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September 2019 – About the cover

The Article of the Month for September was written by researchers from Brisbane, Queensland, Australia: Risk of metastatic disease on 68gallium‐prostate‐specific membrane antigen positron emission tomography/computed tomography scan for primary staging of 1253 men at the diagnosis of prostate cancer

The cover image shows Brisbane by night. The city is located on the Brisbane river, which is named after the Scotsman Sir Thomas Brisbane, a former governor of New South Wales. Brisbane became the capital of Queensland in 1859.

North of the city are the Glasshouse Mountains and South is the Gold Coast – there are also several islands which are just a short ferry ride away.

 

© istock.com/lovro77

 

Article of the month: Risk of metastatic disease on 68-gallium‐prostate‐specific membrane antigen PET/CT scan for primary staging of 1253 men at the diagnosis of PCa

Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial  and a video prepared by the authors. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this month, it should be this one.

Risk of metastatic disease on 68Gallium‐prostate‐specific membrane antigen positron emission tomography/computed tomography scan for primary staging of 1253 men at the diagnosis of prostate cancer

John W. Yaxley*†‡, Sheliyan Raveenthiran†‡, François-Xavier Nouhaud‡§, Hemamali Samaratunga†¶, William J. Yaxley†‡, Geoff Coughlin*, Anna J. Yaxley**, Troy Gianduzzo††, Boon Kua‡‡, Louise McEwan‡‡ and David Wong‡‡

 

*Wesley Urology Clinic, Department of Medicine, University of Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, §Department of Urology, Rouen University Hospital, Rouen, France, Aquesta Uro-pathology, **School of Medicine, Griffith University, ††Brisbane Prostate Clinic, and ‡‡Wesley Medical Imaging, Brisbane, Queensland, Australia

Read the full article

Abstract

Objective

To determine the number of men with 68gallium‐prostate‐specific membrane antigen positron emission tomography/computed tomography (68Ga‐PSMA PET/CT) avid metastasis at diagnosis, as most data on 68Ga‐PSMA PET/CT are for the evaluation of recurrent disease after primary treatment and to our knowledge this study is the largest series of primary prostate cancer staging with 68Ga‐PSMA PET/CT.

Patients and Methods

A retrospective review conducted on 1253 consecutive men referred by urologists or radiation oncologists to our tertiary referral centre for 68Ga‐PSMA PET/CT scan for staging at the initial diagnosis of prostate cancer between July 2014 and June 2018.

The primary outcome measure was to determine the risk of metastasis based on 68Ga‐PSMA PET/CT. Patients were risk stratified based on histological biopsy International Society of Urological Pathology (ISUP) grade, prostate‐specific antigen (PSA) level, and staging with pre‐biopsy multiparametric magnetic resonance imaging (mpMRI). Univariate and multivariate logistic regression were used to analyse results.

Results

The median PSA level was 6.5 ng/mL and median ISUP grade was 3, with high‐risk disease in 49.7%. The prostate primary was PSMA avid in 91.7% of men. Metastatic disease was identified in 12.1% of men, including 8.2% with a PSA level of <10 ng/mL and 43% with a PSA level of >20 ng/mL. Metastases were identified in 6.4% with ISUP grade 2–3 and 21% with ISUP grade 4–5. Pre‐biopsy mpMRI identified metastasis in 8.1% of T2 disease, increasing to 42.4% of T3b. Lymph node metastases were suspected in 107 men, with 47.7% outside the boundaries of an extended pelvic lymph node dissection. Skeletal metastases were identified in 4.7%. In men with intermediate‐risk prostate cancer, metastases were identified in 5.2%, compared to 19.9% with high‐risk disease.

Conclusions

These results support the use of 68Ga‐PSMA PET/CT for primary staging of prostate cancer. Increasing PSA level, ISUP grade and radiological staging with mpMRI were all statistically significant prognostic factors for metastasis on both univariate and multivariate analysis.

