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Video: Prostate cancer in kidney transplant recipients – a nationwide register study

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Prostate cancer in kidney transplant recipients – a nationwide register study

Abstract

Objective

To investigate whether post‐transplantation immunosuppression negatively affects prostate cancer outcomes in male kidney transplant recipients.

Patients and Methods

We used the Swedish Renal Register and the National Prostate Cancer Register to identify all kidney transplantation recipients diagnosed with prostate cancer in Sweden 1998–2016. After linking these registers with Prostate Cancer Database Sweden (PCBaSe), a case‐control study was designed to compare time period and risk category‐specific probabilities of a prostate cancer diagnosis amongst kidney transplantation recipients versus the male general population. The registers did not include information about the specific immunosuppression agent used in all transplantation recipients. Data from PCBaSe were used to compare prostate cancer characteristics at diagnosis and survival for patients with prostate cancer with versus without a kidney transplant. Propensity score matching, Cox regression analysis and Fisher’s exact test were used and 95% confidence intervals (CIs) calculated.

Results

Almost half of the 133 kidney transplantation recipients were transplanted before the mid‐1990s, when PSA testing became common. The transplant recipients were not more likely than age‐matched control men to be diagnosed with any (odds ratio [OR] 0.84, 95% CI 0.70–0.99) or high‐risk or metastatic prostate cancer (OR 0.84, 95% CI 0.62–1.13). None of the ORs for the different categories of prostate cancer increased with time since transplantation. Cancer characteristics at the time of diagnosis and cancer‐specific survival were similar amongst transplant recipients and the control group of 665 men diagnosed with prostate cancer without a kidney transplant.

Conclusions

This Swedish nationwide, register‐based study gave no indication that immunosuppression after kidney transplantation increases the risk of prostate cancer or adversely affects prostate cancer outcomes. The study suggests that men with untreated low‐grade prostate cancer can be accepted for transplantation.

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Article of the week: Using data from an online health community to examine the impact of prostate cancer on sleep

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Every week, the Editor-in-Chief selects an Article of the Week 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 this post, there is an editorial written by a prominent member of the urological community. Please use the comment buttons below to join the conversation.

If you only have time to read one article this week, we recommend this one. 

Using data from an online health community to examine the impact of prostate cancer on sleep

Rebecca Robbins*, Girardin Jean‐Louis†, Nicholas Chanko†, Penelope Combs†, Nataliya Byrne†‡, Stacy Loeb†‡

*Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA, †Department of Population Health, New York University (NYU) School of Medicine, and ‡Department of Urology, NYU School of Medicine and Manhattan Veterans Affairs, New York, NY, USA

Read the full article

Previous epidemiological studies have examined the relationship between sleep disturbances and prostate cancer risk and/or survival. However, less has been published about the impact of sleep disturbance on quality of life (QoL) for prostate cancer survivors and their in home caregiver. Although prostate cancer presents numerous potential barriers to sleep (e.g., hot flashes, nocturia), current survivorship guidelines do not address sleep. In addition to its impact on QoL, sleep disturbances also mediate the impact of cancer status on missed days from work and healthcare expenditures.

A broader examination of contributors to poor sleep in prostate cancer, and the impact on patients and caregivers would be an important contribution to raise awareness of these issues in the medical community, improve survivorship care, reduce healthcare costs, and stimulate future research. The objective of our letter is to analyse sleep barriers reported by patients with prostate cancer and caregivers posted to a large online health community. You can check lot of article on coolsculptny related to health.

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Editorial: The provision of comfort – addressing barriers to sleep in prostate cancer

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“In whatever disease sleep is laborious, it is a deadly symptom,” is a famed aphorism by Hippocrates, because he deeply understood the role of sleep in the process of healing. One of the main goals of any comprehensive cancer management plan should be the provision of comfort. In academic literature, discussions of advances in prostate cancer treatment are often limited to novel therapeutics, such as immunotherapy. What gets often ignored in these discussions is the patient’s perspective—especially that of sleep disturbances. This is why an intriguing qualitative analysis in this BJUI issue by Robbins et al is a refreshing read [1]. The authors examined discussions on an online health community to elucidate the barriers to sleep among prostate cancer patients and caregivers.

