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Introduction Men with prostate cancer (PCa) and their support providers face challenges in accessing high‐quality, impartial information tailored to their specific needs to enhance their overall care and decision‐making. We describe the development, piloting and evaluation of the co‐designed web portal ‘BroSupPORT’. Methods IT teams developed and integrated BroSupPORT into the Victorian Prostate Cancer Outcomes Registry (PCOR‐Vic) electronic patient‐reported outcome follow‐up process. A comparator tool was built enabling men to compare their patient‐reported outcome results against men of similar age, risk profile and after the same treatment. PCOR‐Vic participants were invited to access BroSupPORT after 12 months of follow‐up patient‐reported outcome measure completion. Factors associated with consent to BroSupPORT were determined using logistic regression. Portal access data were gathered from PCOR‐Vic data extracts and Google Analytics. A survey on portal exit and 2 weeks after consent was used to collect feedback. Results Over a 4‐month pilot, 331/583 (57%) men consented to accessing BroSupPORT. Among those men who accessed the portal, the majority (209/331 =63%) were diagnosed in a private hospital and resided in a major city (214/331=65%). On average, men spent 3:20 min on the portal, with sexual function aspects receiving the most attention. Twenty‐three percent of men revisited the portal during the pilot. Most men found the portal easy to use, reassuring and informative, while 9% found the patient‐reported comparisons difficult to interpret. Conclusion A patient portal—enabling men to compare their patient‐reported outcomes with other similar men and providing access to information and resources—may be a scalable solution in addressing the complex supportive care needs of men with PCa on a population basis.

During the COVID-19 pandemic, all fifty states and Washington, D.C., passed licensure waivers that allowed patients to participate in telehealth visits with out-of-state clinicians (that is, interstate telehealth). Because many of these temporary flexibilities have expired or are set to expire, we analyzed trends in interstate telehealth use by Medicare beneficiaries during 2017-20, which covers the period both directly before and during the first year of the pandemic. Although the volume of interstate telehealth use increased in 2020, out-of-state telehealth made up a small share of all outpatient visits (0.8 percent) and of all telehealth visits (5 percent) overall. For individual states, out-of-state telehealth made up between 0.2 percent and 9.3 percent of all outpatient visits. We found that most out-of-state telehealth use was for established patient care and that a higher percentage of out-of-state telehealth users lived in rural areas compared with beneficiaries who did not receive care outside of their state (28 percent versus 23 percent). Our collective findings suggest that the elimination of pandemic licensure flexibilities will affect different states to varying degrees and will also affect the delivery of care for both established patients and rural patients.

Quality of life and satisfaction with outcome of treatment were ascertained by questionnaires in men with prostate cancer and their spouses or partners after prostatectomy, brachytherapy, or external-beam radiotherapy (with or without adjuvant hormonal treatment). Each treatment had it own pattern of effects on the quality of life, and in each case, residual effects of treatment caused distress in the patients' partners. Quality of life and satisfaction with outcome of treatment were ascertained by questionnaires in men with prostate cancer and their spouses or partners after prostatectomy, brachytherapy, or external-beam radiotherapy (with or without adjuvant hormonal treatment). Assessment of the outcome of prostate-cancer treatment entails measuring not only the duration of survival but also the health-related quality of life. 1 , 2 Early studies of patient-reported outcomes of prostatectomy or conventional radiotherapy found concern about urinary incontinence, bowel function, and sexual activity. 3 – 5 However, little is known about the quality of life after newer treatments such as brachytherapy and androgen-suppression therapy as an adjunct to radiotherapy. 6 – 8 Single-institution studies and one retrospective analysis of a longitudinal, multicenter cohort used instruments that had been developed for assessment of standard external-beam radiotherapy and prostatectomy to probe the quality of life after . . .

Most large bowel cancers are moderately to well-differentiated adenocarcinomas comprised chiefly or entirely of glands lined by tall columnar cells. We have identified a subset of poorly differentiated colon carcinomas with a distinctive histopathological appearance that we term large cell minimally differentiated carcinomas (LCMDCs). These tumors likely include a group of poorly differentiated carcinomas previously described by others as medullary adenocarcinomas. To better understand the pathogenesis of these uncommon neoplasms, we compared molecular features of 15 LCMDCs to those present in 25 differentiated adenocarcinomas (DACs) of the colon. Tumors were examined for alterations commonly seen in typical colorectal carcinomas, including increased p53 and β-catenin immunoreactivity, K-ras gene mutations, microsatellite instability, and loss of heterozygosity of markers on chromosomes 5q, 17p, and 18q. In addition, tumors were evaluated by immunohistochemistry for CDX2, a homeobox protein whose expression in normal adult tissues is restricted to intestinal and colonic epithelium. Markedly reduced or absent CDX2 expression was noted in 13 of 15 (87%) LCMDCs, whereas only 1 of the 25 (4%) DACs showed reduced CDX2 expression ( P < 0.001). Nine of 15 (60%) LCMDCs had the high-frequency microsatellite instability phenotype, but only 2 of 25 (8%) DACs had the high-frequency microsatellite instability phenotype ( P = 0.002). Our findings provide support for the hypothesis that the molecular pathogenesis of LCMDCs is distinct from that of most DACs. CDX2 alterations and DNA mismatch repair defects have particularly prominent roles in the development of LCMDCs.