Read more Articles of the week

Video: Risk of metastatic disease on 68-Ga‐PSMA PET/CT scan for primary staging of 1253 men with PCa

 

Risk of metastatic disease on 68Gallium‐prostate‐specific membrane antigen positron emission tomography/computed tomography scan for primary staging of 1253 men at the diagnosis of prostate cancer

Read the full article

Abstract

Objective

To determine the number of men with 68gallium‐prostate‐specific membrane antigen positron emission tomography/computed tomography (68Ga‐PSMA PET/CT) avid metastasis at diagnosis, as most data on 68Ga‐PSMA PET/CT are for the evaluation of recurrent disease after primary treatment and to our knowledge this study is the largest series of primary prostate cancer staging with 68Ga‐PSMA PET/CT.

Patients and Methods

A retrospective review conducted on 1253 consecutive men referred by urologists or radiation oncologists to our tertiary referral centre for 68Ga‐PSMA PET/CT scan for staging at the initial diagnosis of prostate cancer between July 2014 and June 2018.

The primary outcome measure was to determine the risk of metastasis based on 68Ga‐PSMA PET/CT. Patients were risk stratified based on histological biopsy International Society of Urological Pathology (ISUP) grade, prostate‐specific antigen (PSA) level, and staging with pre‐biopsy multiparametric magnetic resonance imaging (mpMRI). Univariate and multivariate logistic regression were used to analyse results.

Results

The median PSA level was 6.5 ng/mL and median ISUP grade was 3, with high‐risk disease in 49.7%. The prostate primary was PSMA avid in 91.7% of men. Metastatic disease was identified in 12.1% of men, including 8.2% with a PSA level of <10 ng/mL and 43% with a PSA level of >20 ng/mL. Metastases were identified in 6.4% with ISUP grade 2–3 and 21% with ISUP grade 4–5. Pre‐biopsy mpMRI identified metastasis in 8.1% of T2 disease, increasing to 42.4% of T3b. Lymph node metastases were suspected in 107 men, with 47.7% outside the boundaries of an extended pelvic lymph node dissection. Skeletal metastases were identified in 4.7%. In men with intermediate‐risk prostate cancer, metastases were identified in 5.2%, compared to 19.9% with high‐risk disease.

Conclusions

These results support the use of 68Ga‐PSMA PET/CT for primary staging of prostate cancer. Increasing PSA level, ISUP grade and radiological staging with mpMRI were all statistically significant prognostic factors for metastasis on both univariate and multivariate analysis.

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Article of the month: Resident burnout in USA and European urology residents: an international concern

Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial  and a visual abstract written by members of the urological community, and a video prepared by the authors. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this month, it should be this one.

Resident burnout in USA and European urology residents: an international concern

Daniel Marchalik*, Charlotte C. Goldman, Filipe F. L. Carvalho*, Michele Talso§, John H. Lynch*, Francesco Esperto, Benjamin Pradere**, Jeroen Van Besien†† and Ross E. Krasnow‡‡

 

*Department of Urology, MedStar Georgetown University Hospital, Washington, DC, MedStar Health, Office of Physician Well-being, Columbia, MD,Georgetown University School of Medicine, Washington DC, USA, §Urology DepartmentMonza Brianza, Azienda Socio-Sanitaria Territoriale (ASST) Vimercate Hospital, Vimercate, Department of Urology, Humanitas Gavazzeni, Bergamo, Italy, **Academic Department of Urology, CHRU Tours, François Rabelais University, Tours, France,††Department of Urology, Ghent University Hospital, Ghent, Belgium, and ‡‡Department ofUrology, MedStar Washington Hospital Center, Washington DC, USA

 

Read the full article

Abstract

Objective

To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood.

Subjects and methods

An anonymous 32‐question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts.

Fig.1. The predicted probability of burnout in residents stratified by non‐medical reading.

Results

Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work–life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non‐medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on‐call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047).

Conclusion

In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.

Read more Articles of the week

Editorial: The pursuit of purpose: reframing strategies to prevent physician burnout

If there is one virtue that drives surgery residents to toil away in sterile, brightly lit operating rooms for extended hours for the best years of their life, it is the pursuit of purpose. However, these extended hours can also lead to what the WHO has now officially recognized as a medical condition: burnout. In a study in this issue of BJUI, Marchalik et al. [1] use qualitative analysis to elaborate on the prevalence and predictors of burnout among urology residents in the USA and in four European countries. Using an anonymous survey, the authors report a high prevalence of burnout in urology residents in both cohorts, with the European residents (44%) experiencing a higher burden than their US counterparts (38%). Given the recent focus, in the academic as well as general media, on the importance and severe implications of physician burnout, and the recognition of burnout as a disease by WHO, the timing of this publication for concrete organizational action seems propitious, especially since this analysis combines data from two continents with different institutional and educational frameworks, providing more granular data for a particularly immersive surgical specialty with a high rate of burnout.

