Prostate magnetic resonance imaging utilization and its relationship with advanced prostate cancer detection.

BACKGROUND: The rise in advanced prostate cancer has coincided with increased use of Magnetic Resonance Imaging (MRI), leading to the hypothesis that this increase in surveillance registries is an artifact of more sensitive imaging tools. We assessed the association between regional variation in prostate MRI and advanced prostate cancer diagnoses. METHODS: We utilized SEER-Medicare data (2004-2015), including men > 65 diagnosed with localized prostate cancer. The predictor variable was the utilization of prostate MRI in each hospital referral region (HRR, representing regional healthcare markets). We compared the proportion of disease recorded as locally advanced or of regional risk group (cT3, cT4, and cN1) which would plausibly have been detected by prostate MRI. We conducted adjusted multivariable analysis and performed correlation analysis with Spearman rank coefficient at the level of the HRR. Sensitivity analysis for years 2011 to 2015 was conducted. RESULTS: Of 98,921 men diagnosed, 4.01% had locally advanced or regional disease. The median prostate MRI utilization rate was 4.58% (IQR [3.03%, 8.12%]). Adjusted multivariable analysis revealed no statistically significant correlation between MRI utilization and proportion of advanced prostate cancer (aOR = 1.01, 95% CI, [0.99,1.03]) in each region. The correlation between MRI usage and advanced diagnosis was not significant (Spearman Ρ = 0.09, P = 0.4). Sensitivity analysis conducted between 2011 and 2015 showed similar results (aOR = 1.008, 95% CI, [0.989, 1.027]; Spearman Ρ = 0.16, P = 0.1). CONCLUSIONS: During our study period, HRR-level utilization of MRI was not associated with higher incidences of advanced prostate cancer. This suggests the rising advanced prostate cancer diagnoses observed in this period are unlikely an artifact of greater sensitivity of modern imaging tests, but potentially due to other factors such as changes in screening or risk factors. With increased utilization and evolving techniques in recent years, the association between MRI and advanced prostate cancer detection warrants continued monitoring.

A qualitative approach to understanding the drivers of unequal receipt of definitive therapy for Black men with prostate cancer in Massachusetts.

BACKGROUND: Despite mandated insurance coverage since 2006 and robust health infrastructure in urban settings with high concentrations of minority patients, race-based disparities in prostate cancer (PCa) treatment persist in Massachusetts. In this qualitative study, the authors sought to identify factors driving inequities in PCa treatment in Massachusetts. METHODS: Four hospitals offering PCa treatment in Massachusetts were selected using a case-mix approach. Purposive sampling was used to conduct semistructured interviews with hospital stakeholders. Additional interviews were conducted with representatives from grassroots organizations providing PCa education. Two study staff coded the interviews to identify major themes and recurrent patterns. RESULTS: Of the 35 informants invited, 25 participated in the study. Although national disparities in PCa outcomes were readily discussed, one half of the informants were unaware that PCa disparities existed in Massachusetts. Informants and grassroots organization representatives acknowledged that patients with PCa are willing to face transportation barriers to receive treatment from trusted and accommodating institutions. Except for chief equity officers, most health care providers lacked knowledge on accessing or using metrics regarding racial disparities in cancer outcomes. Although community outreach was recognized as a potential strategy to reduce treatment disparities and engender trust, informants were often unable to provide a clear implementation plan. CONCLUSIONS: This statewide qualitative study builds on existing quantitative data on the nature and extent of disparities. It highlights knowledge gaps in recognizing and addressing racial disparities in PCa treatment in Massachusetts. Improved provider awareness, the use of disparity metrics, and strategic community engagement may ensure equitable access to PCa treatment. PLAIN LANGUAGE SUMMARY: Despite mandated insurance and urban health care access, racial disparities in prostate cancer treatment persist in Massachusetts. This qualitative study revealed that, although national disparities were acknowledged, awareness about local disparities are lacking. Stakeholders highlighted the importance of ancillary services, including translators, rideshares, and navigators, in the delivery of care. In addition, whereas hospital stakeholders were aware of collected equity outcomes, they were unsure whether and who is monitoring equity metrics. Furthermore, stakeholders agreed that community outreach showed promise in ensuring equitable access to prostate cancer treatment. Nevertheless, most interviewed stakeholders lacked clear implementation plans.

