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What’s the diagnosis?

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Surgery is Not Normal

The man was unconscious on the operating table, in lithotomy position and fully prepped for the major extirpative surgery which he was about to undergo. Four of us from different surgical specialities stood around his nether regions with arms folded, having all done a very thorough bimanual examination. We were discussing whether his recurrent colorectal cancer felt mobile enough to get away with a posterior exenteration, or if all the pelvic organs had to go. As we considered the physical exam findings it occurred to me that this was not a normal situation. I looked at the patient and said to the head of Colo-Rectal surgery, “you know, in some workplaces people discuss things around the watercooler”. All of a sudden the stark reality of this bizarre situation was apparent as it might be to the casual observer.

Surgery is not normal, and neither are surgeons.

Surgical training is not normal. Much has been written about the unique legal status that medical trainees have, whereby they may dismember dead human bodies with impunity in the course of their education. As training progresses we are not only allowed, but expected to assault people with an array of sterilized weapons, so long as we expect that they will be better off for it. Only a fool would promise this will definitely be the case of course. Less has been written about the fact that it is not normal to be occasionally scolded in your workplace like a school kid and given “homework” in your thirties. It only seems normal because our colleagues seem to accept it.

That surgeons are not normal, I believe, is both self-selection and indoctrination.

Even the kindest, most humane surgeons have steel beneath the surface in my experience. At best, this is only revealed when advocating for a patient, such as demanding theatre access for an urgent after-hours case, but at worst…we have all met that surgeon. Almost all of us have surely had to grit our teeth late one night performing a procedure at the limit of our ability, unable or unwilling to call for help. Timid people do not self-select for surgery. In most countries the process requires an at least somewhat forceful personality to get through selection interviews. A certain drive is required to jump through the necessary hoops and survive the long hours and emotional trauma of the training. Once training begins, as is the case in the military, the majority of waking hours are spent with colleagues in the same environment, but sometimes in different locations. No-one on the outside truly understands the unique demands on the individual. Survival tips are shared, but competition is fierce even when unspoken. Even closest friends can be an obstacle to getting enough experience.

My non-medical father called me one evening some years ago and asked how busy I was. I told him “not bad”, I just had to knock out an appendix and I was almost done. He was taken aback by what seemed a cavalier attitude to what must be a frightened 18 year old about to undergo an anaesthetic for the first time and have his belly cut into. If you are a surgeon, it is understood that no-one has the emotional resources to care this much for every one of the endless multitude of people we treat. I care very much about doing my job as well as I can, but out of necessity I do not routinely involve myself in their personal drama. This would impact my ability to make them better.

Is that normal?

James Duthie is a Uro-Oncology Trainee (Robot Surgery) at Peter MacCallum Cancer Centre, Melbourne. He is interested in Human Factors Engineering, & making people better through electronic means. @Jamesduthie1

 

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Editorial: VR simulators can improve patient safety

You wouldn’t expect the pilot of the aeroplane in which you fly to the EAU or AUA meeting to be a novice who was training on the aeroplane that you were being transported in! Similarly, patients undergoing robot-assisted surgery do not expect to be the “guinea pigs” upon which trainee surgeons move up the learning curve of surgical experience. Sometimes, however, they are.

Surgical simulators offer the means for surgeons to gain experience before moving to operating on actual patients. However, the publication from Guy’s and St Thomas’s illustrates how little research has been done yet to confirm that outcomes are improved by such a move.

Patient safety is a “buzz word” at present, especially after the report of Robert Francis QC on the Mid-Staffordshire NHS Trust disaster. It seems probable that virtual reality (VR) simulators can improve safety, not only by improving technical skills, but also by enhancing non-technical “human factor” responses.

Much work needs to be done to provide the VR training facilities and ensure access to them for all urology trainees. Once they are in place studies will be needed to confirm their value. In a world where doctors and Trusts are facing a tidal wave of litigation there seems little doubt that this is the way ahead.

Roger Kirby
The Prostate Centre, London W1G 8GT

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Twitter Chat Tools for International Urology Journal Club

Twitter is a great social channel for professionals to exchange ideas. I regularly use Twitter to connect with urologists, health care professionals, patients and thought leaders around the world. I also use Twitter to share my blog posts.

 

Participating in Twitter Chats

One of the many other ways I find value on the platform is by participating in Twitter Chats. Twitter chats are a great way to get people with a common interest into a community. A Twitter Chat can be a one-time event; however, most take place on a regular basis – weekly or monthly – and are organized around a designated hashtag.

