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Article of the Week: Association of HDI with global bladder, kidney, prostate and testis cancer

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 the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is 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 week, it should be this one.

Association of Human Development Index with global bladder, kidney, prostate and testis cancer incidence and mortality

Alyssa K. Greiman*, James S. Rosoff† and Sandip M. Prasad*

 

*Department of Urology, Medical University of South Carolina, Charleston, SC, Department of Urology, Yale School of Medicine, New Haven, CT, and Department of Surgery, Ralph M. Johnson VA Medical Center, Charleston, SC, USA

 

Abstract

Objectives

To describe contemporary worldwide age-standardized incidence and mortality rates for bladder, kidney, prostate and testis cancer and their association with development.

Materials and Methods

We obtained gender-specific, age-standardized incidence and mortality rates for 184 countries and 16 major world regions from the GLOBOCAN 2012 database. We compared the mortality-to-incidence ratios (MIRs) at national and regional levels in males and females, and assessed the association with socio-economic development using the 2014 United Nations Human Development Index (HDI).

Results

Age-standardized incidence rates were 2.9 (bladder) to 7.4 (testis) times higher for genitourinary malignancies in more developed countries compared with less developed countries. Age-standardized mortality rates were 1.5–2.2 times higher in more vs less developed countries for prostate, bladder and kidney cancer, with no variation in mortality rates observed in testis cancer. There was a strong inverse relationship between HDI and MIR in testis (regression coefficient 1.65, R2 = 0.78), prostate (regression coefficient −1.56, R2 = 0.85), kidney (regression coefficient −1.34, R2 = 0.74), and bladder cancer (regression coefficient −1.01, R2 = 0.80).

Conclusion

While incidence and mortality rates for genitourinary cancers vary widely throughout the world, the MIR is highest in less developed countries for all four major genitourinary malignancies. Further research is needed to understand whether differences in comorbidities, exposures, time to diagnosis, access to healthcare, diagnostic techniques or treatment options explain the observed inequalities in genitourinary cancer outcomes.

Editorial: Human development and its impact on genitourinary cancers

Using the extensive data from the WHO International Agency for Research on Cancer and the United Nations Human Development Report, Greiman et al. [1] aimed to investigate how human development is associated with incidence and mortality of genitourinary cancers. Even though they generate some interesting descriptive findings, we have to remain critical of these descriptive statistics and carefully assess what needs to be investigated next.

Firstly, despite having highlighted the need for attention to indicators of longevity, education, and income per head when assessing human development, the human development index (HDI) is a rather crude measurement. As a geometric mean of normalised indices for each of these three domains, the HDI simplifies but only captures part of what human development entails. Important indicators of health care such as inequalities, poverty, human security, and empowerment are not reflected in the HDI (www.hdr.undp.org). In the context of cancer incidence and mortality this is an important limitation, as it has for instance been shown that socioeconomic status affects early phase cancer trial referrals, which can be considered as a proxy for access to health care [2]. This inequality has been hypothesised to be linked to more comorbidities and lower education in those who are most deprived – a complex interaction which may not be completely captured by the HDI.

Secondly, registration of incidence and mortality of cancers may vary substantially between countries based on both medical practice and governance. These differences are important when trying to generate hypotheses following the ecological study of Greiman et al. [1]. In the case of bladder cancer, for instance, mortality has been estimated to be 17% in the Netherlands, compared to 22% in the USA, and 50% in the UK. As cancer treatments are expected to be similar in these developed countries, it has been thought that a lower registration of non-muscle-invasive bladder cancer in the UK could explain this higher proportion [3]. Thus, discrepancies in cancer registration, even between developed countries, may limit our awareness of cancer burden.

Thirdly, the study design suffers from ‘ecological fallacy’. The latter refers to the inability to draw causal inference about the effect of the HDI on genitourinary cancer at the individual level, in conjunction with the underlying problem of heterogeneity of exposure levels [4]. This limitation was not mentioned by Greiman et al. [1], but affects their conclusions. The lack of information on, for instance, smoking data, comorbidities, and ethnicity make it difficult to understand how development is affecting cancer incidence or mortality. It would have been interesting to also investigate cancers other than genitourinary cancers because a comparison of different tumour types might have shed light on differences in medical practice or risk factors across countries and help tease out the ecological effect of human development.

