Receptive Anal Intercourse: Impact on Colorectal and Urologic Diagnoses.

Purpose: We evaluated the relationship between lifetime receptive anal intercourse (RAI) and the risk of common colorectal and urologic diagnoses. Methods: We conducted an internet-based survey on sensations during RAI between July 2022 and March 2023. We used multivariable logistic regression to assess the independent impact of lifetime RAI exposure on the diagnosis of common urologic and colorectal conditions. Participants completed a main survey and were invited to complete randomly assigned patient-reported outcome measures (PROMs), which measured pelvic symptoms, mental health symptoms, and sexual satisfaction. Results: In total, 1100 participants completed the main survey and 416 completed the PROMs. Participants of the main survey ranged from 18 to 78 years old and the median age of the sample was 32 years. There was no significant association between lifetime RAI exposure and any medical diagnosis, except for anal fissures, which increased linearly with additional RAI exposure. Both sexual satisfaction and mental health symptoms improved with RAI exposure. Conclusions: RAI was not associated with most of the colorectal and urologic diagnoses tested and was associated with fewer mental symptoms and increased sexual satisfaction. Development of anal fissures may be directly related to trauma of the anal canal from penetration.

Needs of transgender children and adolescents presenting to an urban gender health program.

BACKGROUND: Youth who identify as transgender and gender diverse (TGD) are increasingly presenting to pediatric providers. Gender-affirming surgery is often delayed until after a patient reaches the age of majority; however, patients may desire surgery at a younger age. OBJECTIVE: We explore the specific clinical needs of this vulnerable population, including surgical requests. STUDY DESIGN: We present a cross-sectional study of patient intake interviews at time of presentation to our gender health program from 2017 to 2020. We summarize patient demographics, medical histories, and gender-affirming care needs by gender identity and age of presentation. RESULTS: Of 92 patients analyzed, those included were 19 trans girls, 55 trans boys, and 18 non-binary individuals. The median age of our sample was 15 (range 5-17). The median age (IQR) while first questioning gender was 10 (7-12). Sexual orientation was variable with 28 (43%) not sure/unknown. The majority of patients present for primary care services (grade schoolers 75%, early teens 78%, and late teens 77%, p = 0.97) and hormone management (grade schoolers 42%, early teens 62%, and late teens 77%, p = 0.06). Late teens were more likely to present for surgical services (49%) compared to grade schoolers (25%) and early teens (11%), p = 0.001. Prior psychiatric diagnoses were common in all age groups. Trans girls were interested in a variety of affirming procedures whereas trans boys and non-binary individuals primarily sought chest surgery (see summary figure). CONCLUSION: Pediatric gender affirming care needs are varied and multidisciplinary within our center. By age 16, about half of TGD individuals are seeking surgical services. On average, there was a 4-5 year delay from age at first questioning one's gender and presenting to our gender health program. Primary care physicians in particular may prepare to serve this complex population by familiarizing themselves with treatment needs, including developing a network of competent surgical referrals.

International Variations in Adherence to Quality Metrics for Locoregional Prostate Cancer.