Estimating the impact of enhanced care at minority-serving hospitals on disparities in the treatment of breast, prostate, lung, and colon cancers.

BACKGROUND: The objective of this study was to quantify disparities in cancer treatment delivery between minority-serving hospitals (MSHs) and non-MSHs for breast, prostate, nonsmall cell lung, and colon cancers from 2010 to 2019 and to estimate the impact of improving care at MSHs on national disparities. METHODS: Data from the National Cancer Database (2010-2019) identified patients who were eligible for definitive treatments for the specified cancers. Hospitals in the top decile by minority patient proportion were classified as MSHs. Multivariable logistic regression adjusted for patient and hospital characteristics compared the odds of receiving definitive treatment at MSHs versus non-MSHs. A simulation was used to estimate the increase in patients receiving definitive treatment if MSH care matched the levels of non-MSH care. RESULTS: Of 2,927,191 patients from 1330 hospitals, 9.3% were treated at MSHs. MSHs had significant lower odds of delivering definitive therapy across all cancer types (adjusted odds ratio: breast cancer, 0.83; prostate cancer, 0.69; nonsmall cell lung cancer, 0.73; colon cancer, 0.81). No site of care-race interaction was significant for any of the cancers (p > .05). Equalizing treatment rates at MSHs could result in 5719 additional patients receiving definitive treatment over 10 years. CONCLUSIONS: The current findings underscore systemic disparities in definitive cancer treatment delivery between MSHs and non-MSHs for breast, prostate, nonsmall cell lung, and colon cancers. Although targeted improvements at MSHs represent a critical step toward equity, this study highlights the need for integrated, system-wide efforts to address the multifaceted nature of racial and ethnic health disparities. Enhancing care at MSHs could serve as a pivotal strategy in a broader initiative to achieve health care equity for all.

Urinary and Sexual Impact of Robotic Radical Prostatectomy: Reporting of Patient-reported Outcome Measures in the First Year after Radical Prostatectomy in a Contemporary Multicentre Cohort in the United Kingdom.

Background and objective: Radical prostatectomy (RP) is an established treatment for localised prostate cancer that can have a significant impact on urinary and sexual function, with recovery over time. Our aim was to describe functional recovery in the first year after RP, reporting descriptive outcomes alongside validated patient-reported outcome measure scores (Expanded Prostate Cancer Index Composite, EPIC-26). Methods: Men undergoing RP between September 2015 and November 2019 completed EPIC-26 at baseline and 1, 3, 6, and 12 mo. Key findings and limitations: Overall, 2030 men consented to participation, underwent RP, and completed EPIC-26. At baseline, 97% were pad-free (1928/1996; 95% confidence interval [CI] 96-97%) and 77% were leak-free and pad-free (1529/1996; 95% CI 75-78), with a median EPIC-26 incontinence domain score of 100 (interquartile range [IQR] 86-100). At 12 mo, 65% were pad-free (904/1388; 95% CI 63-68%) and 42% were leak-free and pad-free (583/1388; 95% CI 39-45%), with a median EPIC-26 score of 76 (IQR 61-100). While one in three men reported wearing a pad at 12 mo, fewer than one in ten men needed more than 1 pad/d. At baseline, 1.9% reported a "moderate or big problem" with urine leakage, which increased to 9.7% at 12 mo. At baseline, the median sexual domain score among 1880 men was 74 (IQR 43-92) and 52% had erections sufficient for intercourse without medication (975/1880; 95% CI 50-54%). Among these 975 men, 630 responded at 12 mo, of whom 17% reported sufficient erections for intercourse (105/630; 95% CI 14-20%), without medication in 6% (37/630; 95% CI 4-8%) and needing medication in 11% (68/630; 95% CI 9-13%); the median EPIC-26 domain score was 26 (IQR 13-57). Conclusions and clinical implications: Reporting of functional outcomes after RP in terms of easily understood concepts such as pad-free and leak-free status, and erections with and with medication, alongside the classical report using EPIC-26 domain scores, increases the understanding of RP recovery patterns over the first year. Patient summary: At 12 months after surgery for prostate cancer, one in ten men reported a moderate or big problem with urine leakage and one in five men reported sufficient erections.