Parsing through thousands of anonymized public comments, the authors report several interesting findings: one, majority of comments related to sleep (86%) are posted by patients—signifying high interest in this aspect of management; second, a plurality of comments discuss sleep medications (22%), with comments about advanced disease discussing these medications three times more than those discussing localized disease; third, associated side effects of fatigue and pain were largely observed in advanced disease comments, according to Discover Magazine many people is using this website https://observer.com/2020/05/best-cbd-hemp-flower/ to buy CBD and reduce the pain cause by the disease . Interestingly, the authors also used Linguistic Inquiry Word Count (LIWC) software—a reasonable tool to assess emotional states—and reported that advanced disease comments were significantly more negative in perspective than localized disease comments. This analysis is an especially useful contribution—and should enable contemporary Prostate Cancer Survivorship Care Guidelines to expand on the impact of sleep disturbances [1].

These findings have considerable implications. To start with, these findings need to be contextualized within the larger body of evidence we have on impact of sleep disturbances on prostate cancer. In a recent study, Markt et al prospectively followed 32,141 men (with 4261 prostate cancer cases) using the Health Professionals Follow-Up Study (HPFS), and found no association between self-reported duration of sleep and prostate cancer outcomes [2]. However, the authors of the HPFS study did emphasize that sleep disruptions were associated with increased risk of developing lethal or aggressive prostate cancer. The finding by Robbins et al that a significant proportion of patients are discussing these issues through online communities suggests that the prevalence of sleep disturbance—and its impact on quality of life—among prostate cancer patients is poorly understood and inadequately measured.

Representative quotes highlighted by Robbins et al also reveal that prostate cancer patients often suffer from severe insomnia, indicating lack of sleep-related patient education initiatives. Additionally, quotes by caregivers also underscore that there is a general lack of information on how to address sleep disruptions for patients they attend to. This is a missed opportunity, as evidence suggests that nutritional therapy (soy supplementation, for example) and combination of resistance training with aerobic exercise may improve cancer related fatigue and quality of life among prostate cancer patients [3], although less is known about effective interventions that would improve sleep. Furthermore, disturbances in sleep have expensive implications for health care spending and workplace absenteeism—with prostate cancer survivorship phase accounting for 50% of total cancer care related costs [4]. Studies that have investigated this relationship report that sleep disturbances significantly increase the utilization of health care and workplace absenteeism, with the impact constituting 2% and 8%, respectively [4]. Given the exponential rise in overall health care spending in the United States, addressing costs stemming from preventable adverse events is urgent—this present study demonstrates that more creative interventions are wanting.  

Beyond economic and survivorship care concerns, this qualitative study paints a grim picture of the conversations happening in these online patient communities, with comments revealing a negative emotional state for many. While sleep disturbances are an important contributor for this development, lack of patient education can also engender greater confusion and distress. Findings from this study should spur greater interest and support for devising and implementing patient-centered initiatives that improve sleep quality. This is required not only because these will likely improve the quality of life for prostate cancer patients, but also because we have a moral responsibility to provide comfort for these patients.

by Junaid Nabi

References

1.         Robbins R, Girardin JL, Chanko N, Combs, P, Byrne N, Loeb S Using data from an online health community to examine the impact of prostate cancer on sleep. BJU Int. 2020; 125(5).

2.         Markt SC, Flynn-Evans EE, Valdimarsdottir UA, Sigurdardottir LG, Tamimi RM, Batista JL, et al. Sleep Duration and Disruption and Prostate Cancer Risk: a 23-Year Prospective Study. Cancer Epidemiol Biomarkers Prev. 2016;25(2):302-8.