Most recently, a costconsequence analysis reported that physician burnout costs approximately $4.6 bn each year to the US healthcare system, with a cost of $7600 per‐physician‐per‐year at the institutional level resulting from reduced clinical productivity and turnover [2]. While addressing these economic losses from burnout is important from an organizational and health system point of view, focusing on these alone would be missing the larger picture. It is only when we consider the depersonalization, emotional drainage, and loss of professional and personal accomplishment associated with burnout that we begin to realize the scope of this epidemic. Deservedly, burnout is being recognized as a ‘moral injury’ [3]. And indeed, it is a moral injury: when physicians working under systems that betray their purpose as a healer, the damage is not only professional and systematic, but deeply personal as well.

The constant act of balancing competing demands – the financial interests of the healthcare institutions, looming litigations and ever‐changing documentation requirements – has undermined effective human interactions with patients and diminished the zeal that drives physicians to spend a major part of their youth in training. Journalist Diane Silver defines moral injury as ‘a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society’ [3]. Except in the context of healthcare delivery, this injury extends to deterioration of relationships with patients and fellow physicians. Indeed, burnout among physicians has been demonstrated to be associated with suboptimal patient care [4], and the consequent inability to deliver high‐quality care because of health system deficiencies leads to decline in physician well‐being and professional dissatisfaction [5].

While the urgency of addressing physician burnout is obvious, this study by Marchalik et al. is also valuable as it highlights some of the practices that are protective, revealing lessons that can be implemented. The authors report that burnout was significantly lower among residents who sought mental health services and those who had access to structured mentorship. Unsurprisingly, those who had a caring environment experienced less depersonalization and emotional drainage. This is an instructive lesson for the residency programme directors: if they want their most important human resource to flourish, they need to start building supportive work environments. This could start with pairing interns and residents with dedicated and experienced faculty mentors; these initiatives would facilitate career coaching and provide space where residents feel comfortable seeking information on mental healthcare.

Interestingly, the authors also found a significant doseresponse relationship between the number of non‐medical books residents read per month and decreased rates of burnout. This finding may surprise some healthcare administrators, who have routinely attempted to integrate ‘wellness’ and ‘mindfulness’ into clinical programmes to stimulate physician motivation, without much benefit. However, the positive relationship between non‐medical literature and medicine is an ancient one. Fortunately, in the last few decades, this relationship has witnessed a comeback and an increasing number of trainees are finding solace in their engagement with medical humanities and narrative medicine. These engagements have led to physicians developing emotional intelligence, empathy for patients and colleagues, and an opportunity to examine their role as healers [6]. This insight from the study should be another lesson for medical educators, who can encourage inclusion of reflections on life as a physician.

The epidemic of burnout among surgery residents requires immediate attention. Taking proactive action towards this is not only a matter of preventing economic loss or improving physician productivity, but an urgent ethical issue. All stakeholders – hospital administrators, healthcare policy‐makers, and regional physician leaders – must work together in developing inventive solutions to address the burnout epidemic. This will be essential to realizing the maximal potential of residency and reinstating purpose of clinical work.

References

  1. Marchalik, DGoldman, CCCarvalho, FFL et al. Resident burnout in USA and European urology residents: an international concern. BJU Int 2019124349‐ 56
  2. Han, SShanafelt, TDSinsky, CA et al. Estimating the attributable cost of physician burnout in the United States cost of physician burnout. Ann Intern Med 2019170784‐ 90
  3. Dean, WTalbot, SPhysicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT News 2018. Available at: https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed May 29, 2019.
  4. Shanafelt, TDBradley, KAWipf, JEBack, ALBurnout and self‐reported patient care in an internal medicine residency program. Ann Intern Med 2002136358– 67
  5. Friedberg, MWChen, PGBusum, KR et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q 201431
  6. Bonebakker, VLiterature & medicine: humanities at the heart of health care: a hospital‐based reading and discussion program developed by the Maine humanities council. Acad Med 200378:963– 7

 

Video: Resident burnout in USA and European urology residents

Resident burnout in USA and European urology residents: an international concern

Abstract

Objective

To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood.