Smoking characteristics and years since quitting smoking of US adults diagnosed with lung and bladder cancer: A national health and nutrition examination survey analysis

ABSTRACT Purpose: Smoking is a recognized risk factor for bladder BC and lung cancer LC. We investigated the enduring risk of BC after smoking cessation using U.S. national survey data. Our analysis focused on comparing characteristics of LC and BC patients, emphasizing smoking status and the latency period from smoking cessation to cancer diagnosis in former smokers. Materials and Methods: We analyzed data from the National Health and Examination Survey (2003-2016), identifying adults with LC or BC history. Smoking status (never, active, former) and the interval between quitting smoking and cancer diagnosis for former smokers were assessed. We reported descriptive statistics using frequencies and percentages for categorical variables and median with interquartile ranges (IQR) for continuous variables. Results: Among LC patients, 8.9% never smoked, 18.9% active smokers, and 72.2% former smokers. Former smokers had a median interval of 8 years (IQR 2-12) between quitting and LC diagnosis, with 88.3% quitting within 0-19 years before diagnosis. For BC patients, 26.8% never smoked, 22.4% were active smokers, and 50.8% former smokers. Former smokers had a median interval of 21 years (IQR 14-33) between quitting and BC diagnosis, with 49.3% quitting within 0-19 years before diagnosis. Conclusions: BC patients exhibit a prolonged latency period between smoking cessation and cancer diagnosis compared to LC patients. Despite smoking status evaluation in microhematuria, current risk stratification models for urothelial cancer do not incorporate it. Our findings emphasize the significance of long-term post-smoking cessation surveillance and advocate for integrating smoking history into future risk stratification guidelines.

Racial differences in postpandemic trends in prostate-specific antigen screening.

Our study investigates the trends in prostate cancer screening amid the COVID-19 pandemic, particularly focusing on racial disparities between Black and White men. Utilizing data from the Behavioral Risk Factor Surveillance System from 2018, 2020, and 2022, we analyzed prostate-specific antigen screening rates in men aged 45-75 years. Our findings reveal initial declines in screening rates for both groups during the pandemic, with subsequent recovery; however, the pace of rebound differed statistically significantly between races. Whereas White men showed a notable increase in screening rates postpandemic, Black men's rates recovered more slowly. This disparity underscores the impact of socioeconomic factors, health-care access, and possibly systemic biases affecting health-care delivery. Our study highlights the need for targeted interventions to address these inequalities and ensure equitable access to prostate cancer preventive care in the aftermath of COVID-19.

Smoking characteristics and years since quitting smoking of US adults diagnosed with lung and bladder cancer: A national health and nutrition examination survey analysis.

PURPOSE: Smoking is a recognized risk factor for bladder BC and lung cancer LC. We investigated the enduring risk of BC after smoking cessation using U.S. national survey data. Our analysis focused on comparing characteristics of LC and BC patients, emphasizing smoking status and the latency period from smoking cessation to cancer diagnosis in former smokers. MATERIALS AND METHODS: We analyzed data from the National Health and Examination Survey (2003-2016), identifying adults with LC or BC history. Smoking status (never, active, former) and the interval between quitting smoking and cancer diagnosis for former smokers were assessed. We reported descriptive statistics using frequencies and percentages for categorical variables and median with interquartile ranges (IQR) for continuous variables. RESULTS: Among LC patients, 8.9% never smoked, 18.9% active smokers, and 72.2% former smokers. Former smokers had a median interval of 8 years (IQR 2-12) between quitting and LC diagnosis, with 88.3% quitting within 0-19 years before diagnosis. For BC patients, 26.8% never smoked, 22.4% were active smokers, and 50.8% former smokers. Former smokers had a median interval of 21 years (IQR 14-33) between quitting and BC diagnosis, with 49.3% quitting within 0-19 years before diagnosis. CONCLUSIONS: BC patients exhibit a prolonged latency period between smoking cessation and cancer diagnosis compared to LC patients. Despite smoking status evaluation in microhematuria, current risk stratification models for urothelial cancer do not incorporate it. Our findings emphasize the significance of long-term post-smoking cessation surveillance and advocate for integrating smoking history into future risk stratification guidelines.

