Active surveillance in prostate cancer is possible for Afro-Caribbean population: Comparison of oncological outcomes with a Caucasian cohort.

BACKGROUND: Prostate cancer is supposedly more aggressive among Afro-Caribbean men. There is a lack of data in this population for active surveillance. Published series are retrospective or have small samples and results are discordant. The objective was to determinate whether actual active surveillance modalities can be applied for Afro-Caribbean men by comparing their oncological outcomes with Caucasian men. METHODS: A total of 449 consecutive patients who underwent active surveillance for favorable-risk prostate cancer in two French University-Medical-Centers between 2005 and 2018: 261 in Guadeloupe, French West Indies, and 188 in Bordeaux, metropolitan France. Median follow-up was 56 months, (95% CI [32-81]) and 52 months (95% CI [30-75]), respectively (P=0.07). Curative treatment was given in case of histological, biological, or imaging progression, or upon patient demand. Primary endpoints were treatment-free, overall and specific survival. Secondary outcomes were reasons of discontinuating active surveillance, histological poor prognosis factors after prostatectomy, CAPRA-S score, biochemical-recurrence-free after treatment and metastasis-free survival. Kaplan-Meier method was used. RESULTS: Median treatment free survival was 58.4 months (CI 95% [48.6-83.1]) for ACM and not reached at 120 months for CM (P=0.002). Overall survival (P=0.53), and specific survival (P=0.21) were similar in the two groups. CM were likely to have poor prognosis factor on prostatecomy piece (57 vs 30%, P=0.01). No difference for repartition of the CAPRA-S score (P=0.86), biochemical-recurrence-free (P=0.92) and metastasis-free (P=0.44) survival. CONCLUSIONS: Oncological outcomes for active surveillance of Afro-Caribbean and Caucasian men were similar in terms of mortality, recurrence and metastasis in our bicentric study, showing usability of current criteria for Afro-Caribbean. The higher rate of disease progression in the Afro-Caribbean population requires close monitoring. LEVEL OF EVIDENCE: 3.

The role of thoracic epidural analgesia in cardiac surgery

It is suggested that TEA improves the myocardial metabolic supply and demand relationship and thereby affords myocardial protection. This is supported by a reduction in myocardial stunning and infarct size in animal models and by improved perioperative hemodynamic stability and reduced markers of ischemic injury in clinical studies. Other beneficial effects include reliable stress response attenuation with a reduction in postoperative analgesia resulting in improved pulmonary function following cardiac surgery. It is furthermore clear that to achieve improved outcome, it is essential that the use of TEA be extended well into the postoperative period as an analgesic component of a multimodal postoperative approach, which should also include such things as early enteral feeding and mobilization. However, because of the potential risk of epidural hematoma, with possible permanent neurological injury, it is essential that the use of TEA be justified through studies showing improved outcomes (e.g., reduced major myocardial events and improved graft patency). This will require large, well-designed multicenter clinical trials and an international registry for complications. Until then, it is essential that epidural anesthesia during cardiac surgery be used cautiously, following recommended guidelines