Despite the aforementioned limitations, the descriptive analysis by Greiman et al. [1] can be helpful for generating hypotheses – as also outlined by the authors. This ecological effect of human development on incidence and mortality rates of genitourinary cancers is particularly relevant when evaluating the impacts of prevention and intervention programmes for these cancers. Their findings suggest that further investigation is required to examine the hypothesis regarding human development and incidence/mortality of genitourinary cancers. To further elucidate this association, methodological challenges will need to be overcome, as HDI assessment has been criticised for being too crude. Nevertheless, it should be possible to collect more detailed information to allow for an understanding of which components of a country’s collective resources affect cancer incidence and mortality the most, e.g. differences in resources used for cancer detection and treatment.

Mieke Van Hemelrijck
Division of Cancer Studies, Translational Oncology and Urology Research (TOUR), Kings College London, London, UK

 

References

 

1 Greiman AKRosoff JSPrasad SM. Association of Human Development Index with global bladder, kidney, prostate and testis cancer incidence and mortality. BJU Int2017; 120: 799-807

 

2 Mohd Noor A Sarker DVizor S et al. Effect of patient socioeconomic status on access to early-phase cancer trials. J Clin Oncol 2013; 31: 224– 30.

 

3 Boormans JLZwarthoff EC. Limited funds for bladder cancer research and what can we do about it. Bladder Cancer 2016; 2: 4951

 

4 Morgenstern H . Ecologic studies in epidemiology: concepts, principles, and methods. Annu Rev Public Health 1995; 16: 618

 

The Surgical Safety Check List – May #urojc

Ever since the World Health Organisation launched the Safe Surgery Saves Lives campaign in 2007, surgical safety has been drawn to the forefront of the daily surgical routine. The introduction of the 19-point Surgical Safety Checklist, aimed at reducing preventable complications, has become key, with shouts of ‘time-out’ or ‘checklist’ becoming the norm at the start of each case. Equally whether known as the ‘huddle’ or ‘team brief’, the meeting of all team members at the beginning of the list not only helps plan for any changes from the normal routine, but gives a good chance to get to know any new members of staff and helps to promote the team-based atmosphere that encompasses a productive operating list. In the 2009 study evaluating the benefits of the Surgical Safety Checklist, a reduction in both the mortality rate and rate of inpatient complications were found to be significantly reduced1. Implementation of these safety protocols however requires effort and engagement from all members of the theatre team.

In the May, the International Urology Journal Club (@iurojc) #urojc debated a study by Haynes et al in which the reduction of 30-day mortality following the implementation of a voluntary, checklist-based surgical quality improvement program2. The study identified that hospitals completing the program had a significantly lower rate of 30-day mortality following inpatient surgery.

One of the first topics brought up in the debate is the variability in the implementation of safety checklists.

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@StorkBrian raised the possibility that due to the addition of more items at the surgical time out, effectiveness decreases. Whether there is a lack of ability to concentrate on too much paper work was discussed

Conflicting evidence regarding the effect surgical checklists have on mortality was identified, with @WallisCJD bringing up the paper by Urbach et al as an example3.

The different outcomes from the two studies may however be attributed to the difference in follow up period and study design.

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Another aspect of study design discussed was the inclusion criteria – which excluded day case procedures. Whether the outcome in 30-day mortality would be different if these are included, as they are more likely to be lower-risk surgery, is unclear.

Equally whether 30-day mortality is the most appropriate endpoint for the study was questioned – although clearly very important, it would be interesting to know if other factors, such as significant morbidity, altered following the quality improvement program.

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Although the surgical checklist has become part of our daily life, the question as to why they are important was raised by @CanesDavid, with a variety of responses.

For many, it seemed that alongside the safety promotion, it helps to promote cohesive teamwork and communication, which may give all team members the confidence to voice any concerns.

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Giving all team members the ability to speak up with confidence if they identify any concerns will only benefit patients and staff.

Equally, the culture of safety promoted in teams who engage with the surgical checklist process may not be limited to the checklist itself, but to the surgical environment in general

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One clear concern some have with the mandating of the surgical checklist is ensuring it does not just become a ‘tick-box’ exercise

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Regardless of whether you find the checklist another form to fill, or a key part of your operating list, the goal of the process is clear: to protect our patients from preventable mistakes.