Exploring preventive care practices among unvaccinated individuals in the United States during the COVID-19 pandemic.

INTRODUCTION: Building on a Canadian study associating unvaccinated individuals to increased car accidents, we examined the relationship between COVID-19 vaccination status and US preventive care practices. METHODS: We queried the 2021 National Health Interview Survey. First, we fitted a model to identify respondent-level factors associated with receipt of at least one COVID-19 vaccination. Second, we fitted a survey-weighted logistic regression model adjusted for respondent-level characteristics to examine whether the receipt of at least one COVID-19 vaccination predicted the receipt of preventive care services. Preventive care services assessed included serum cholesterol, glucose, and blood pressure measurements, as well as guideline-concordant cancer screening including breast, cervical, colorectal, and prostate cancer screening. RESULTS: Factors predicting receipt of COVID-19 vaccination were age (adjusted Odds Ratio (aOR) 1.03; 95 % confidence interval (CI) [1.03-1.03]), Hispanic (aOR 1.25; 95 % CI [1.08-1.44]), and non-Hispanic Asian (aOR 3.52; 95 % CI [2.74-4.52]) ethnicity/race, and history of cancer (aOR 1.61; 95 % CI [1.13-2.30]). Unvaccinated respondents were less likely to have received serum cholesterol (aOR 0.69; 95 % CI [0.50-0.70), serum glucose (aOR 0.65; 95 % CI [0.56-0.75]), or blood pressure measurements (aOR 0.47; 95 % CI [0.33-0.66]); and were less likely to have received breast cancer (aOR 0.35; 95 % CI [0.25-0.48]), colorectal cancer (aOR 0.52; 95 % CI [0.46-0.60]) and prostate cancer screening (aOR 0.61; 95 % CI [0.48-0.76]). There was no significant association between unvaccinated respondents receiving cervical cancer screening (aOR 0.96; 95 % CI [0.81-1.13]; p = 0.616). CONCLUSION: Non-receipt of COVID-19 vaccination was associated with non-receipt of preventive care services including cancer screening. Further studies are needed to assess if this association is due to system-level factors or reflects a general distrust of medical preventive care amongst this population.

A Phase II Prospective Blinded Trial of Magnetic Resonance Imaging and In-Bore Biopsy in Active Surveillance for Prostate Cancer.

OBJECTIVE: To demonstrate the added benefit of multiparametric (mp)MRI risk stratification during active surveillance. METHODS: This prospective, single-arm, nonrandomized study included 82 men with low-risk prostate cancer (PCa). We compared two biopsy strategies in parallel. The first biopsy strategy was an in-bore and transrectal ultrasound (TRUS) biopsy in men with suspicious mpMRI findings. The second was a TRUS biopsy in all 82 men, blinded to the results of the previously performed mpMRI. RESULTS: We identified 27/82 men with suspicious mpMRI. Of those 27 men, we detected 8/27 with csPCa on biopsy, and we identified two men with in-bore biopsy exclusively, three men with TRUS biopsy exclusively, and three men with both biopsy strategies. Of the 55/82 men with nonsuspicious mpMRI (who only received TRUS biopsies), two men had csPCa. TRUS biopsy of the entire cohort of 82 men would have led to the correct diagnosis of 80% men with csPCa, requiring all 82 men to receive biopsies (csPCa in 10% of the 82 biopsies). Conducting in-bore biopsies plus TRUS biopsies in men with suspicious mpMRI would have also led to the detection of 80% of men with csPCa, requiring only 27 men to receive biopsies (csPCa in 30% of the 27 biopsies). CONCLUSION: The combination of TRUS and in-bore biopsies, limited to men with suspicious mpMRI, resulted in a similar detection rate of csPCa compared to TRUS biopsies of all men but required only one-third of men to undergo biopsy. Our results indicate that in-bore and TRUS biopsies continue to complement each other.