To understand the effects of accountable care organizations (ACOs) on use of surgery in patients with Alzheimer disease and related dementias (ADRD). Retrospective national cohort study of all Medicare beneficiaries identified in a 20% sample between 2010 and 2017. The primary exposure was participation in ACOs. The primary outcome was use of 1 of 6 common surgical procedures (aortic valve replacement [AVR], abdominal aortic aneurysm [AAA] repair, colectomy, carotid artery repair, major joint repair, and prostatectomy). Multivariable logistic regression models were fit using beneficiary-year as the unit of analysis to estimate the likelihood of undergoing each procedure among patients with ADRD and without ADRD, stratified by ACO participation. Additional models were fit to determine how the relationship between ACO participation and surgery was altered based on procedure urgency and the availability of minimally invasive technology. Adjusted odds for use of surgery were lower among patients with ADRD compared with patients without ADRD for all procedures. ACO participation had varying impact on patients with ADRD, with higher odds of AVR and major joint surgery and lower odds of carotid artery repair. Availability of minimally invasive technology increased the likelihood of AVR and AAA repair among patients with ADRD; however, ACO participation reduced these effects. The effect of ACO participation on the likelihood of undergoing surgery did not vary by urgency of the procedure. The likelihood of undergoing surgery is overall lower among patients with ADRD and may vary by ACO participation for specific procedures.

Background: There has been a strong push to move outpatient surgery from hospital settings to ambulatory surgery centers (ASCs). Despite the efficiency advantages of ASCs, many are concerned that these facilities could increase overall utilization. Objective: To assess the impact of ASC opening on rates of outpatient surgery. Design: This was a retrospective cohort study of Medicare beneficiaries undergoing outpatient surgery between 2001 and 2010. We compared population-based rates of outpatient surgery in Hospital Service Areas (HSAs) with freestanding ASCs to those without. After adjusting for differences using multiple propensity score methods, we assessed the impact of ASC opening in an HSA previously without one on rates of outpatient surgery. Subjects: Patients included were Medicare beneficiaries with Part B eligibility. Main Outcome Measure: Adjusted HSA-level rates of outpatient surgery. Results: Adjusted outpatient surgery rates increased from 2806 to 3940 per 10,000 and the number of ASC operating rooms grew from 7036 to 11,223 (both P < 0.001 for trend). By the fourth year after opening, rates of outpatient surgery increased by 10.9% (from 3338 to 3701 per 10,000) in HSAs adding an ASC for the first time. In contrast, outpatient surgery rates grew by only 2.4% and 0.6% in HSAs where an ASC was always or never present, respectively (P < 0.001 for test between 3 slopes). Conclusions: Rather than redistributing patients from one setting to another, the opening of ASCs increases outpatient surgery use. However, the 10.9% increase is more modest than previously suggested by state-level data.

Purpose Assessment of patient-reported outcomes (PROs), such as health-related quality of life, has become an important component of healthcare that measures the impact of disease and medical treatment on patient health. Collecting PROs during point-of-care assessments and integrating them into the clinical setting, however, remains challenging. The objective of this pilot study was to evaluate the reliability, usability, and acceptability of point-of-care electronic PRO assessments implemented in a prostate cancer clinic. Methods Fifty subjects completed paper-pencil and computerized formats of the Expanded Prostate Cancer Index Composite (EPIC), a validated, condition-specific QOL instrument, at separate times before treatment. Parallel-forms reliability was evaluated by comparing mean scores, variations in response distribution, and correlations between administration formats. Correlation coefficients of at least 0.70 were used for reliability testing. Differences between administration forms, indicating potential bias, were compared using the signed-rank test. A 6-item acceptability scale was also used to evaluate patient acceptability and satisfaction with the electronic format. Results Mean scores and standard deviations were similar between the paper-pencil and electronic forms across all EPIC instrument domains, and no assessment bias was found. Each EPIC domain demonstrated a high reliability between administration formats (correlation coefficients: 0.70-0.98). The majority (>90 %) of respondents found that the computerized QOL format was user friendly and simple to use. Conclusions Point-of-care computerized QOL assessments were reliable and acceptable to patients in this study, supporting the feasibility of PRO integration at the pointof-care in clinical settings.