BACKGROUND AND OBJECTIVE: Adherence to guideline recommendations can improve the quality of care for patients with prostate cancer (PCa). Our aim was to assess adherence to guidelines for locoregional PCa by international region. METHODS: The study cohort comprised patients diagnosed with locoregional PCa in the 10-country Movember TrueNTH Global Registry (n = 62 688; 2013-2022). We assessed adherence to four quality metrics: (1) active surveillance for low-risk PCa; (2) definitive treatment within 12 mo of diagnosis for unfavorable-risk PCa; (3) no staging imaging for favorable-risk PCa; and (4) staging imaging for unfavorable-risk PCa. For χ2 analyses, we combined the three most recent years of data entered by region for each outcome, with adjustment for multiple tests (p = 0.05 ÷ 4 = 0.0125). We also conducted multivariable logistic regression and temporal analyses. KEY FINDINGS AND LIMITATIONS: Active surveillance rates for low-risk PCa ranged from 85% in Australia/New Zealand (vs USA: adjusted odds ratio [aOR] 1.042, 95% confidence interval [CI] 0.740-1.520) to 14% in Central Europe (aOR 0.028, 95% CI 0.022-0.036). For patients with unfavorable-risk disease, the highest uptake rate for treatment within 12 mo of diagnosis was in Central Europe (98%; aOR 2.885, 95% CI 1.260-6.603), compared to 70% in Italy (aOR 0.031, 95%CI 0.014-0.072). The proportion of patients with favorable-risk disease who did not undergo imaging ranged from 94% in the USA to 30% in Italy (aOR 0.004, 95% CI 0.002-0.008), while the rate of imaging for unfavorable-risk PCa ranged from 8% in Hong Kong (aOR 65.222, 95% CI 43.676-97.398) to 39% in the USA (all χ2p < 0.0125). Regional temporal trends also varied. CONCLUSIONS AND CLINICAL IMPLICATIONS: In this international study comparing adherence to quality care metrics for the quality of care for locoregional PCa, we identified regional variance, possibly because of regional differences in cultural attitudes and health care structures. These benchmarks highlight opportunities for interventions to improve adherence to evidence-based guidelines. PATIENT SUMMARY: Our study shows that adherence to recommended management goals for patients with prostate cancer varies greatly by global region.

Anorectal Sexual Function Index: Development and Validation of a Health-related Quality of Life Measure.

OBJECTIVE: To assess the reliability and validity of measuring receptive anal intercourse (RAI) sensation and associated satisfaction and bother. METHODS: Between July 2022 and January 2023, we conducted a survey on sensations during RAI among people with prostates (ie, cisgender men and transgender women). The survey content was developed based on our previous qualitative study. We assessed internal reliability and consistency through time. Sensations experienced during RAI were correlated with health-related quality-of-life measures to ensure construct validity. RESULTS: The final index contained four scales: pleasure (four items), pain (seven items), urinary (four items), and bowel (four items). Overall, 1084 individuals filled out the questionnaire. The internal consistency for all subscales was at or above 0.79. Scores tended to be stable across time with all test-retest coefficients at or above 0.72. Pleasure scores were inversely correlated with pain scores (r = -0.46). Pleasure was positively correlated with erections (r = 0.36) and orgasms (r = 0.44) during RAI, and sexual satisfaction (r = 0.39). Notable positive correlations for pain scores were with bowel scores (r = 0.49), internalized homophobia (r = 0.35), and prostatitis symptoms (r = 0.37). Urinary scores were moderately associated with IPSS scores (r = 0.22). Bowel scores were positively correlated with GI symptoms (r = 0.24), mental health symptoms (r = 0.28), and chronic prostatitis symptoms (r = 0.29). CONCLUSION: The results of the current study provide evidence that the Anorectal Sexual Function Index is both reliable and valid. The Anorectal Sexual Function Index may be a particularly useful health-related quality-of-life measure to assess outcomes regarding a host of urologic issues that may affect RAI.

International Variations in Surgical Quality of Care in Men With Prostate Cancer: Results From the TrueNTH Global Registry.

PURPOSE: Functional problems such as incontinence and sexual dysfunction after radical prostatectomy (RP) are important outcomes to evaluate surgical quality in prostate cancer (PC) care. Differences in survival after RP between countries are known, but differences in functional outcomes after RP between providers from different countries are not well described. METHODS: Data from a multinational database of patients with PC (nonmetastatic, treated by RP) who answered the EPIC-26 questionnaire at baseline (before RP, T0) and 1 year after RP (T1) were used, linking survey data to clinical information. Casemix-adjusted incontinence and sexual function scores (T1) were calculated for each country and provider on the basis of regression models and then compared using minimally important differences (MIDs). RESULTS: A total of 21,922 patients treated by 151 providers from 10 countries were included. For the EPIC-26 incontinence domain, the median adjusted T1 score of countries was 76, with one country performing more than one MID (for incontinence: 6) worse than the median. Eighteen percent of the variance (R2) of incontinence scores was explained by the country of the providers. The median adjusted T1 score of sexual function was 33 with no country performing perceivably worse than the median (more than one MID worse), and 34% (R2) of the variance of the providers' scores could be explained by country. CONCLUSION: To our knowledge, this is the first comparison of functional outcomes 1 year after surgical treatment of patients with PC between different countries. Country is a relevant predictor for providers' incontinence and sexual function scores. Although the results are limited because of small samples from some countries, they should be used to enhance cross-country initiatives on quality improvement in PC care.

