controlled trials. The first part included 31 observational studies [20 prospective (per 5 nmol/L increment) and 11 prospective and retrospective cohort studies (per 1 unit increment)]. None of the 20 prospective studies found a significant association between total testosterone (5 nmol/L increment) and increased- or decreased-risk of PCa. Two out of the 11 studies/analyses showed a significant decreased-risk of PCa for total testosterone per 1 unit increment, but also two other studies showed a significant increased-risk of PCa. Remaining studies reported null-risks values. Second part: eight of out of 25 studies reported an increased-risk of PCa for men with high levels of testosterone compared to low, but only four were statistically significant. However, 17 studies showed a decreased-risk of PCa after comparing high . low levels of testosterone, but 11 studies/analyses were statistically significant. Third part: two meta-analyses of randomized placebo-controlled trials (n=8 and n=11, each) that investigated use of TTh with PCa reported not significant decreased-risks of PCa. The contention that high levels of testosterone or that the use of TTh increases the risk of PCa doesn't seem to be supported from the literature. Yet, we still need a study with the adequate power, follow-up data, epidemiological, pathological and clinical data that can support the safety and beneficial effects of high levels of endogenous testosterone or use of TTh in the natural history of PCa and in men's health.
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http://dx.doi.org/10.21037/tau.2017.05.35DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503974PMC
June 2017

Testosterone replacement therapy and the heart: friend, foe or bystander?

Transl Androl Urol 2016 Dec;5(6):898-908

Division of Urology, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA.

The role of testosterone therapy (TTh) in cardiovascular disease (CVD) outcomes is still controversial, and it seems will remain inconclusive for the moment. An extensive body of literature has investigated the association of endogenous testosterone and use of TTh with CVD events including several meta-analyses. In some instances, a number of studies reported beneficial effects of TTh on CVD events and in other instances the body of literature reported detrimental effects or no effects at all. Yet, no review article has scrutinized this body of literature using the magnitude of associations and statistical significance reported from this relationship. We critically reviewed the previous and emerging body of literature that investigated the association of endogenous testosterone and use of TTh with CVD events (only fatal and nonfatal). These studies were divided into three groups, "beneficial (friendly use)", "detrimental (foe)" and "no effects at all (bystander)", based on their magnitude of associations and statistical significance from original research studies and meta-analyses of epidemiological studies and of randomized controlled trials (RCT's). In this review article, the studies reporting a significant association of high levels of testosterone with a reduced risk of CVD events in original prospective studies and meta-analyses of cross-sectional and prospective studies seems to be more consistent. However, the number of meta-analyses of RCT's does not provide a clear picture after we divided it into the beneficial, detrimental or no effects all groups using their magnitudes of association and statistical significance. From this review, we suggest that we need a study or number of studies that have the adequate power, epidemiological, and clinical data to provide a definitive conclusion on whether the effect of TTh on the natural history of CVD is real or not.
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http://dx.doi.org/10.21037/tau.2016.10.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5182236PMC
December 2016

A Systematic Review and Meta-analysis Comparing the Effectiveness and Adverse Effects of Different Systemic Treatments for Non-clear Cell Renal Cell Carcinoma.

Eur Urol 2017 03 8;71(3):426-436. Epub 2016 Dec 8.

Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands. Electronic address:

Context: While vascular endothelial growth factor-targeted therapy and mammalian target of rapamycin inhibition are effective strategies in treating clear cell renal cell carcinoma (ccRCC), the most effective therapeutic approach for patients with non-clear cell RCC (non-ccRCC) is unknown.

Objective: To systematically review relevant literature comparing the oncological outcomes and adverse events of different systemic therapies for patients with metastatic non-ccRCC.

Evidence Acquisition: Relevant databases including MEDLINE, Embase, and the Cochrane Library were searched up to March 24, 2016. Only comparative studies were included. Risk of bias and confounding assessments were performed. A meta-analysis was planned for and only performed if methodologically appropriate; otherwise, a narrative synthesis was undertaken.