3.         Baguley BJ, Bolam KA, Wright ORL, Skinner TL. The Effect of Nutrition Therapy and Exercise on Cancer-Related Fatigue and Quality of Life in Men with Prostate Cancer: A Systematic Review. Nutrients. 2017;9(9):1003.

4.         Gonzalez BD, Grandner MA, Caminiti CB, Hui S-KA. Cancer survivors in the workplace: sleep disturbance mediates the impact of cancer on healthcare expenditures and work absenteeism. Support Care Cancer. 2018;26(12):4049-55.

Article of the week: Information on surgical treatment of benign prostatic hyperplasia on YouTube is highly biased and misleading

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Every week, the Editor-in-Chief selects an Article of the Week 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 this post, there is an editorial written by a prominent member of the urological community and a visual abstract for a swift overview of the article. Please use the comment buttons below to join the conversation.

If you only have time to read one article this week, we recommend this one. 

Information on surgical treatment of benign prostatic hyperplasia on YouTube is highly biased and misleading

Patrick Betschart*, Manolis Pratsinis*, Gautier Müllhaupt*, Roman Rechner*, Thomas RW Herrmann†, Christian Gratzke‡, Hans–Peter Schmid*, Valentin Zumstein* and Dominik Abt*

*Department of Urology, Cantonal Hospital St Gallen, St Gallen, †Urology Clinic, Spital Thurgau AG, Frauenfeld, Switzerland, and ‡Department of Urology, Albert–Ludwigs–University, Freiburg, Germany

Read the full article

Abstract

Objectives

To assess the quality of videos on the surgical treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) available on YouTube, given that such video‐sharing platforms are frequently used as sources of patient information and the therapeutic landscape of LUTS/BPH has evolved substantially during recent years.

Materials and Methods

A systematic search for videos on YouTube addressing treatment options for LUTS/BPH was performed in May 2019. Measures assessed included basic data (e.g. number of views), grade of misinformation and reporting of conflicts of interest. The quality of content was analysed using the validated DISCERN questionnaire. Data were analysed using descriptive statistics.

Fig. 1. Degree of misinformation compared to currently available evidence on surgical BPH treatment 7 (no: green; very little: light green; moderate: light blue; high: light red; extreme: dark red), rate of commercial bias (yes: red; no: light green) and rate of declaration of conflicts of interests (COI; yes: blue; no: orange) for the analysed videos divided by topics. BipolEP, bipolar enucleation of the prostate; HoLEP, holmium laser enucleation of the prostate; iTIND, temporary implantable Nitinol device; PAE, prostatic artery embolization; ThuLEP, thulium laser enucleation of the prostate

Results

A total of 159 videos with a median (range) of 8570 (648–2 384 391) views were included in the analysis. Only 21 videos (13.2%) were rated as containing no misinformation, 26 (16.4%) were free of commercial bias, and two (1.3%) disclosed potential conflicts of interest. According to DISCERN, the median overall quality of the videos was low (2 out of 5 points for question 16). Only four of the 15 assessed categories (bipolar and holmium laser enucleation of the prostate, transurethral resection of the prostate and patient‐based search terms) were scored as having moderate median overall quality (3 points).

Conclusion

Most videos on the surgical treatment of LUTS/BPH on YouTube had a low quality of content, provided misinformation, were subject to commercial bias and did not report on conflicts of interest. These findings emphasize the importance of thorough doctor–patient communication and active recommendation of unbiased patient education materials.

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Editorial: Fake news about benign prostatic hyperplasia on YouTube

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YouTube is a widely used video‐sharing and social networking platform. It contains a large volume of content about medical topics, including urological conditions. In this issue of BJUI, Betschart et al. [1] examined the quality of 159 YouTube videos about surgical treatment of BPH with ≥500 views. The median overall quality of videos was poor (2 out of 5 possible points) based on validated criteria for the assessment of consumer health information. Nearly 87% of videos contained some misinformation and 84% had commercial bias.