A qualitative study of barriers and facilitators for health behavior change in low-income men with prostate cancer.

PURPOSE: Low-income prostate cancer survivors, who typically have worse outcomes and greater all-cause mortality, often have poor health-promoting behaviors. Our objective was to assess perceived facilitators of and barriers to healthy behavior change by interviewing low-income men with prostate cancer who received no-cost treatment through a state-funded program. METHODS: Between September 2021 and April 2022, we conducted semi-structured interviews with 19 men (ages 60-75). Purposive sampling was utilized from participants of a cohort of men with prostate cancer from low-income backgrounds. Interviews were recorded, transcribed, and then coded by the authors to generate salient themes via thematic analysis. RESULTS: We found internal characteristics and structural characteristics that functioned independently and in concert to promote and/or hinder healthy behavior change. Internal characteristics such as motivations (prostate cancer diagnosis, self-perceptions, support system, and preferences) and determination, defined as level of motivation, drove behavior actualization. Structural characteristics that influenced behavior change included resources (access to food and opportunities for exercise) and social support. CONCLUSIONS: These outcomes suggest that motivation and determination can serve as protective facilitators encouraging healthy behaviors despite structural barriers low-income prostate cancer survivors may face. However, motivations challenged by financial constraints were not sufficient to guide healthy behavior change. With this in mind, we recommend that interventions promoting healthy behavior change among this population should focus on identifying and strengthening internal assets such as motivations, self-perceptions, preferences, and support systems.

Relationship between pelvic sensations and lifetime exposure to receptive anal intercourse among people with prostates.

BACKGROUND: Despite the negative stigma on receptive anal intercourse (RAI), this behavior has a positive influence on individuals' sexual and relationship health. No large studies have previously looked at specific sensations experienced during RAI and how these sensations may change with experience. AIM: In this study we aimed to quantify commonly reported pelvic sensations during RAI and determine whether their presentation changes with increasing experience of RAI. METHODS: An internet survey was conducted on sensations felt during RAI among people with prostates from July 2022-January 2023. The survey content was developed based on a mixed-methods qualitative study and inquired about demographic and sexual histories as well as sensations (pleasure, pain, urinary, and bowel) experienced during RAI. We used descriptive statistics to describe demographic and sexual histories. All data were stratified by lifetime exposure to RAI. OUTCOMES: The primary outcomes assessed included the quantification of both the primary sensations experienced during RAI and the associated bother. RESULTS: In total, 975 participants completed the survey. The median age was 32 (range 18-78) years. The average age of first participation in RAI was 21 ± 6.6 years. Most respondents were having sex at least once a week (65%). Nine percent of respondents reported fewer than 10 experiences with RAI, 26% reported 11-50 RAI experiences, 32% reported 51-200 experiences, 16% reported 201-500 experiences, and 18% reported >500 experiences. As the number of experiences with RAI increased (from <10 to >500 exposures), the reported frequency of pleasurable sensation increased from 41% to 92% (P < .0001), whereas severe insertional pain and symptoms of bowel urgency decreased from 39% to 13% and from 21% to 6%, respectively (P < .0001). Urinary urgency sensation did not differ by lifetime RAI experience. CLINICAL IMPLICATIONS: Lifetime RAI exposure can be readily assessed and correlates not only with pelvic sensation but also many other aspects of sexual health. These results imply that the etiology of dissatisfaction with pleasure or anodyspareunia during RAI may differ by lifetime RAI exposure. STRENGTHS AND LIMITATIONS: This is the first study to our knowledge to assess pelvic sensations experienced during RAI among a large sample of individuals. This is a cross-sectional study, and we cannot conclude how pelvic sensations change over time among individuals. Internet-based participants may not be representative of clinical populations. CONCLUSION: Lifetime exposure to RAI is positively associated with pleasure and is negatively associated with pain and bowel urgency. Pelvic sensations experienced during RAI appear to be dependent on lifetime RAI exposure history regardless of age.