The effect of limited english proficiency on prostate-specific antigen screening in American men.

PURPOSE: To evaluate how limited English proficiency (LEP) impacts the prevalence of prostate-specific antigen (PSA) screening in a contemporary, nationally representative cohort of men in the USA. METHODS: The Medical Expenditure Panel Survey was utilized to identify the prevalence of PSA screening between 2013 and 2016 among men ≥ 55. Men who speak a language other than English at home were stratified by self-reported levels of English proficiency (men who speak English very well, well, not well, or not at all). Survey weights were applied, and groups were compared using the adjusted Wald test. A multivariable logistic regression model was used to identify predictors of PSA screening adjusting for patient-level covariates. RESULTS: The cohort included 2,889 men, corresponding to a weighted estimate of 4,765,682 men. 79.6% of men who speak English very well reported receiving at least one lifetime PSA test versus 58.4% of men who do not speak English at all (p < 0.001). Men who reported not speaking English at all had significantly lower prevalence of PSA screening (aOR 0.56; 95% CI 0.35-0.91; p = 0.019). Other significant predictors of PSA screening included older age, income > 400% of the federal poverty level, insurance coverage, and healthcare utilization. CONCLUSIONS: Limited English proficiency is associated with significantly lower prevalence of PSA screening among men in the USA. Interventions to mitigate disparities in prostate cancer outcomes should account for limited English proficiency among the barriers to guideline-concordant care.

Racial Disparities in Prostate Cancer Screening: The Role of Shared Decision Making.

INTRODUCTION: The 2018 U.S. Preventive Services Task Force recommendations endorsed shared decision making for men aged 55-69 years, encouraging consideration of patient race/ethnicity for prostate-specific antigen screening. This study aimed to assess whether a proxy shared decision-making variable modified the impact of race/ethnicity on the likelihood of prostate-specific antigen screening. METHODS: A cross-sectional analysis of men aged between 55 and 69 years, who responded to the prostate-specific antigen screening portions of the 2020 U.S.-based Behavioral Risk Factor Surveillance System survey, was performed between September and December 2022. Complex sample multivariable logistic regression models with an interaction term combining race and estimated shared decision making were used to test whether shared decision making modified the impact of race/ethnicity on screening. RESULTS: Of a weighted sample of 26.8 million men eligible for prostate-specific antigen screening, 25.7% (6.9 million) reported for prostate-specific antigen screening. In adjusted analysis, estimated shared decision making was a significant predictor of prostate-specific antigen screening (AOR=2.65, 95% CI=2.36, 2.98, p<0.001). The interaction between race/ethnicity and estimated shared decision making on the receipt of prostate-specific antigen screening was significant (pint=0.001). Among those who did not report estimated shared decision making, both non-Hispanic Black (OR=0.77, 95% CI=0.61, 0.97, p=0.026) and Hispanic (OR=0.51, 95% CI=0.39, 0.68, p<0.001) men were significantly less likely to undergo prostate-specific antigen screening than non-Hispanic White men. On the contrary, among respondents who reported estimated shared decision making, no race-based differences in prostate-specific antigen screening were found. CONCLUSIONS: Although much disparities research focuses on race-based differences in prostate-specific antigen screening, research on strategies to mitigate these disparities is needed. Shared decision making might attenuate the impact of race/ethnic disparities on the likelihood of prostate-specific antigen screening.

Long-Term Impact of Medicaid Expansion on Prostate Cancer Screening.