We previously reported similar findings in the first 150 videos in a YouTube search for prostate cancer [2]. The median overall quality of videos was moderate (3 out of 5 points), and 77% contained biased and/or misinformative content in the video or comments beneath it. Furthermore, videos with lower expert‐rated quality had higher user engagement.

In the study by Betschart et al. [1], most of the YouTube videos about BPH had very good production quality, and 69% were posted by healthcare providers (e.g., doctor, clinic, hospital or university). These attributes might lead health consumers to have more trust in the information that is provided. In fact, they found that two‐thirds of videos with the most views in each topic had a quality score below the median score for videos about that topic.

Unfortunately, these issues are pervasive across many health domains. A recent review article reported on the prevalence of commercial bias and misinformation in social media posts about a variety of urology topics, including female pelvic medicine, endourology, sexual medicine, and infertility [3].

What can be done to combat the large quantity of misinformative urological information circulating online? For BPH on YouTube alone, Betschart et al. [1] reported that there were >12 000 videos as of May 2019. It is not practical for medical experts to manually vet the vast and continually changing repository of online medical information.

One future possibility is the development of computational tools to help evaluate the quality of information. For example, using an annotated dataset of 250 YouTube videos about prostate cancer, we created an automatic classification model for the identification of misinformation with an accuracy of 74% [4]. Further study is warranted to develop and test the use of machine learning to help filter the quality of online content.

As healthcare providers, what can we do to address these problems in the near‐term? We previously reported that USA adults who perceive worse patient‐physician communications are significantly more likely to watch health videos on YouTube [5]. This highlights the importance of shared decision‐making and proactively directing our patients to trusted sources of information. A curated list of reputable sources of online urological health information is presented in a recent review [6]. In addition, healthcare providers should be encouraged to actively participate in social media to flag any content that is inaccurate or dangerous and to help provide accurate information to the public. The BJUI, European Association of Urology, and AUA have all published guidance regarding best practices for social media engagement, which should be incorporated into urological education in the future [7].

In conclusion, social networks have a huge global audience and offer great potential to benefit the care of BPH and other urological conditions. However, to meet this potential and offset the risks will require significant ongoing efforts from the urological community.

by Stacy Loeb

References

  1. Betschart P, Pratsinis M, Müllhaupt G et al. Information on surgical treatment of benign prostatic hyperplasia on YouTube is highly biased and misleading. BJU Int 2020; 125: 595-601
  2. Loeb S, Sengupta S, Butaney M et al. Dissemination of misinformative and biased information about prostate cancer on YouTube. Eur Urol 2019; 75: 564– 7
  3. Loeb S, Taylor J, Borin JF et al. Fake News: Spread of misinformation about urological conditions on social media. Eur Urol Focus 2019 [Epub ahead of print].
  4. Hou R, Perez‐Rosas V, Loeb S, Mihalcea R. Towards Automatic Detection of Misinformation in Online Medical Videos. International Conference on Multimodal Interaction. Suzhou, Jiangsu, China: ACM, 2019. Available at: https://arxiv.org/abs/1909.01543. Accessed January 2020
  5. Langford A, Loeb S. Perceived patient‐provider communication quality and sociodemographic factors associated with watching health‐related videos on YouTube: a cross‐sectional analysis. J Med Internet Res 2019; 21: e13512. 
  6. Langford AT, Roberts T, Gupta J, Orellana KT, Loeb S. Impact of the internet on patient‐physician communication. Eur Urol Focus 2019: 31582312 [Epub ahead of print].
  7. Taylor J, Loeb S. Guideline of guidelines: social media in urology. BJU Int 2020; 125: 379-382

Visual abstract: Information on surgical treatment of benign prostatic hyperplasia on YouTube is highly biased and misleading

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Re: Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline

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Letter to the Editor

Dear Sir

Fluoroquinolones must not be used inappropriately when treating chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS).