Subjects and methods

An anonymous 32‐question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts.

Results

Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work–life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non‐medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on‐call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047).

Conclusion

In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.

View more videos

 

Residents’ podcast: Resident burnout

Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the month:

Resident burnout in USA and European urology residents: an international concern

Read the full article

Abstract

Objective

To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood.

Subjects and methods

An anonymous 32‐question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts.

Results

Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work–life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non‐medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on‐call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047).

Conclusion

In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.

More podcasts

BJUI Podcasts now available on iTunes, subscribe here https://itunes.apple.com/gb/podcast/bju-international/id1309570262

August 2019 – About the cover

The Article of the Month for August is on work carried out by researchers at the Medstar Georgetown University Hospital, Washington DC, USA along with colleagues from Italy, France and Belgium: Resident burnout in USA and European urology residents: an international concern.

The cover image shows the Lincoln Memorial, which is located in the National Mall in Washington DC. It commemorates the 16th US President, Abraham Lincoln. Washington itself was named after the first US President, George Washington. It lies along the Potomac river and is surrounded by the states of Maryland and Virginia.

 

© istock.com/Stephen Emlund

Article of the month: NICE Guidance – Prostate cancer: diagnosis and management

Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this month, it should be this one.

NICE Guidance – Prostate cancer: diagnosis and management

Read the full article

Overview

This guideline covers the diagnosis and management of prostate cancer in secondary care, including information on the best way to diagnose and identify different stages of the disease, and how to manage adverse effects of treatment. It also includes recommendations on follow‐up in primary care for people diagnosed with prostate cancer.

Who is it for?

  • Healthcare professionals
  • Commissioners and providers of prostate cancer services
  • People with prostate cancer, their families and carers

Context

Prostate cancer is the most common cancer in men, and the second most common cancer in the UK. In 2014, there were over 46,000 new diagnoses of prostate cancer, which accounts for 13% of all new cancers diagnosed. About 1 in 8 men will get prostate cancer at some point in their life. Prostate cancer can also affect transgender women, as the prostate is usually conserved after gender-confirming surgery, but it is not clear how common it is in this population.

More than 50% of prostate cancer diagnoses in the UK each year are in men aged 70 years and over (2012), and the incidence rate is highest in men aged 90 years and over (2012 to 2014). Out of every 10 prostate cancer cases, 4 are only diagnosed at a late stage in England (2014) and Northern Ireland (2010 to 2014). Incidence rates are projected to rise by 12% between 2014 and 2035 in the UK to 233 cases per 100,000 in 2035.

A total of 84% of men aged 60 to 69 years at diagnosis in 2010/2011 are predicted to survive for 10 or more years after diagnosis. When diagnosed at the earliest stage, virtually all people with prostate cancer survive 5 years or more: this is compared with less than a third of people surviving 5 years or more when diagnosed at the latest stage.

There were approximately 11,000 deaths from prostate cancer in 2014. Mortality rates from prostate cancer are highest in men aged 90 years and over (2012 to 2014). Over the past decade, mortality rates have decreased by more than 13% in the UK. Mortality rates are projected to fall by 16% between 2014 and 2035 to 48 deaths per 100,000 men in 2035.

People of African family origin are at higher risk of prostate cancer (lifetime risk of approximately 1 in 4). Prostate cancer is inversely associated with deprivation, with a higher incidence of cases found in more affluent areas of the UK.

Costs for the inpatient treatment of prostate cancer are predicted to rise to £320.6 million per year in 2020 (from
£276.9 million per year in 2010).

This guidance was updated in 2014 to include several treatments that have been licensed for the management of
hormone-relapsed metastatic prostate cancer since the publication of the original NICE guideline in 2008.
Since the last update in 2014, there have been changes in the way that prostate cancer is diagnosed and treated. Advances in imaging technology, especially multiparametric MRI, have led to changes in practice, and new evidence about some prostate cancer treatments means that some recommendations needed to be updated.

 

Read more Articles of the week
Read more Urology guidelines

 

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