Weekly healthcare chats that I regularly enjoy include: #hcsmanz (Healthcare and Social Media in Australia and New Zealand) and #hcsm (Healthcare Communications and Social Media) both on Sundays, #hcldr (Healthcare Leader) on Tuesdays, and #HITsm (Health IT Social Media) on Fridays.

My favorite Twitter chat, however, is the monthly #UROJC chat, International Urology Journal Club on Twitter. #UROJC takes place on the first Sunday of every month, starting at 3 pm Eastern time, and continues over a 48-hour period, rather than one hour. During this time, I can review and discuss current research in urology and engage with academic and community urologists around the world. The origins of #UROJC have previously been described by Dr. Henry Woo, @DrHWoo, in a BJUI blog post.

 

Twitter Chat Tools to Know

When you participate in #UROJC, or any other Twitter Chat, there are a few tools and tips that can be used to enhance your experience.

1. Tweetchat

A great application for Twitter Chats and conferences is Tweetchat.com. You can tweet directly from Tweetchat, and your tweets will automatically be appended with the hashtag. All participants using the hashtag can be viewed in a real-time stream.

How to use Tweetchat:

  • Go to Tweetchat.com.
  • Log in with your Twitter account.
  • Add the hashtag for the chat, i.e., #UROJC, in the “room” text box.
  • Now you will see all the people participating in the chat displayed in the stream in real time.
  • You can tweet directly from the platform through the tweet box provided. Tweetchat.com will automatically add the hashtag, and you are visible in the stream. You can click on buttons next to a tweet to reply or retweet another user.
  • You can also click to follow colleagues in the chat via Tweetchat. This is a great way to expand your network.

 

2. Twitterfall

Twitterfall is similar to Tweetchat, but has some customizable features. For example, you can edit out retweets, and control the speed of the Twitter stream. Twitterfall also has a place to create lists of people you want to engage with.

To get started on Twitterfall:

  • Go to Twitterfall.com.
  • Log in with your Twitter account to tweet directly from the platform.
  • Enter the hashtag #UROJC into the “search” text box.
  • View the discussion and participants in the stream.
  • Set your selections for a variety of other options including creating a list of participants.


3. Symplur

You can get a transcript of the tweets from each monthly #UROJC chat courtesy of Symplur. This is valuable if you want to review a chat or if you happened to miss a chat altogether.

In addition to chats, Symplur’s Healthcare Hashtag project is a rich resource for discovering and mining healthcare conversations on Twitter around specialties, disease states, patient communities, and healthcare conferences.

It is also interesting, at the end of a chat, to view Symplur’s analytics that show the participants who have the most mentions, tweets and impressions. Symplur can also a great place to identify new people to follow.

 

4. World Clock:

Because #UROJC is a global discussion over a two-day period, it can be confusing to keep track of starting times across multiple time zones. A great tool to find the time in your part of the world is the World Clock time zone converter.

 

I hope that you find these Twitter Chat tools and tips helpful, and I look forward to seeing you in the stream of our next monthly #UROJC. You can keep updated on what is up and coming on #UROJC by following the official Twitter account for the chat at @iurojc. You can always connect with me on Twitter @storkbrian.

 

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What’s the diagnosis?

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From Famine to Feast. Systemic Therapy for Prostate Cancer Comes of Age.

OR The Hare Becomes the Tortoise??

When I was a medical oncology trainee in 2001 looking for an area to specialise in my mentors told me prostate cancer was going to be the next big thing. I must admit I was dubious but now more than 10 years later this is amongst the best advice I have ever received. On a par with support Manchester United and buy property in London! Systemic treatment for prostate cancer has well and truly arrived and we are in a position where at times we are spoilt for choice.

So how did we get here and why did it take so long. To answer the second part first we need to go back to 1941 and Huggins and Hodges ground-breaking work showing the profound effect of castration on metastatic prostate cancer. Both the original paper and the Nobel lecture are fascinating reading. Castration remains a cornerstone of the treatment of prostate cancer. The androgen receptor is one of, if not the, most dominant biological pathway in solid tumour oncology. Apart from chemotherapy for testicular cancer, another urological success, I cannot think of another systemic treatment that has such profound activity both in terms of clinical response and disease control rates. For instance androgen deprivation far surpasses the activity seen with tamoxifen in ER +ve breast cancer. So prostate cancer got off to a flier and perhaps was the hare to the tortoise when compared to other cancers, which have slowly but surely overtaken.