Evidence Synthesis: The literature search identified 812 potential titles and abstracts. Five randomized controlled trials, recruiting a total of 365 patients, were included. Three studies compared sunitinib against everolimus, one of which reported the results for non-ccRCC as a subgroup rather than as an entire randomized cohort. Individually, the studies showed a trend towards favoring sunitinib in terms of overall survival and progression-free survival (PFS; Everolimus versus Sunitinib in Patients with Metastatic Non-clear Cell Renal Cell Carcinoma hazard ratio [HR]: 1.41, 80% confidence interval [CI] 1.03-1.92 and 1.41, 95% CI: 0.88-2.27, Evaluation in Metastatic Non-clear Cell Renal Cell Carcinoma HR: 1.16, 95% CI: 0.67-2.01, Efficacy and Safety Comparison of RAD001 Versus Sunitinib in the First-line and Second-line Treatment of Patients with Metastatic Renal Cell Carcinoma HR: 1.5, 95% CI: 0.9-2.8), but this trend did not reach statistical significance in any study. Meta-analysis was performed on two studies which solely recruited patients with non-ccRCC reporting on PFS, the results of which were inconclusive (HR: 1.30, 95% CI: 0.91-1.86). Sunitinib was associated with more Grade 3-4 adverse events than everolimus, although this was not statistically significant.

Conclusions: This systematic review and meta-analysis represent a robust summary of the evidence base for systemic treatment of metastatic non-ccRCC. The results show a trend towards favoring vascular endothelial growth factor-targeted therapy for PFS and overall survival compared with mammalian target of rapamycin inhibitors, although statistical significance was not reached. The relative benefits and harms of these treatments remain uncertain. Further research, either in the form of an individual patient data meta-analysis involving all relevant trials, or a randomized controlled trial with sufficient power to detect potential differences between treatments, is needed.

Patient Summary: We examined the literature to determine the most effective treatments for advanced kidney cancer patients whose tumors are not of the clear cell subtype. The results suggest that a drug called sunitinib might be more effective than everolimus, but the statistics supporting this statement are not yet entirely reliable. Further research is required to clarify this unmet medical need.
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http://dx.doi.org/10.1016/j.eururo.2016.11.020DOI Listing
March 2017

Conflict of Evidence: Resolving Discrepancies When Findings from Randomized Controlled Trials and Meta-analyses Disagree.

Eur Urol 2017 05 30;71(5):811-819. Epub 2016 Nov 30.

Academic Urology Unit, University of Aberdeen, Aberdeen, UK.

Context: Clinicians and treatment guideline developers are faced with a dilemma when the results of a new, large, well-conducted randomized controlled trial (RCT) are in direct conflict with the results of a previous systematic review (SR) and meta-analysis (MA).

Objective: To explore and discuss possible reasons for disagreement in results from SRs/MAs and RCTs and to provide guidance to clinicians and guideline developers for making well-informed treatment decisions and recommendations in the face of conflicting data.

Evidence Acquisition: The advantages and limitations of RCTs and SRs/MAs are reviewed. Two practical examples that have a direct bearing on European Association of Urology guidelines on treatment recommendations are discussed in detail to illustrate the points to be considered when conflicts exist between the results of large RCTs and SRs/MAs.

Evidence Synthesis: RCTs are the gold standard for providing evidence of the effectiveness of interventions. However, concerns regarding the internal and external validity of an RCT may limit its applicability to clinical practice. SRs/MAs synthesize all evidence related to a given research question, but two urologic examples show that the validity of the results depends on the quality of the individual studies, the clinical and methodological heterogeneity of the studies, and publication bias.

Conclusions: Although SRs/MAs can provide a higher level of evidence than RCTs, the quality of the evidence from both RCTs and SRs/MAs should be investigated when their results conflict to determine which source provides the better evidence. Guideline developers should have a well-defined and robust process to assess the evidence from MAs and RCTs when such conflicts exist.

Patient Summary: We discuss the advantages and limitations of using data from randomized controlled trials and systematic reviews/meta-analyses in informing clinical practice when there are conflicting results. We provide guidance on how such conflicts should be dealt with by guideline organizations.
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http://dx.doi.org/10.1016/j.eururo.2016.11.023DOI Listing
May 2017

Informed decision making before prostate-specific antigen screening: Initial results using the American Cancer Society (ACS) Decision Aid (DA) among medically underserved men.

Cancer 2017 02 11;123(4):583-591. Epub 2016 Oct 11.

Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: The American Cancer Society (ACS) recommends men have the opportunity to make an informed decision about screening for prostate cancer (PCa). The ACS developed a unique decision aid (ACS-DA) for this purpose. However, to date, studies evaluating the efficacy of the ACS-DA are lacking. The authors evaluated the ACS-DA among a cohort of medically underserved men (MUM).