Clinical guidelines from the Prostatitis Expert Reference Group (PERG) on chronic bacterial prostatitis (CBP), chronic prostatitis and chronic pelvic pain syndrome [1] — which have been propagated by other guideline providers such as NICE Clinical Knowledge Summaries and the primary care resource, Guidelines — include the following recommendation:

‘For patients with early-stage CBP and CP/CPPS, offer a quinolone (e.g. ciprofloxacin or ofloxacin) for 4–6 weeks as first-line therapy.’

While the PERG guidelines do mention diagnostic tests for a bacterial cause, readers will be left with the impression that a course of fluoroquinolone without a diagnostic workup is acceptable for the initial management of CP and CPPS. This impression may be reinforced by PERG’s subsequent recommendations, in particular the second one:

‘A repeated course of antibiotic therapy (4–6 weeks) should be offered only if a bacterial cause is confirmed or if there is a partial response to the first course.

‘If a bacterial cause is excluded (e.g. via urine dipstick or culture) and symptoms do not improve after antibiotic therapy, a different treatment method or referral to specialist care should be considered.’

Recent recommendations [2] from the European Medicines Agency (EMA) make it clear that fluoroquinolones should be reserved for treating bacterial prostatitis. EMA’s review of fluoroquinolones was prompted by reports of serious, disabling and permanent side effects after fluoroquinolone use.

To reach its recommendations, EMA’s safety committee (Pharmacovigilance Risk Assessment Committee, PRAC) reviewed all available evidence, brought together EU experts in the field, and heard patients’ and healthcare professionals’ testimonies at a public hearing. Many patients who had developed long-lasting serious disability reported receiving a fluoroquinolone for chronic prostatitis despite the lack of evidence of a bacterial cause.

EMA’s new recommendations restrict the indications and have led to an update of the prescribing information for all systemic fluoroquinolones to prevent further unnecessary cases of rare but life-changing side effects; the narrow indications also help to reduce antibiotic selection pressure. Guidelines on chronic prostatitis should therefore be revised to clarify that fluoroquinolones are not appropriate for the empirical treatment of chronic prostatitis or chronic pelvic pain syndrome. The European Association of Urology emphasises use of appropriate culture techniques to demonstrate bacterial infection [3].

And when treating bacterial prostatitis with a fluoroquinolone, healthcare professionals should discuss with their patients the risks, including the potential for permanent musculoskeletal and neurological side effects. Details of these effects are set out in the updated prescribing information for fluoroquinolone antibacterials.

It is vital to communicate the changes in the fluoroquinolones prescribing information to all healthcare professionals involved in the management of men with prostatitis or chronic pelvic pain syndrome, they can use CBD from Observer for pain. Promoting this crucial change in practice will ultimately lead to more rational use of antibiotics and limit the unnecessary exposure of patients to potentially persistent and seriously disabling side effects.

Gernot Bonkat, alta uro AG, Merian Iselin Klinik, Center of Biomechanics & Calorimetry, University of Basel; Chairman, European Association of Urology (EAU) Urological Infections Guidelines

Juan Garcia Burgos, Head of Public Engagement Department, European Medicines Agency (EMA)

Martin Huber, Co-rapporteur, quinolone and fluoroquinolone review by the EMA’s Pharmacovigilance Risk Assessment Committee (PRAC)

Eva Jirsová, Rapporteur, quinolone and fluoroquinolone review by the EMA’s Pharmacovigilance Risk Assessment Committee (PRAC)

Florian Wagenlehner, Clinic of urology, pediatric urology and andrology, Justus Liebig University Giessen, Germany; Chairman, European Section of Infections in Urology (ESIU) of the European Association of Urology (EAU)

Correspondence: Juan Garcia Burgos, European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS Amsterdam, The Netherlands

email: [email protected]