There was a long lull with very little positive data for metastatic prostate cancer. Why was this? Perhaps the activity of androgen deprivation set too high a bar for subsequent treatments and a sense of nihilism for those that followed. This is shown by the negative reaction to the data on docetaxel first published in 2004. The 50% PSA response rate (a decline in PSA of 50% or greater) is impressive particularly in this highly pre-treated population. More importantly docetaxel improves quality of life and provides a small but significant survival advantage against an active comparator. We now have a second chemotherapy, cabazitaxel, which again shows a significant survival advantage. Whilst chemotherapy in prostate cancer remains controversial, and worthy of a future blog, there is no doubt for a significant number of patients it provides real benefit.

Prostate cancer is leading the way for other areas of systemic therapy. Sipuleucel-T is one of the only immunotherapies to show a survival benefit in solid tumour oncology. Whilst Sipuleucel-T is controversial and has many detractors, it does have level 1 evidence to support it. During my fellowship with Phil Kantoff’s group in Boston, I saw several patients who I am convinced benefited from this treatment. Alpharadin is the first radionucleotide to show a survival advantage and is likely to become an integral part of systemic therapy for CRPC.

The drugs that have provided most excitement and the greatest benefit in day-to-day practise are abiraterone and enzalutamide. These drugs build on the work of Huggins and Hodges and show that 70 years of targeting the androgen receptor is still relevant even with castration. These drugs have changed how we describe the disease moving from ‘hormone-refractory’ to ‘castration-refractory’. Abiraterone is now licensed in the pre- and post-chemotherapy setting and it is likely that enzalutamide will follow in the not too distant future. In my own practise these drugs are game changers. Ones that provide real benefits relieving symptoms, controlling disease and allowing some men with prostate cancer to live much longer.

Who should be responsible for all these new drugs? Medical oncologists? Urologists? Nurse specialists? For me this shouldn’t be territorial. I want men with prostate cancer looked after by those with a real interest in this area. The days of people dabbling should be in the past and testicular cancer has shown us that patients do better when looked after in high volume centres. In reality men with metastatic prostate cancer have complex medical needs and only with the input from the whole multidisciplinary team are we able to give them the best care.

So systemic treatment for prostate cancer is suddenly fashionable and my mentors (Ellis and Harper) were proved right! ‘Told you so Chowdhury!’ This is only going to be the beginning with prostate cancer, which is now at the forefront of cancer research. Our understanding of the biology of prostate cancer is likely to grow exponentially and with it our ability to improve treatment. So watch this blog – to be continued…

 

Simon Chowdhury is Consultant Medical Oncologist at Guy’s, King’s and St Thomas’ Hospitals, London. He is actively involved in clinical trial research into urological cancers.

 

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Editorial: Obesity is associated with worse oncological outcomes in patients treated with radical cystectomy

Michael R. Abern, Stephen J. Freedland and Brant A. Inman

Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA

Obesity is a worldwide epidemic: it is estimated over 300 million adults are obese and over 1 billion are overweight. As obesity is a risk factor for cancers and is modifiable, the authors of this report retrospectively analyse the association between body mass index (BMI) and outcomes in a large multinational cohort of bladder cancer patients that underwent radical cystectomy. They found that obese patients were older and more likely to have high-grade tumours. Furthermore, obese patients received inferior lymphadenectomies, had more positive margins, and were less likely to receive adjuvant chemotherapy. The end result is an association between obesity and bladder cancer recurrence, and both cancer-specific and overall mortality.

Although these data suggest that obesity is associated with poor radical cystectomy outcomes, this contrasts with evidence showing no link between obesity and bladder cancer mortality in population-based trials such as the Cancer Prevention Study II, which prospectively followed over 900 000 participants. Why the discrepancy? One possible explanation is the presence of confounding factors and one possible confounder is the presence of type 2 diabetes. In population-based studies that considered both BMI and diabetes, people with diabetes were noted to have an increased risk of developing bladder cancer independent of BMI, whereas the converse was not true. Additionally, diabetes has been associated with recurrence and progression of non-muscle invasive bladder cancer whereas obesity has not. The impact of diabetes was not adequately addressed in the current study.