INTRODUCTION: Prostate cancer is the most common noncutaneous malignancy in men. The updated PSA testing 2018 United States Preventive Services Task Force guidelines recommend shared decision-making for men ages 55 to 69. In 2010, the Affordable Care Act expanded Medicaid coverage to childless adults earning < 138% of the federal poverty level. Thereafter, individual states have chosen to adopt or defer Medicaid expansion at different times. This allows for the opportunity to study the effects of expansion on a population that did not previously qualify for Medicaid. We examine the long-term association of Medicaid expansion on prostate cancer screening. METHODS: Data from the Behavioral Risk Factor Surveillance System were extracted for childless men earning less than 138% of the federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were classified into 4 expansion categories: very early expansion states, early expansion states, late expansion states, and nonexpansion states. Prevalence of PSA screening was determined for each category of expansion. Difference-in-difference analyses were used to understand variations in very early expansion states, early expansion states, and late expansion states trends with reference to nonexpansion states. RESULTS: PSA screening prevalence decreased in very early expansion states (27.76% vs 18.50%), early expansion states (33.79% vs 18.09%), late expansion states (36.08% vs 19.14%), and nonexpansion states (38.82% vs 24.40%) from 2012 to 2020. However, the difference-in-difference analyses did not show statistically significant results among any of the years and expansion category groups in our study period. CONCLUSIONS: PSA screening prevalence decreased in all states, regardless of expansion category. No long-term effect of Medicaid expansion on PSA screening prevalence was observed among states with different expansion statuses.

Climate change perception and its association with cancer screening intent.

As the climate crisis deepens, its adverse effects on human health are becoming evident, including impacts on cancer pathogenesis and treatment. This study explored the link between individuals' awareness of the health impacts of climate change and interest in cancer screening. Using the 2021 Health Information National Trends Survey, our study demonstrated a statistically significant association between recognition of climate change as a personal health threat and interest in cancer screening. Although the study's retrospective nature and self-reported data pose some limitations, these findings signal a promising avenue for future research on the intersection of climate and cancer risk. This research supports the development of public health interventions that incorporate components of environmental health literacy alongside cancer screening efforts.

Racial differences in knowledge, attitudes, and sources of information about germline cancer genetic testing in the U.S.A.: An analysis of the health information National Trends Survey System.

PURPOSE: To understand racial disparities in germline cancer genetic testing and the role of prior knowledge, attitudes, and sources of information. METHODS: A cross-sectional analysis of the Health Information National Trends Survey 5 (HINTS 5) was conducted between February 24th and June 15th, 2020. The study aimed to investigate knowledge and receipt of genetic testing, attitudes toward the importance of genetic testing in preventing, detecting, and treating cancer, and information sources of genetic testing in the United States of America. RESULTS: Non-Hispanic Black (NHB) and Hispanic race/ethnicity were associated with lower odds of being informed about genetic testing, whereas those of NHB race were more likely to endorse the importance of genetic testing in cancer prevention and treatment. Regarding sources of information about genetic testing: Non-Hispanic Asians were less likely to be informed about genetic testing from television (Mean Predicted Probability (MPP) 0.38 95%CI; 0.21-0.55, (Adjusted Risk Difference) ARD vs. Non-Hispanic White (NHW); -0.228, p = 0.01), NHB were less likely to report being informed about genetic testing from social media (MPP 0.27 95%CI; 0.20-0.34, ARD vs. NHW; -0.139, p < 0.01). CONCLUSIONS: NHB and Hispanic groups face unequal access to information about genetic testing. There are significant race-based differences in information sources. These differences could be used to promote equitable access to cancer genetic testing.

Changes in Prostate-specific Antigen Screening after the 2018 United States Preventive Services Task Force Recommendations and Through the COVID-19 Pandemic.