References

  1. Rees J, Abrahams M, Double, A, Cooper A. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int 2015; 116: 509–525
  2. EMA. Disabling and potentially permanent side effects lead to suspension or restrictions of quinolone and fluoroquinolone antibiotics, 2018. Available at: https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products. Accessed January 2020
  3. Bonkat G, Bartoletti RR, Bruyère F, Cai T, Geerlings SE, Köves B, Schubert S, Wagenlehner F, Guidelines Associates: Mezei T, Pilatz A, Pradere B, Veeratterapillay R. EAU guidelines on urological infections 2019: 28–32. ISBN/EAN:978-94-92671-04-2. Available at: https://uroweb.org/guideline/urological-infections. Accessed January 2020

Residents’ podcast: the ProtecT trial

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Mr Joseph Norris is a Specialty Registrar in Urology in the London Deanery. He is currently undertaking an MRC Doctoral Fellowship at UCL, under the supervision of Professor Mark Emberton. His research interest is prostate cancer that is inconspicuous on mpMRI. Joseph sits on the committee of the BURST Research Collaborative as the Treasurer and BSoT Representative.

The ProtecT trial: analysis of the patient cohort, baseline risk stratification and disease progression

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Abstract

Objective

To test the hypothesis that the baseline clinico‐pathological features of the men with localized prostate cancer (PCa) included in the ProtecT (Prostate Testing for Cancer and Treatment) trial who progressed (n = 198) at a 10‐year median follow‐up were different from those of men with stable disease (n = 1409).

Patients and Methods

We stratified the study participants at baseline according to risk of progression using clinical disease stage, pathological grade and PSA level, using Cox proportional hazard models.

Results

The findings showed that 34% of participants (n = 505) had intermediate‐ or high‐risk PCa, and 66% (n = 973) had low‐risk PCa. Of 198 participants who progressed, 101 (51%) had baseline International Society of Urological Pathology Grade Group 1, 59 (30%) Grade Group 2, and 38 (19%) Grade Group 3 PCa, compared with 79%, 17% and 5%, respectively, for 1409 participants without progression (P < 0.001). In participants with progression, 38% and 62% had baseline low‐ and intermediate‐/high‐risk disease, compared with 69% and 31% of participants with stable disease (P < 0.001). Treatment received, age (65–69 vs 50–64 years), PSA level, Grade Group, clinical stage, risk group, number of positive cores, tumour length and perineural invasion were associated with time to progression (P ≤ 0.005). Men progressing after surgery (n = 19) were more likely to have a higher Grade Group and pathological stage at surgery, larger tumours, lymph node involvement and positive margins.

Conclusions

We demonstrate that one‐third of the ProtecT cohort consists of people with intermediate‐/high‐risk disease, and the outcomes data at an average of 10 years’ follow‐up are generalizable beyond men with low‐risk PCa.

More podcasts

BJUI Podcasts are available on iTunes: https://itunes.apple.com/gb/podcast/bju-international/id1309570262

What’s the diagnosis?

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Image from Blok et al, BJUI 2019. This paper reports on the results of sentinel node biopsy in patients with clinical stage I testes cancer.

No such quiz/survey/poll

March 2020 – about the cover

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The Article of the Month for March 2020 – Guideline of guidelines: social media in urology – was written by Drs Stacy Loeb and Jacob Taylor, who are based in New York City. The cover features the Manhattan skyline as seen from New Jersey, famous for its skyscrapers, which have been built there on bedrock left over from the last ice age at ever-increasing heights since the 1890s, and the song by Norwegian band A-ha. The skyline was dominated by the 1930s-built Empire State and Chrysler buildings until the 1970s when the World Trade Center was completed. The new One World Trade Center is now the tallest building in the city at 1776 feet (541 m) but since the 2000s nine towers over 1000 feet have been built with 16 more being planned. This is partly fuelled by a desire for high city living but also by technological advances meaning thinner bases can be used to support the structures.

 

 

 

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