Other limitations also probably affect the results. In the current study, overweight patients (BMI 25–30) had significantly better cancer-specific survival (hazard ratio 0.80, P = 0.01) than those of ‘normal’ weight (BMI < 25). However, a threshold BMI ≥ 30 has been shown to have poor sensitivity for obesity in elderly populations, with over 25% of patients with BMI under 30 qualifying as obese based on body fat. This may result in an overstatement of the effect of obesity. Conversely, the inclusion of underweight patients (BMI < 18.5) in the ‘normal’ group may underestimate the effect between obesity and outcome, as cachexia may be associated with poor outcomes. Another factor mentioned by the authors is the inferior lymphadenectomies performed in obese patients, which introduces a detection bias for lymph node positivity, the strongest predictor after advanced stage for all of their tested outcomes on multivariate analysis (hazard ratio 2.01–2.33, P < 0.001).

Although the true effect of obesity may be hard to quantify with these data, all would agree that maintaining a non-obese bodyweight will help many disease states with little apparent harm. Patients undergoing neoadjuvant chemotherapy before radical cystectomy have a 3-month window to lose weight and exercise more. This could improve surgical outcomes, and possibly tolerance of chemotherapy. Furthermore, if we can prove that obesity leads to increased bladder cancer recurrence or progression, a window of opportunity may exist when a low-risk tumour is diagnosed. Otherwise, we are left with the eighteenth century wisdom of Benjamin Franklin: ‘An ounce of prevention is worth a pound of cure.’

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EWTD: Quantity or Quality?

The European Working Time Directive (EWTD) was due to be in full implementation from August 2009 limiting junior doctors to a 48-hour week averaged over a 6-month period. The reality of this is somewhat different from the legislation. In truth, the questions needed to be asked were – was it ever feasible? What was the training impact in a craft-based speciality going to be? Where are we now?

The detrimental effects to training in a reduced working environment has been documented in both hemispheres. Canter, in a review of the EWTD in the United Kingdom and Ireland reported ~90% non-compliance of the restricted working week. Time for Training reviewed the implications of the EWTD and Professor Temple felt ‘high quality training can be delivered in 48 hours’; however, this is precluded where trainees have a ‘major role in out of hours services’. As most trainees, in all health systems, will attest to junior doctors do play a ‘major role’ in on-call services.

As a current urological trainee, the pressures to develop skills to operate in an ever-changing and exciting field are evident. A limited working week, twinned with health service cut backs and limited hospitals beds is without doubt a concern when filling in our logbooks. Could a passage to India be the way to get more surgical experience?, a feature in the BMJ in 2012, Elliot sends trainees abroad to gain the invaluable exposure to numbers we are limited by here.

There are two sides to the impact that a limited working week will have to an aspiring surgeon’s experience, the quantity and quality of time spent in the hospital. The debate remains regarding the length of surgical training the current structures are changing in Ireland, led by the RCSI, in an effort to shorten the length of surgical training in line with other jurisdictions. We need to strive to efficiently and effectively train surgeons within an appropriate timeframe within the restraints of legislation without a drop in the standard of skills required.

As time has passed, it remains to be seen if the EWTD will ever be implementable in keeping with the continuity of patient care to the highest standard they deserve and that we aspire to offer them. The EWTD is currently being debated at a European Commission level in order to negotiate a revised directive more in line with the challenges of healthcare professionals in a 21st century health service. Revisions to the directive may allow for longer hours in certain disciplines such as the skill based surgical specialities.

Gregory J. Nason, MRCSI, is currently Registrar in Urology, St Vincent’s University Hospital, Dublin.

 

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Prostate Cancer Outcomes Study Meets Twitter Face to Face

The International Urology Journal Club on Twitter discussion for February 2103 was based upon the recently published Prostate Cancer Outcomes Study in the New England Journal of Medicine on 31 January 2013.

The originally planned discussion paper that was only hours away from being announced when it became apparent through Twitter notification by @NEJM that the PCOS paper was going to be published that day. With this news, ‘urology twitter’ spoke loud and clearly (well, tweeted to be technically correct), and it was clear that this paper required our urgent attention.

The primary and senior authors of the PCOS manuscript in Matthew Resnick and David Penson, respectively, were kind enough to commit to making themselves available for the twitter discussion and proved to be valuable contributors.