Gender Affirming Surgery in Nonbinary Patients: A Single Institutional Experience.

Background An increasing number of nonbinary patients are receiving gender-affirming procedures due to improved access to care. However, the preferred treatments for nonbinary patients are underdescribed. The purpose of this study was to investigate the goals and treatments of nonbinary patients. Methods A retrospective study of patients who self-identified as nonbinary from our institutional Gender Health Program was conducted. Patient demographics, clinical characteristics, surgical goals, and operative variables were analyzed. Results Of the 375 patients with gender dysphoria, 67 (18%) were nonbinary. Over half of the nonbinary patients were assigned male at birth ( n = 57, 85%) and nearly half preferred the gender pronoun they/them/theirs ( n = 33, 49%). A total of 44 patients (66%) received hormone therapy for an average of 2.5 ± 3.6 years, primarily estrogen ( n = 39). Most patients ( n = 46, 69%) received or are interested in gender-affirming surgery, of which, almost half were previously on hormone therapy ( n = 32, 48%). The most common surgeries completed or desired were facial feminization surgery ( n = 15, 22%), vaginoplasty ( n = 15, 22%), mastectomy ( n = 11, 16%), and orchiectomy ( n = 9, 13%). Nonbinary patients who were assigned male at birth (NB-AMAB) were more often treated with hormones compared to nonbinary patients assigned female at birth (NB-AFAB) (72% vs. 30%, p = 0.010). Conversely, patients who were AFAB were more likely to complete or desire surgical intervention than those who were AMAB (100% vs. 63.0%, p < 0.021). Conclusion Majority of nonbinary patients were assigned male at birth. NB-AFAB patients all underwent surgical treatment, whereas NB-AMAB patients were predominantly treated with hormone therapy.

Atlas of the receptive anal sex experience among people with prostates.

BACKGROUND: Receptive anal intercourse (RAI) is commonly practiced among individuals of all sexual orientations. However, negative stigmatization by society and health care professionals leads to the underreporting or this practice. AIM: We sought to assess and describe the subjective role of the prostate as a pleasure center in participants with diverse RAI experiences. The secondary aim was to describe nonprostatic areas within the anorectal region that produce erotic sensation and/or pain. METHODS: The exploratory sequential multimethod study design included focus groups and semistructured interviews with 30 individuals with prostates who had engaged in RAI. We used graphic elicitation of natal male anatomy to enhance visualization and assess participant perspectives. OUTCOMES: The main outcome of interest was the identification of anatomic locations of erogenous sensation and pain during RAI. RESULTS: Among the participants (median age 38, range 24-77 years), most participants (90%) identified as cisgender male. Three major themes emerged within the motivations for RAI, including (1) deriving intrinsic pleasure, (2) providing both pleasure for a partner and a way to improve intimacy/connection, and (3) an inability to be the insertive partner due to physical or mental challenges. The data suggest that the anorectal region produces a variety of erogenous sensations which participants find pleasurable. Overall, 2 major areas of erogenous sensation occur along the anterior rectal wall and within the anus. Within the context of RAI, 2 distinct categories of pain emerged, including pain with insertion and pain at other times. CLINICAL IMPLICATIONS: Understanding where erogenous sensation originates for each individual may predict sexual functioning after various surgical interventions. Timing and location of pain may aid in further characterizing anodyspareunia. STRENGTHS AND LIMITATIONS: Our study utilized a sequential design (from focus groups to interviews) with diverse RAI experiences, especially regarding age, geographic location, and prostate pathology. We included individuals of diverse gender identities, but too few to evaluate these groups independently from cisgender men. CONCLUSION: People with prostates experience pleasure in multiple areas during RAI. Contrary to some lay literature, the prostate region is not the subjective pleasure center for all individuals. Timing and location of pain during RAI may inform areas for intervention. Providing a language for pleasure and pain during RAI may improve communication between not only sexual partners but also clinicians and patients.