This study, confirming the original findings from the 2009 study that surgical safety checklists improve operative mortality, adds to the argument that this must become an inherent part of our practice. Key in this study however was the entire program promoting engagement in the concept of surgical safety, and supporting the team as a unit in this. The debate around this paper has highlighted that although the process of completing the mandatory checklists is important, perhaps the more important aspect is creating a culture of safety, openness and honest communication in which all team members can work together to promote safe surgery.

 

Sophia Cashman is a urology trainee working in the East of England region, UK. Her main areas of interest are female and functional urology. @soph_cash

 

References

1. Haynes AB, Weiser TG, Berry WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 2009;360(5):491-9
2. Haynes AB, Edmondson LBA, Lipsitz SR, et al. Mortality Trends After a Voluntary Checklist-based Surgical Safety Collaborative. Annals of Surgery 2017. Published Ahead-of-Print
3. Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada. New England Journal of Medicine 2014;370(11):1029-1038

 

The Zika virus epidemic in the Americas

In May 2015, Brazil reported for the first time home-grown cases of Zika virus, since that moment the cases have increased dramatically and the infection caused by this virus has been spreading quickly to 22 other countries in the Caribbean, South and Central America. The spread of Zika in South America has been developing rapidly, pushing the WHO to declare the Zika epidemic as a Public Health Emergency of International Concern in February of 2016.

Zika virus was isolated accidentally for the first time from rhesus macaques in 1947, in the area known as Zika forest, located in Uganda; later, researchers observed that the virus could infect humans, but human infections have remained confined to Africa and Asia with few cases reported, until now when thousands of cases have been reported in South American countries since 2015.

Zika is an emerging mosquito borne virus, closely related to other important human viruses transmitted by mosquitoes like Yellow Fever, Dengue, and West Nile virus. The virus has a positive single strain of RNA genome, and belongs to the Flavivirus family. It is transmitted through the infected female mosquito Aedes spp bite, the same vector as Yellow Fever, Dengue, and recently Chinkungunya in the Americas. Distinct species of Aedes mosquitoes are related with the transmission of the virus; however, Aedes aegypti is the most common vector associated with the infection in humans. These mosquitoes are found in many countries in the Americas, a fact that have been contributing to introduction and spread of the virus inside the continent. Additionally, researchers have reported sexual, blood transfusions, and perinatal transmission.

The symptoms of the Zika infections are pretty similar to other mosquito-borne diseases that are circulating in the same geographical areas such as Dengue and Chinkungunya. These diseases are characterized by fever, headache, arthralgia, myalgia, rash, and conjunctivitis, making it difficult to make a differential diagnosis. Epidemiological data showed that until December of 2015, between 440,000 and 1.3 million of Zika cases were reported in Brazil. Additionally, data obtained from Health Ministry of Brazil also reported a significantly increasing number of microcephaly cases in areas infested with Zika, suggesting a possible relation between Zika and microcephaly. Recently, The New England Journal of Medicine reported the identification of Zika virus in fetal brain tissue obtained from a 32 weeks of gestation fetus with serious signs of microcephaly that was aborted after his mother had symptoms related with Zika some weeks after, supporting the idea that Zika virus could be associated with the development of microcephaly in the fetus. Sexual transmission of Zika has also been reported, but the information about it remains confused. Nevertheless, Zika virus has been isolated from semen.

Other neurological symptoms like Guillain-Barré syndrome have been associated with Zika infections. Reports obtained from outbreaks of Zika in French Polynesia in 2013, and Brazil in 2015, showed an increasing number of Guillain-Barré cases probably associated with Zika.

According with the epidemiological data, Colombia is the country second most affected by the Zika virus. Reports from Instituto Nacional de Salud (INS) showed that until January of 2016, 27,454 cases of Zika have been reported, no official data about increasing cases of microcephaly or Guillain-Barré related with Zika infection were observed.

With the 2016 Olympic games due to be held in Rio de Janeiro in August, the World will be watching how Brazil and other South American countries manage the spread of Zika virus in the coming months.

 

Miguel Hernando Parra Avila, Bact. MSc. PhD.

Posición Post Doctoral

Grupo BCEM (bcem.uniandes.edu.co)

Departamento de Ciencias Biológicas

Universidad de los Andes

Bogotá, Colombia

 

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