Level I evidence has failed to demonstrate an overall survival (OS) advantage for cytoreductive nephrectomy in patients with metastatic clear cell renal cell carcinoma (ccRCC) in the modern era, which is at odds with observational studies reporting a marked OS benefit associated with these operations. These observational studies were not designed to adjust for unmeasured confounding. To assess whether cytoreductive nephrectomy is associated with improved OS in patients with metastatic ccRCC. This cohort study identified patients with metastatic ccRCC in the National Cancer Database from January 1, 2006, to December 31, 2016, who received systemic targeted therapy. The analysis was finalized on July 23, 2021. Receipt of cytoreductive nephrectomy. The primary outcome was OS from the date of diagnosis to death or censoring at last follow-up. Distance from the patients' zip code of residence to the treating facility was identified as a valid instrument and was used in a 2-stage residual inclusion instrumental variable analysis. Conventional adjustments for selection bias, multivariable Cox proportional hazards regression, and propensity score matching were performed for comparison. Measured covariates adjusted for in all analyses included age, sex, race, Charlson-Deyo score, facility type, year of diagnosis, clinical T stage, and clinical N stage. The final study population included 12 766 patients (median age, 63 years; IQR, 56-70 years; 8744 [68%] male; 11 206 [88%] White). Cytoreductive nephrectomy was performed in 5005 patients (39%). Conventional adjustments for selection bias demonstrated a significant OS benefit associated with cytoreductive nephrectomy (multivariable Cox proportional hazards regression: hazard ratio [HR], 0.49; 95% CI, 0.47-0.51; propensity score matching: HR, 0.48; 95% CI, 0.46-0.50). Instrumental variable estimates did not demonstrate an association between cytoreductive nephrectomy and OS (HR, 0.92; 95% CI, 0.78-1.09). Instrumental variable analysis did not demonstrate a survival advantage associated with cytoreductive nephrectomy for patients with metastatic ccRCC. This discrepancy likely reflects the fact that surgical indication for cytoreductive nephrectomy is primarily driven by factors that are not commonly measured or available in observational data sets.

Abstract Background Issues with randomized controlled trial generalizability are well described, but whether these issues result from differences in patient treatment across contexts remains unknown. We studied treatment of patients with high-risk prostate cancer after radical prostatectomy inside and outside a randomized controlled trial evaluating the impact of a genomic classifier on post–radical prostatectomy treatment decision making (Genomics in Michigan Impacting Observation of Radiation [G-MINOR]; ClinicalTrials.gov identifier NCT02783950). Methods G-MINOR enrolled 338 patients; propensity score–matched eligible but unenrolled patient cohorts (pretrial and trial contemporary) from the Michigan Urological Surgery Improvement Collaborative (MUSIC), in which the trial was embedded, were compared for rates and time to secondary treatment (adjuvant or salvage therapy) after prostatectomy. Results Among 338 patients in the G-MINOR cohort, 69 (31 adjuvant, 38 salvage) received secondary treatment compared with 266 (183 adjuvant, 83 salvage) and 104 (60 adjuvant, 44 salvage) in the 1014 contemporary and 338 pretrial–matched MUSIC cohorts. Time to secondary treatment was much shorter in the MUSIC cohort across all comparisons. For example, matching G-MINOR to synchronous MUSIC patients demonstrated 84% vs 74% estimated 2-year treatment-free survival for trial and real-world patients, respectively (P < .001). Conclusions Controlling for key clinicopathologic factors, patients in the G-MINOR randomized controlled trial and MUSIC cohorts were treated differently, even after stratifying by genomic risk. These findings suggest that challenges in randomized controlled trial generalizability extend beyond the representativeness of trial participants. Differences in management may also explain why divergent patient outcomes are observed in randomized controlled trials vs real-world settings.

In this study, we sought to determine the burden and characteristics of orgasmic dysfunction (OD) and concomitant erectile dysfunction (ED) in men with type 1 diabetes (T1D) enrolled in the Epidemiology of Diabetes Interventions and Complications (EDIC) study. In 2010, we assessed orgasmic and erectile function using the International Index of Erectile Function (IIEF). Sociodemographic, clinical, and diabetes characteristics were compared by OD status (OD only, OD and ED, no ED or OD). Age-adjusted associations between risk factors and OD status were examined. OD and ED information was available from 563 men. Eighty-three men (14.7%) reported OD of whom 21 reported OD only and 62 reported OD and ED. Age-adjusted odds ratios demonstrated that men who reported OD only had higher odds of depression, low sexual desire, and decreased alcohol use compared with men reporting no dysfunction. Men with OD concomitant with ED had greater odds of elevated hemoglobin A1C, peripheral and autonomic neuropathy, and nephropathy. Men reporting both dysfunctions were also more likely to report smoking, lower urinary tract symptoms, and had greater odds of androgen deficiency than men with no sexual dysfunction. Men with longstanding T1D suffer from an increased burden of OD. Psychogenic factors predominate in men reporting OD only while men who present with concomitant ED report increased burden of diabetes severity, characteristics previously observed with incident ED. ED may be the central impediment to sexual function in men with OD and ED. Longitudinal studies to characterize OD and ED experience over time are warranted.