Readmissions after radical nephrectomy in a national cohort.

OBJECTIVE: To analyze the factors and costs associated with 30-day readmissions for patients undergoing radical nephrectomy. MATERIALS AND METHODS: We used the 2014 Nationwide Readmission Database to identify adults who underwent radical nephrectomy for renal cancer, stratified by surgical approach. We determined patient factors associated with readmission rates, diagnoses, and costs using multivariate logistic regression. RESULTS: Among 19,523 individuals, the 30-day readmission rate was 7.7% (n = 1,506). On multivariate regression, odds of readmission were significantly increased with age ≥75 in those who underwent open nephrectomy (OR: 1.35; 95%CI: 1.03-1.78). Subjects with a Charlson comorbidity score ≥3 had significantly higher rates of readmission regardless of surgical approach (Open RN - OR: 1.85; 95%CI: 1.33-2.56; Lap RN - OR: 1.99; 95%CI 1.10-3.59; Robotic RN - OR: 2.18; 95%CI: 1.23-3.86). Common reasons for readmission were gastrointestinal, cardiovascular, urinary tract infections, and wound complications across all surgical approaches. The mean cost per readmission was as high as 126% ($20,357) of the mean index admission cost. CONCLUSION: One in 13 adults undergoing radical nephrectomy is readmitted within 30 days of discharge. Associated readmission cost is up to 1.26 times the cost of index admission. Our findings may inform efforts aiming to reduce hospital readmissions and curtail healthcare costs.

Effect of Gender-affirming Facial Feminization Surgery on Psychosocial Outcomes.

OBJECTIVE: This study investigates the effect of gender-affirming facial feminization surgery (FFS) on psychosocial outcomes in patients with gender dysphoria. BACKGROUND: Comprehensive analyses of psychosocial outcomes after gender-affirming FFS are absent in the literature resulting in a paucity of information on the impact of FFS on quality of life as well as ramifications in health insurance coverage of FFS. METHODS: Scores from 11 validated, quantitative instruments from the Patient-Reported Outcomes Measurement Information System (PROMIS) assessing anxiety, anger, depression, global mental health, global physical health, satisfaction with sex life, positive affect, emotional support, social isolation, companionship, and meaning and purpose. Patients within the preoperative group (pre-FFS) were evaluated >30 days before surgery and patients within the postoperative group (post-FFS) were evaluated ≥10 weeks after surgery. RESULTS: A total of 169 patients [mean (SD) age, 33.5 (10.8) years] were included. Compared with the pre-FFS group (n=107), the post-FFS group (n=62) reported improved scores anxiety (56.8±8.8 vs 60.1±7.9, P =0.01), anger (47.4±7.6 vs 51.2±9.6, P =0.01), depression (52.2±9.2 vs 57.0±8.9, P =0.001), positive affect (46.6±8.9 vs 42.9±8.7, P =0.01), meaning and purpose (49.9±10.7 vs 46.2±10.5, P =0.03), global mental health (46.7±7.6 vs 43.1±9.2, P =0.01), and social isolation (52.2±7.5 vs 55.4±7.4, P =0.01). Multivariable analysis to account for the effects of other gender-affirming surgeries, hormone therapy duration, preexisting mental health diagnoses, socioeconomic disparities, and patient-reported quality of social relationships on psychosocial functioning demonstrated that completion of FFS was independently predictive of improved scores. CONCLUSIONS: Gender-affirming FFS improves the quality of life by multiple psychosocial domains in transfeminine patients.

Impact of Comprehensive Health Insurance on Quality of Life in Low-Income Hispanic Men with Prostate Cancer.