We analyzed trends in prostate-specific antigen (PSA) screening for prostate cancer, with a focus on the impact of the 2018 US Preventive Services Task Force (USPSTF) recommendations and the COVID-19 outbreak. Using National Health Interview Survey data, we performed difference-in-difference (DID) analyses to examine the PSA screening trend for men aged 55-69 yr, the target population in the 2018 USPSTF update, with men aged >69 yr included as the reference and adjustment for sociodemographic factors. We found that PSA screening increased for men aged 55-69 yr (+4.6%, 95% confidence interval [CI] 1.7-7.5%) or >69 yr (+6.5%, 95% CI 2.7-10.4%) in 2019 (after the 2018 recommendations) in comparison to 2015. There was a decrease in PSA screening for men aged 55-69 yr in 2021 in comparison to 2019 (after the COVID-19 outbreak in 2020) of -3.1% (95%CI -0.4% to -5.8%). Adjusted DID analysis revealed no significant variations in the rate of change in PSA screening between the two age groups following both events. Despite its observational nature, our design mitigates major challenges in inferring causal relationships. Our results suggest a causal relationship between the 2018 screening guidelines and an increase in screening rates for men aged 55-69 yr. Conversely, they also indicate that preventive care disruptions related to COVID-19 may have induced deceleration or potentially reversal of these advances. PATIENT SUMMARY: We used data from a large national survey to study the rate of prostate-specific antigen (PSA) screening for prostate cancer in the USA in response to the 2018 United States Preventive Services Task Force recommendations and to the COVID-19 pandemic. We found an increase in PSA screening in 2019 among men aged 55-69 yr, the target population in the 2018 recommendations, as well as men aged >69 yr. However, this increase was reduced after the COVID-19 outbreak. It remains to be seen how PSA screening continues to change as the world recovers from COVID-19.

The Association of County-level Prostate-specific Antigen Screening with Metastatic Prostate Cancer and Prostate Cancer Mortality.

BACKGROUND AND OBJECTIVE: There exists ongoing debate about the benefits and harms of prostate-specific antigen (PSA) screening for prostate cancer. This study sought to evaluate the association of county-level PSA screening rates with county-level incidence of metastatic prostate cancer and prostate cancer mortality in the USA. METHODS: This ecological study used data from the 2004-2012 Behavioral Risk Factor Surveillance System (BRFSS) to build a multilevel mixed-effect model with poststratification using US Census data to estimate county-level PSA screening rates for all 3143 US counties adjusted for age, race, ethnicity, and county-level poverty rates. The exposure of interest was average county-level PSA screening rate from 2004 to 2012, defined as the proportion of men aged 40-79 yr who underwent PSA screening within the prior 2 yr. The primary outcomes were county-level age-adjusted incidence of regional/distant prostate cancer during 2015-2019 and age-adjusted prostate cancer mortality during 2016-2020. KEY FINDINGS AND LIMITATIONS: A total of 416 221 male BRFSS respondents aged 40-79 yr met the inclusion criteria and were used in the multilevel mixed-effect model. The model was poststratified using 63.4 million men aged 40-79 yr from all 3143 counties in the 2010 Decennial Census. County-level estimated PSA screening rates exhibited geographic variability and were pooled at the state level for internal validation with direct BRFSS state-level estimates, showing a strong correlation with Pearson correlation coefficients 0.77-0.90. A 10% higher county-level probability of PSA screening in 2004-2012 was associated with a 14% lower county-level incidence of regional/distant prostate cancer in 2015-2019 (rate ratio 0.86, 95% confidence interval [CI] 0.85-0.87, p < 0.001) and 10% lower county-level prostate cancer mortality in 2016-2020 (rate ratio 0.90, 95% CI 0.89-0.91, p < 0.001). CONCLUSIONS AND CLINICAL IMPLICATIONS: In this population-based ecological study of all US counties, higher PSA screening rates were associated with a lower incidence of regional/distant prostate cancer and lower prostate cancer mortality at extended follow-up. PATIENT SUMMARY: US counties with higher rates of prostate-specific antigen (PSA) screening had significantly lower rates of metastatic prostate cancer and prostate cancer mortality in subsequent years. These data may inform shared decision-making regarding PSA screening for prostate cancer.

Impact of COVID-19 pandemic on ambulatory urologic oncology surgeries.