Methods: A multiethnic cohort of MUM (n = 285) was prospectively included between June 2010 and December 2014. The ACS-DA was presented in a group format. Levels of knowledge on PCa were evaluated before and after the presentation. Participants' decisional conflict and thoughts about the presentation also were evaluated. Logistic regression analyses were performed to determine factors associated with having an adequate level of knowledge.

Results: Before receiving the ACS-DA, 33.1% of participants had adequate knowledge on PCa, and this increased to 77% after the DA (P < .0001). On multivariate analysis, higher education level (odds ratio, 11.19; P = .001) and history of another cancer (odds ratio, 7.45; P = .03) were associated with having adequate knowledge after receiving the DA. Levels of decisional conflict were low and were correlated with levels of knowledge after receiving the DA. The majority of men also rated the presentation as favorable and would recommend the ACS-DA to others.

Conclusions: Use of the ACS-DA was feasible among MUM and led to increased PCa knowledge. This also correlated with low levels of decisional conflict. The ACS-DA presented to groups of men may serve as a feasible tool for informed decision making in a MUM population. Cancer 2017;123:583-591. © 2016 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293675PMC
February 2017

Review: Newer and older drugs do not differ for lower urinary tract symptoms due to benign prostatic hyperplasia.

Ann Intern Med 2016 10;165(8):JC45

University of Texas McGovern Medical SchoolHouston, Texas, USA.

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http://dx.doi.org/10.7326/ACPJC-2016-165-8-045DOI Listing
October 2016

European Association of Urology Guidelines for Clear Cell Renal Cancers That Are Resistant to Vascular Endothelial Growth Factor Receptor-Targeted Therapy.

Eur Urol 2016 11 24;70(5):705-706. Epub 2016 Jun 24.

Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.

The European Association of Urology renal cancer guidelines panel recommends nivolumab and cabozantinib over the previous standard of care in patients who have failed one or more lines of vascular endothelial growth factor-targeted therapy. New data have recently become available showing a survival benefit for cabozantinib.
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http://dx.doi.org/10.1016/j.eururo.2016.06.009DOI Listing
November 2016

Association of Urinary Phthalate Metabolites With Erectile Dysfunction in Racial and Ethnic Groups in the National Health and Nutrition Examination Survey 2001-2004.

Am J Mens Health 2017 05 1;11(3):576-584. Epub 2016 Apr 1.

2 The University of Texas Medical School, Houston, TX, USA.

Phthalates are endocrine-disrupting compounds detectable in more than 75% of the U.S. population with differential distributions across racial and ethnic groups, and they have been linked with reduced levels of serum testosterone. This study aims to investigate the associations of phthalate metabolites with erectile dysfunction (ED) and to determine whether these associations vary by race/ethnicity among men in the United States. Analyzed data for 12 phthalate metabolites from 3,746 men (≥20 years old), who participated in the National Health and Nutrition Examination Survey 2001-2004 cross-sectional study, were included. Metabolites included MBP, MCHP, MEP, MEHP, MiNP, MBzP, MMP, MCPP, MEHHP, MEOHP, MiBP, and MECPP. Racial/ethnic groups included non-Hispanic Blacks ( n = 770), non-Hispanic Whites ( n = 2,147), and Mexican Americans ( n = 829). ED was assessed by a single question during a self-paced, computer-assisted self-interview. In racial/ethnic stratified analyses, there were higher MBP and MBzP concentrations that had a strong-dose response association with lower prevalence odds of ED among Mexican Americans, p < .01, and p = .03, respectively. Similarly, a significant inverse association between MEHHP and likelihood of ED among non-Hispanic Black men ( p < .04) was observed. Furthermore, significant inverse associations between higher concentrations of phthalates and ED were identified only in minority populations. Further investigations, particularly prospective studies, are warranted to determine the role of phthalates on the biological mechanism(s) associated with ED. A focus may be placed on testosterone levels which are suggested to be affected by phthalates, and also low levels of testosterone are suggested to increase the risk of ED.
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http://dx.doi.org/10.1177/1557988316641370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5675227PMC
May 2017

Systematic Review of Surgical Management of Nonmetastatic Renal Cell Carcinoma with Vena Caval Thrombus.

Eur Urol 2016 08 23;70(2):265-80. Epub 2015 Dec 23.

Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; Academic Urology Unit, University of Aberdeen, Aberdeen, UK. Electronic address:

Context: Overall, 4-10% of patients with renal cell carcinoma (RCC) present with venous tumour thrombus. It is uncertain which surgical technique is best for these patients. Appraisal of outcomes with differing techniques would guide practice.

Objective: To systematically review relevant literature comparing the outcomes of different surgical therapies and approaches in treating vena caval thrombus (VCT) from nonmetastatic RCC.

Evidence Acquisition: Relevant databases (Medline, Embase, and the Cochrane Library) were searched to identify relevant comparative studies. Risk of bias and confounding assessments were performed. A narrative synthesis of the evidence was presented.

Evidence Synthesis: The literature search identified 824 articles. Fourteen studies reporting on 2262 patients were included. No distinct surgical method was superior for the excision of VCT, although the method appeared to be dependent on tumour thrombus level. Minimal access techniques appeared to have better perioperative and recovery outcomes than traditional median sternotomy, but the impact on oncologic outcomes is unknown. Preoperative renal artery embolisation did not offer any oncologic benefits and instead resulted in significantly worse perioperative and recovery outcomes, including possibly higher perioperative mortality. The comparison of cardiopulmonary bypass versus no cardiopulmonary bypass showed no differences in oncologic outcomes. Overall, there were high risks of bias and confounding.

Conclusions: The evidence base, although derived from retrospective case series and complemented by expert opinion, suggests that patients with nonmetastatic RCC and VCT and acceptable performance status should be considered for surgical intervention. Despite a robust review, the findings were associated with uncertainty due to the poor quality of primary studies available. The most efficacious surgical technique remains unclear.

Patient Summary: We examined the literature on the benefits of surgery to remove kidney cancers that have spread to neighbouring veins. The results suggest such surgery, although challenging and associated with high risk of complications, appears to be feasible and effective and should be contemplated for suitable patients if possible; however, many uncertainties remain due to the poor quality of the data.
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http://dx.doi.org/10.1016/j.eururo.2015.11.034DOI Listing
August 2016

Updated EAU Guidelines for Clear Cell Renal Cancer Patients Who Fail VEGF Targeted Therapy.

Eur Urol 2016 Jan 24;69(1):4-6. Epub 2015 Oct 24.

Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.

The European Association of Urology renal cancer guidelines have been updated to recommend nivolumab and cabozantinib over the previous standard of care in patients who have failed one or more lines of VEGF targeted therapy.
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http://dx.doi.org/10.1016/j.eururo.2015.10.017DOI Listing
January 2016

Systematic Review and Meta-analysis of Diagnostic Accuracy of Percutaneous Renal Tumour Biopsy.

Eur Urol 2016 Apr 29;69(4):660-673. Epub 2015 Aug 29.

Division of Urology, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy. Electronic address:

Context: The role of percutaneous renal tumour biopsy (RTB) remains controversial due to uncertainties regarding its diagnostic accuracy and safety.

Objective: We performed a systematic review and meta-analysis to determine the safety and accuracy of percutaneous RTB for the diagnosis of malignancy, histologic tumour subtype, and grade.

Evidence Acquisition: Medline, Embase, and Cochrane Library were searched for studies providing data on diagnostic accuracy and complications of percutaneous core biopsy (CB) or fine-needle aspiration (FNA) of renal tumours. A meta-analysis was performed to obtain pooled estimates of sensitivity and specificity for diagnosis of malignancy. The Cohen kappa coefficient (κ) was estimated for the analysis of histotype/grade concordance between diagnosis on RTB and surgical specimen. Risk of bias assessment was performed (QUADAS-2).

Evidence Synthesis: A total of 57 studies recruiting 5228 patients were included. The overall median diagnostic rate of RTB was 92%. The sensitivity and specificity of diagnostic CBs and FNAs were 99.1% and 99.7%, and 93.2% and 89.8%, respectively. A good (κ = 0.683) and a fair (κ = 0.34) agreement were observed between histologic subtype and Fuhrman grade on RTB and surgical specimen, respectively. A very low rate of Clavien ≥ 2 complications was reported. Study limitations included selection and differential-verification bias.

Conclusions: RTB is safe and has a high diagnostic yield in experienced centres. Both CB and FNA have good accuracy for the diagnosis of malignancy and histologic subtype, with better performance for CB. The accuracy for Fuhrman grade is fair. Overall, the quality of the evidence was moderate. Prospective cohort studies recruiting consecutive patients and using homogeneous reference standards are required.