OBJECTIVE: To evaluate the effect of the transition from IMPACT, a disease-focused treatment program, to comprehensive health insurance under Medicaid through the Affordable Care Act (ACA) on general and prostate cancer-specific quality of life (QoL) on a cohort of previously uninsured low-income men. We hypothesize that general QoL would improve and prostate cancer-specific QoL would remain the same after the transition to comprehensive health insurance. METHODS: We assessed and compared general QoL using the RAND SF-12v2™ (12-Item Short Form Survey, version 2) and prostate cancer-specific QoL using the UCLA PCI (Prostate Cancer Index) one year before, at, and one year after the transition between 30 men who transitioned to comprehensive insurance (newly insured/Medicaid group) and 54 men who remained in the prostate cancer program (uninsured/IMPACT group). We assessed the independent effects of Medicaid coverage on QoL outcomes using repeated-measures regression. RESULTS: Our cohort was composed primarily of Hispanic men (82%). At transition, patient demographics and clinical characteristics were similar between the groups. General and prostate cancer-specific QoL did not differ between the groups and remained stable over time, Radical prostatectomy as primary treatment and shorter time since treatment were associated with worse urinary and sexual function across both groups and over all three time points. CONCLUSION: Those who transitioned to full-scope insurance and those who remained in the free prostate cancer-focused treatment program had stable general and prostate cancer-specific QoL. High-touch navigation aspects of a disease-focused program may have contributed to stability in outcomes.

Quality-of-Life Outcomes and Toxicity Profile Among Patients With Localized Prostate Cancer After Radical Prostatectomy Treated With Stereotactic Body Radiation: The SCIMITAR Multicenter Phase 2 Trial.

PURPOSE: Postoperative radiation therapy (RT) is an underused standard-of-care intervention for patients with prostate cancer and recurrence/adverse pathologic features after radical prostatectomy. Although stereotactic body RT (SBRT) is a well-studied and convenient option for definitive treatment, data on the postprostatectomy setting are extremely limited. The purpose of this study was to evaluate short-term physician-scored genitourinary (GU) and gastrointestinal (GI) toxicities and patient-reported outcomes after postprostatectomy SBRT. METHODS AND MATERIALS: The SCIMITAR trial was a phase 2, dual-center, open-label, single-arm trial that enrolled patients with postoperative prostate-specific antigen >0.03 ng/mL or adverse pathologic features. Coprimary endpoints were 4-year biochemical recurrence-free survival, physician-scored acute and late GU and GI toxicities by the Common Terminology Criteria for Adverse Events (version 4.03) scale, and patient-reported quality-of-life (QOL) outcomes, as represented by the Expanded Prostate Cancer Index-26 and the International Prostate Symptom Score. Patients received SBRT 30 to 34 Gy/5 fractions to the prostate bed ± bed boost ± pelvic nodes with computed tomography (CTgRT) or magnetic resonance imaging guidance (MRgRT) in a nonrandomized fashion. Physician-scored toxicities and patient-reported QOL outcomes were collected at baseline and at 1, 3, and 6 months of follow-up. Univariable and multivariable analyses were performed to evaluate predictors of toxicities and QOL outcomes. RESULTS: One hundred participants were enrolled (CTgRT, n = 69; MRgRT, n = 31). The median follow-up was 29.5 months (CTgRT: 33.3 months, MRgRT: 22.6 months). The median (range) prostate bed dose was 32 (30-34) Gy. Acute and late grade 2 GU toxicities were both 9% while acute and late grade 2 GI toxicities were 5% and 0%, respectively. Three patients had grade 3 toxicity (n = 1 GU, n = 2 GI). No patient receiving MRgRT had grade 3 GU or grade ≥2 GI toxicity. Compared with CTgRT, MRgRT was associated with a 30.5% (95% confidence interval, 11.6%-49.5%) reduction in any-grade acute GI toxicity (P = .006). MRgRT was independently associated with improved any-grade GI toxicity and improved bowel QOL. CONCLUSIONS: Postprostatectomy SBRT was well tolerated at short-term follow-up. MRgRT may decrease GI toxicity. Longer toxicity and/or efficacy follow-up and randomized studies are needed.

Engagement With HIV and COVID-19 Prevention: Nationwide Cross-sectional Analysis of Users on a Geosocial Networking App.