 

In short, PCOS examined 1655 men who had been diagnosed with prostate cancer in 1994 or 1995, between the ages of 55 and 74 years, and who had either undergone radical prostatectomy (1164 men) or radiotherapy (491 men). Functional status was assessed at ‘baseline’ and at 2, 5 and 15 years after diagnosis. The study found patients undergoing surgery were more likely to have urinary incontinence and erectile dysfunction at 2 and 5 years, but there was no significant difference at 15 years. Patients undergoing surgery were less likely to have bowel urgency at 2 and 5 years, but again, there was no discernible distinction between the two groups at 15 years.

The functional results as stated in the manuscript are poor and this generated discussion that attempted to place these results into context. It was pointed out by Stacey Loeb that with the Massachusetts Male Aging Study (MMAS), 79% of men had ED as defined by IIEF and that there was a concern that, with the present data, the media could interpret it as that all prostate cancer treatments universally cause ED. A later constructive comment was made that if the study had followed matched controls to 15 years, it would allow for meaningful estimation of risk with treatment superimposed on aging.

Discussion shifted to the changes that have occurred over time since men entered the study. A number contributors, including Matt Coward, Rajiv Singal, Quoc Trinh and others commented to the effect that many of the men treated in that era would probably no longer be treated radically and would be managed conservatively. Ben Davies in agreement declared that he would promise never to operate on a man with a Gleason score 2–4 prostate cancer. However, Sean Williamson, Alanna Jacobs and others pointed out that this was not really relevant to the study, which was an examination of functional outcomes.

Is the data applicable to today? In response to Tony Finelli’s tweet of “Why is it that the urologic community always criticizes longterm well designed studies with ’The data are no longer applicable today?’“, Rajiv Singal made a very sobering comment that “Data is very applicable. Study well designed. It’s just that over Tx in many in this group makes side effects more appalling

Prokar Dasgupta provided some British input with “are patients happier if they are clear of cancer @15 years or would they rather be potent?” Michael Leveridge from Canada provided constructive input with “As rational CaPr treatment shifts toward higher risk (wide fields, less nerve sparing), functional outcomes may actually get worse

Criticism made that there were many men who missed out on completing their 2 and 5 year questionnaires was responded to by Dave Penson who explained that they were included in the study by using imputed data with a hot deck technique – whilst imperfect, it was the best that they could do to overcome this issue.

Stacey Loeb pointed out that a key strength of the study was that it showed that many short-term differences functional outcomes between RP & RT dissipate over time. From a functional perspective, Tim Averch may have a point when he commented that at 15 years that it may not make any difference as to whether we had performed surgery or radiotherapy.

The question was raised about correlating nerve-sparing surgery and subsequent results. Author Matt Resnick indicated that this was something that was being analysed right now with results forthcoming. On the general issue of improvements in surgery and radiotherapy leading to improved functional outcomes, Matt Resnick indicated that “While tech. improvements in RP and EBRT may incrementally improve outcomes, likely non-differential.” Towards the end of the discussion, it was generally agreed that robotic surgery was the primary manner by which surgery was being performed (at least in the US) and that it was an ‘operative leveler’ in terms of how well surgeons performed a radical prostatectomy.

Helen Nicholson from Australia asked if the late serious effects of radiotherapy were considered and on a similar theme, Matt Cooperberg raised the issue of where only incontinence was reported with regard to urinary function but irritative urinary symptoms were often of greater bother and worse with radiotherapy. Dave Penson responded in that they had data on bother from urinary symptoms and that it was worse at 2 and 5 years for surgery but the same for both radiotherapy and surgery at 15 years.

To complete the round up of the discussion content, the Best Tweet Prize was awarded to Dr Rajiv Singal for the following tweet:-

The Best Tweet Prize was kindly donated by Urology Match.

The above summary only touches upon the discussion, which had 32 participants who made a total of 171 recorded tweets to the hashtag #urojc. This does not include participants and their tweets where the #urojc had been omitted. We had quite a number of new participants this month who were still learning the necessity to include #urojc in all tweets in order for them to be visible to the discussion.

It is also interesting to look at the impact of the Superbowl. The first dip is related to our North American friends signing off to concentrate on the Superbowl and the last dip correlates when the majority of participants are with their heads buried in a robot console/wound or asleep on the other side of the world.

We look forward to seeing your participation in the March #urojc. For further information about what #urojc is all about, see my earlier blog entry on the subject.

 

Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo

 

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