INTRODUCTION: Robot-assisted laparoscopic prostatectomy (RALP) and transurethral resection of bladder tumor (TURBT) are two common surgeries for prostate and bladder cancer. We aim to assess the trends in the site of care for RALP and TURBT before and after the COVID outbreak. MATERIALS AND METHODS: We identified adults who underwent RALP and TURBT within the California Healthcare Cost and Utilization Project State Inpatient Database and the State Ambulatory Surgery Database between 2018 and 2020. Multivariable analysis and spline analysis with a knot at COVID outbreak were performed to investigate the time trend and factors associated with ambulatory RALP and TURBT. RESULTS: Among 17,386 RALPs, 6,774 (39.0%) were ambulatory. Among 25,070 TURBTs, 21,573 (86.0%) were ambulatory. Pre-COVID, 33.5% of RALP and 85.3% and TURBT were ambulatory, which increased to 53.8% and 88.0% post-COVID (both p < 0.001). In multivariable model, RALP and TURBT performed after outbreak in March 2020 were more likely ambulatory (OR 2.31, p < 0.0001; OR 1.25, p < 0.0001). There was an overall increasing trend in use of ambulatory RALP both pre- and post-COVID, with no significant change of trend at the time of outbreak (p = 0.642). TURBT exhibited an increased shift towards ambulatory sites post-COVID (p < 0.0001). CONCLUSIONS: We found a shift towards ambulatory RALP and TURBT following COVID outbreak. There was a large increase in ambulatory RALP post-COVID, but the trend of change was not significantly different pre- and post-COVID - possibly due to a pre-existing trend towards ambulatory RALP which predated the pandemic.

Clinical stage and grade migration of localized prostate cancer at diagnosis during the past decade.

OBJECTIVES: Early 2010s data suggest a reverse stage and grade migration towards more aggressive prostate cancer (PCa) at diagnosis, accelerated by the 2012 US Preventive Services Task Force recommendation against PSA screening. Using the National Cancer Database, we investigated the impact of the 2018 USPSTF recommendation and the COVID-19 outbreak on this shift. We hypothesized that the COVID-19 outbreak would further contribute to a stage and grade migration towards more aggressive disease. MATERIAL AND METHODS: We identified men with localized PCa diagnosed between 2010 and 2020. We analyzed the shift in the proportion of PCa stratified according to D'Amico risk classification. We used multivariable logistic regression models to assess the association between year of diagnosis and dichotomous variables related to clinical stage and grade of PCa. Predicted probabilities with 95% CI were computed through marginal effect analyses. RESULTS: We identified 910,898 men with localized PCa. The proportion of low-risk PCa almost halved from 34.9% in 2010 to 17.7% in 2020 (P < 0.001). Compared to 2010, we found in each year increased odds of: PSA≥10 ng/dL starting from 2012 (aOR2012 1.05; 95% CI, 1.02-1.08); cT3-T4 starting from 2015 (aOR2015 1.10; 95% CI, 1.03-1.17); ISUP GG 3-5 starting from 2011 (aOR2011 1.06; 95% CI, 1.03-1.08); and consequently, D'Amico intermediate/high-risk class starting from 2011 (aOR2011 1.03; 95% CI, 1.01-1.05). Fluctuations in the probabilities of PSA≥10 ng/dL and cT3-T4 at diagnosis were observed over time (all P < 0.001). The probability of PSA≥10 ng/dL peaked at 29.0% (95% CI, 28.0%-29.0%) in 2018, while the probability of cT3-T4 peaked at 3.7% (95% CI, 3.6%-3.8%) in 2020. All other outcome variables demonstrated a consistent upward shift (all P < 0.001), with the highest probabilities in 2020 for ISUP GG 3-5 (42.3%, 95% CI, 41.9%-42.6%) and D'Amico intermediate/high-risk (81.3%, 95% CI, 81.0%-81.6%). CONCLUSIONS: Our study confirms an enduring shift towards a higher proportion of aggressive PCa at diagnosis, likely influenced by the COVID-19 pandemic. The impact of the 2018 USPSTF PCa screening recommendation on the proportion of aggressive PCa seems restricted and likely affected by the pandemic outbreak. Future investigations should evaluate the long-term effects of the 2018 USPSTF recommendations in the postpandemic setting.