BACKGROUND: Geosocial networking (GSN) apps play a pivotal role in catalyzing sexual partnering, especially among men who have sex with men. OBJECTIVE: To quantify the prevalence and disparities in disclosure of pre-exposure prophylaxis (PrEP) use and COVID-19 vaccination among GSN app users, mostly men who have sex with men, in the United States. METHODS: Web-based Grindr profiles from the top 50 metropolitan areas as well as the 50 most rural counties in the United States by population were randomly sampled. Grindr provides an option to disclose current PrEP use (HIV positive, HIV negative, or HIV negative with PrEP use). The free text in all profiles was analyzed, and any mention of COVID-19 vaccination was recorded. Multivariable logistic regression to assess independent associations with PrEP disclosure and COVID-19 vaccination was performed. Imputation analyses were used to test the robustness of the results. RESULTS: We evaluated 1889 urban and 384 rural profiles. Mean age among urban profiles was 32.9 (SD 9.6) years; mean age among rural profiles was 33.5 (SD 12.1) years (P=.41). Among the urban profiles, 16% reported being vaccinated against COVID-19 and 23% reported PrEP use compared to 10% and 8% in rural profiles, respectively (P=.002 and P<.001, respectively). Reporting COVID-19 vaccination (adjusted odds ratio [aOR] 1.7, 95% CI 1.2-2.4), living in an urban center (aOR 3.2, 95% CI 1.8-5.7), and showing a face picture as part of the Grindr profile (aOR 4.0, 95% CI 2.3-7.0) were positively associated with PrEP disclosure. Self-identified Black and Latino users were less likely to report PrEP use (aOR 0.6, 95% CI 0.4-0.9 and aOR 0.5, 95% CI 0.4-0.9, respectively). Reporting PrEP use (aOR 1.7, 95% CI 1.2-2.4), living in an urban center (aOR 2.5, 95% CI 1.4-4.5), having a "discreet" status (aOR 1.6, 95% CI 1.0-2.5), and showing a face picture (aOR 2.7, 95% CI 1.5-4.8) were positively associated with reporting COVID-19 vaccination on their profile. Users in the southern United States were less likely to report COVID-19 vaccination status than those in the northeast United States (aOR 0.6, 95% CI 0.3-0.9). CONCLUSIONS: Variations in PrEP disclosure are associated with race, whereas COVID-19 vaccination disclosure is associated with geographic area. However, rural GSN users were less likely to report both PrEP use and COVID-19 vaccination. The data demonstrate a need to expand health preventative services in the rural United States for sexual minorities. GSN platforms may be ideal for deployment of preventative interventions to improve access for this difficult-to-reach population.

Comprehension, utility, and preferences of prostate cancer survivors for visual timelines of patient-reported outcomes co-designed for limited graph literacy: meters and emojis over comics.

OBJECTIVE: Visual timelines of patient-reported outcomes (PRO) can help prostate cancer survivors manage longitudinal data, compare with population averages, and consider future trajectories. PRO visualizations are most effective when designed with deliberate consideration of users. Yet, graph literacy is often overlooked as a design constraint, particularly when users with limited graph literacy are not engaged in their development. We conducted user testing to assess comprehension, utility, and preference of longitudinal PRO visualizations designed for prostate cancer survivors with limited literacy. MATERIALS AND METHODS: Building upon our prior work co-designing longitudinal PRO visualizations with survivors, we engaged 18 prostate cancer survivors in a user study to assess 4 prototypes: Meter, Words, Comic, and Emoji. During remote sessions, we collected data on prototype comprehension (gist and verbatim), utility, and preference. RESULTS: Participants were aged 61-77 (M = 69), of whom half were African American. The majority of participants had less than a college degree (95%), had inadequate health literacy (78%), and low graph literacy (89%). Among the 4 prototypes, Meter had the best gist comprehension and was preferred. Emoji was also preferred, had the highest verbatim comprehension, and highest rated utility, including helpfulness, confidence, and satisfaction. Meter and Words both rated mid-range for utility, and Words scored lower than Emoji and Meter for comprehension. Comic had the poorest comprehension, lowest utility, and was least preferred. DISCUSSION: Findings identify design considerations for PRO visualizations, contributing to the knowledge base for visualization best practices. We describe our process to meaningfully engage patients from diverse and hard-to-reach groups for remote user testing, an important endeavor for health equity in biomedical informatics. CONCLUSION: Graph literacy is an important design consideration for PRO visualizations. Biomedical informatics researchers should be intentional in understanding user needs by involving diverse and representative individuals during development.