Patient Summary: We systematically reviewed the literature to assess the safety and diagnostic performance of renal tumour biopsy (RTB). The results suggest that RTB has good accuracy in diagnosing renal cancer and its subtypes, and it appears to be safe. However, the quality of evidence was moderate, and better quality studies are required to provide a more definitive answer.
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http://dx.doi.org/10.1016/j.eururo.2015.07.072DOI Listing
April 2016

Role of Caffeine Intake on Erectile Dysfunction in US Men: Results from NHANES 2001-2004.

PLoS One 2014 28;10(4):e0123547. Epub 2015 Apr 28.

Division of Urology, University of Texas- Houston Medical School, Houston, TX, United States of America.

Objectives: Caffeine is consumed by more than 85% of adults and little is known about its role on erectile dysfunction (ED) in population-based studies. We investigated the association of caffeine intake and caffeinated beverages with ED, and whether these associations vary among comorbidities for ED.

Material And Method: Data were analyzed for 3724 men (≥20 years old) who participated in the National Health and Nutrition Examination Survey (NHANES). ED was assessed by a single question during a self-paced, computer-assisted self-interview. We analyzed 24-h dietary recall data to estimate caffeine intake (mg/day). Multivariable logistic regression analyses using appropriate sampling weights were conducted.

Results: We found that men in the 3rd (85-170 mg/day) and 4th (171-303 mg/day) quintiles of caffeine intake were less likely to report ED compared to men in the lowest 1st quintile (0-7 mg/day) [OR: 0.58; 95% CI, 0.37-0.89; and OR: 0.61; 95% CI, 0.38-0.97, respectively], but no evidence for a trend. Similarly, among overweight/obese and hypertensive men, there was an inverse association between higher quintiles of caffeine intake and ED compared to men in the lowest 1st quintile, P≤0.05 for each quintile. However, only among men without diabetes we found a similar inverse association (Ptrend = 0.01).

Conclusion: Caffeine intake reduced the odds of prevalent ED, especially an intake equivalent to approximately 2-3 daily cups of coffee (170-375 mg/day). This reduction was also observed among overweight/obese and hypertensive, but not among diabetic men. Yet, these associations are warranted to be investigated in prospective studies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0123547PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4412629PMC
January 2016

EAU guidelines on renal cell carcinoma: 2014 update.

Eur Urol 2015 May 21;67(5):913-24. Epub 2015 Jan 21.

Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands. Electronic address:

Context: The European Association of Urology Guideline Panel for Renal Cell Carcinoma (RCC) has prepared evidence-based guidelines and recommendations for RCC management.

Objectives: To provide an update of the 2010 RCC guideline based on a standardised methodology that is robust, transparent, reproducible, and reliable.

Evidence Acquisition: For the 2014 update, the panel prioritised the following topics: percutaneous biopsy of renal masses, treatment of localised RCC (including surgical and nonsurgical management), lymph node dissection, management of venous thrombus, systemic therapy, and local treatment of metastases, for which evidence synthesis was undertaken based on systematic reviews adhering to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Relevant databases (Medline, Cochrane Library, trial registries, conference proceedings) were searched (January 2000 to November 2013) including randomised controlled trials (RCTs) and retrospective or controlled studies with a comparator arm. Risk of bias (RoB) assessment and qualitative and quantitative synthesis of the evidence were performed. The remaining sections of the document were updated following a structured literature assessment.

Evidence Synthesis: All chapters of the RCC guideline were updated. For the various systematic reviews, the search identified a total of 10,862 articles. A total of 151 studies reporting on 78,792 patients were eligible for inclusion; where applicable, data from RCTs were included and meta-analyses were performed. For RCTs, there was low RoB across studies; however, clinical and methodological heterogeneity prevented data pooling for most studies. The majority of studies included were retrospective with matched or unmatched cohorts based on single or multi-institutional data or national registries. The exception was for systemic treatment of metastatic RCC, in which several RCTs have been performed, resulting in recommendations based on higher levels of evidence.

Conclusions: The 2014 guideline has been updated by a multidisciplinary panel using the highest methodological standards, and provides the best and most reliable contemporary evidence base for RCC management.

Patient Summary: The European Association of Urology Guideline Panel for Renal Cell Carcinoma has thoroughly evaluated available research data on kidney cancer to establish international standards for the care of kidney cancer patients.
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http://dx.doi.org/10.1016/j.eururo.2015.01.005DOI Listing
May 2015