Quality of life in low-income men after surgical castration for metastatic prostate cancer.

OBJECTIVE: To compare health-related quality of life in men who underwent surgical vs. medical castration for metastatic prostate cancer. METHODS: We analyzed data from a prospective cohort of men enrolled in a statewide public health program that provides care for prostate cancer among low-income, uninsured men from 2001 to 2020. Outcome measures included the RAND SF-12 and the UCLA Prostate Cancer Index (PCI) at baseline and every 6 months. We used generalized estimating equations to assess the independent impact of surgical vs. medical castration on health-related quality of life. RESULTS: Among men with metastatic prostate cancer, 27 underwent orchiectomy, and 274 underwent medical castration. Median cohort age at enrollment was 61.3 years (IQR 56-65); 239 (79%) men had less than a high school education. Average follow-up was 8 months (range 0-45) since study enrollment. Seventy percent of patients within the surgical castration group had their orchiectomy prior to study enrollment (median months since orchiectomy at study enrollment was 9 months, IQR 1-43). Similarly, 59% of patients within the medical castration group had begun ADT prior to study enrollment (median months since ADT initiation at study enrollment was 4 months, IQR 1-12). The majority (66%) had metastatic disease at diagnosis. The 2 groups did not differ in age, race/ethnicity, education, monthly income, baseline PSA, Gleason score, or percent metastatic at diagnosis. SF-12 domains did not differ between those who underwent surgical vs. medical castration (on average throughout follow-up, physical component difference -2.0, 95% CI -8.0-3.9 and mental component difference -1.0, 95% CI -5.4-+3.4). Patients treated with orchiectomy reported better urinary function than those who underwent medical castration (+16 point, 95%CI 5.3-26). CONCLUSIONS: Surgical castration did not negatively impact general or disease-specific quality of life. The finding of improved urination after orchiectomy merits further inquiry. This may inform urologists' discussion of surgical vs. medical options for men with castration-sensitive metastatic prostate cancer.

Testis Cancer Care in North Carolina: Implications for Real-World Evidence and Cancer Surveillance.

INTRODUCTION: Contemporary testis cancer management requires fastidious adherence to clinical guidelines and care principles, especially for those pursuing active surveillance (AS). However, real-world testis cancer care remains largely undescribed. Accordingly, we sought to assess the rigor of evaluation and monitoring among men with testis cancer. PATIENTS AND METHODS: Using North Carolina Central Cancer Registry data linked to insurance claims, we selected adult males diagnosed with primary testis cancer from 2003 to 2013. After identifying demographics, care setting, histology, stage, and index management, we evaluated the receipt of tumor markers, imaging, and clinic visits during initial evaluation and subsequent monitoring with respect to contemporaneous clinical guidelines. Care patterns were compared using chi-squared testing and multivariable logistic regression. RESULTS: Of 2526 men with primary testis cancer, we assembled a cohort of 487 with seminoma (59.3%) or nonseminoma (40.7%), losing most to a lack of insurance or continuous coverage. The cohort was predominantly white (92.4%) and had stage I disease (87.9%). Overall, 18.9% had complete tumor markers, staging imaging, and visits with 2 relevant specialists as recommended during their initial evaluation. For subsequent monitoring, 17.5% of patients with seminoma on active surveillance met minimal thresholds for recommended testing and follow-up during the first year vs. 21.9% and 34.9% of patients with seminoma treated with adjuvant radiation and chemotherapy, respectively. For nonseminoma, 10.1% of men on active surveillance met the minimal thresholds for recommended monitoring compared with 60.4% and 62.0% of those treated with surgery and chemotherapy, respectively. Recommended monitoring also differed by academic vs. community setting and receipt of recommended evaluation (P < .05). CONCLUSIONS: From real-world data, the evaluation and monitoring of patients with testis cancer appears substandard. Ongoing data and quality gaps highlight potential challenges with generating real-world evidence and ensuring adequate surveillance in this population.