Incorporating multiparametric magnetic resonance imaging (mpMRI) for initial staging can reduce the time to correct treatment (TTCT) for patients with muscle-invasive bladder cancer (MIBC), according to a study published online Jan. 14 in the Journal of Clinical Oncology.

Richard T. Bryan, Ph.D., from the University of Birmingham in the United Kingdom, and colleagues conducted a prospective open-label randomized study within 17 U.K. hospitals involving patients with suspected new bladder cancer who were randomly assigned to transurethral resection of bladder tumor (TURBT)-staged or mpMRI-staged care to examine whether treatment could be expedited for MIBC with mpMRI.

A total of 638 patients were screened between May 31, 2018, and Dec. 31, 2021, and 143 were randomly assigned to TURBT or initial mpMRI (72 and 71, respectively). Thirty-six of 39 participants with suspected MIBC underwent mpMRI for feasibility. The researchers found that for participants with MIBC, the median TTCT was significantly shorter with initial mpMRI (53 days versus 98 days for TURBT). No detriment was seen for participants with non-MIBC (median TTCT, 17 days for mpMRI versus 14 days for TURBT). There were no reports of serious adverse events.

"Incorporating mpMRI ahead of TURBT into the standard pathway was beneficial for all patients with suspected MIBC. TURBT could be avoided in a proportion of these patients," the authors write. "This approach can improve decision-making and accelerate time to treatment."

Several authors disclosed ties to the biopharmaceutical industry.

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Men with negative multiparametric magnetic resonance imaging (mpMRI) results avoiding biopsy do not have an increased risk for clinically significant prostate cancer (PCa), according to a study published online Dec. 12 in JAMA Oncology.

Charlie A. Hamm, M.D., Ph.D., from Charité-Universitätsmedizin Berlin, and colleagues examined the feasibility and safety of a community-based MRI diagnostic strategy in men aged 18 to 75 years with suspected PCa. Participants underwent 3-Tesla mpMRI; those with findings suspected to be PCa were recommended for targeted prostate biopsy (PB). Men with negative mpMRI results or positive mpMRI results and benign findings on PB were monitored systematically for three years.

Overall, 593 men underwent mpMRI and 48 percent had negative MRI results; 44 and 41 percent avoided PB initially and over three years, respectively. The researchers found that clinically significant PCa was detected in 27 and 29 percent of men after immediate PB and after three years, respectively. Seven men with negative MRI results had PCa diagnosed by immediate PB and 279 entered the monitoring phase. A total of 233 completed three-year monitoring, with seven PCa diagnoses. Nineteen percent of the 307 men with positive MRI results showed no PCa after immediate PB; of these, 71 and 7 percent completed monitoring and were diagnosed with clinically significant PCa, respectively.

"By providing programmatic three-year monitoring data for both patients with negative and positive MRI results, findings from this study address the gap of knowledge highlighted in current guidelines on the use of MRI in the diagnosis and management of PCa," the authors write.

Several authors disclosed ties to pharmaceutical and medical technology companies, including Bayer Pharma AG and Siemens Healthineers, both of which contributed funding for the study.

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For patients undergoing breast reconstruction, a 16-fraction course of hypofractionated postmastectomy radiation therapy (PMRT) is noninferior to a 25-fraction conventional course, according to a study presented at the annual meeting of the American Society for Radiation Oncology (ASTRO), held from Sept. 29 to Oct. 2 in Washington, D.C.

Matthew M. Poppe, M.D., from the Huntsman Cancer Institute at the University of Utah in Salt Lake City, and colleagues enrolled breast cancer patients with unilateral larger tumors (pT3N0) or smaller tumors and invasion of the regional lymph nodes (pT0-2 pN1-2) who were planning delayed or immediate breast reconstruction and PMRT. Patients were randomly assigned to receive 50.0 Gy in 25 fractions (conventional PMRT) or 42.56 Gy in 16 fractions (hypofractionated PMRT), delivered five days per week (422 and 403 patients, respectively). Patients from 209 centers in the United States and Canada were enrolled from 2018 to 2021 and were followed for a median of 4.5 years.

Of the 650 patients who completed reconstruction, 45 and 55 percent had immediate and delayed breast reconstruction, respectively; 59 and 41 percent had implant alone and autologous +/− implant, respectively. The researchers found that the 24-month incidence of reconstruction complications was 14 and 12 percent with hypofractionation and conventional PMRT, respectively (estimated difference, 2.3 percent, which met the noninferiority margin of 10 percent). Regardless of arm, there was a decrease seen in the complication rate with autologous versus implant-only reconstruction (odds ratio, 0.504). There was no significant difference in acute and late toxicity rates between the arms. Three-year local or regional recurrences occurred in 1.5 and 2.3 percent of hypofractionated and conventional patients, respectively.

"The results of this trial show we can safely reduce treatment time for these patients to three weeks, without compromising their reconstruction," Poppe said in a statement.

Several authors disclosed ties to the biopharmaceutical industry.

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Postmastectomy reconstruction (PMR) rates among American Indian/Alaska Native (AI/AN) women with breast cancer increased from 2004 to 2017, but remain significantly lower than rates among non-Hispanic White (NHW) women, according to a study published in the July issue of Plastic and Reconstructive Surgery.

McKenzie J. White, M.D., from the University of Minnesota in Minneapolis, and colleagues examined factors associated with disparities in PMR surgical care. The National Cancer Database (2004 to 2017) was used to identify 414,036 NHW and 1,980 AI/AN women (aged 18 to 64) who underwent mastectomy for stage 0 to III breast cancer.

The researchers found that compared to NHW women, AI/AN women had more comorbidities (20 versus 12 percent), more often had nonprivate insurance (49 versus 20 percent), and more frequently underwent unilateral mastectomy (69 versus 61 percent). Over the study period, PMR rates increased from 13 to 47 percent for AI/AN women and from 29 to 62 percent for NHW women. There was an independent association between AI/AN race and decreased likelihood of PMR (odds ratio, 0.62). Among AI/AN women, there were significant associations between older age at diagnosis, more remote year of diagnosis, advanced disease (tumor size >5 cm and positive lymph nodes), unilateral mastectomy, nonprivate insurance, and lower educational attainment in patient’s area of residence with decreased likelihood of PMR.

"Multidisciplinary efforts to improve care delivery to AI/AN women may continue to minimize disparities through earlier diagnosis and treatment," the authors write. "Simultaneously, qualitative research into AI/AN perspectives on breast cancer care could improve shared decision-making between physicians and AI/AN patients, empowering AI/AN women to choose postmastectomy reconstruction if they so desire."

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Bothersome urinary symptoms and incontinence are common at 12 months postpartum, according to a study recently published in Urogynecology.

Sonia Bhandari Randhawa, M.D., from University of Texas Southwestern Medical Center in Dallas, and colleagues sought to identify factors associated with persistent (i.e., 12 months postpartum), bothersome urinary symptoms, including stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). The analysis included data from 419 participants in the extending Maternal Care After Pregnancy cohort.

The researchers found that SUI (32.5 percent) was significantly associated with increasing body mass index at the time of delivery and greater depression screening scores. There was no association for SUI and fetal birth weight, mode of delivery, degree of laceration, or breastfeeding status. There was a significant association between UUI (16.5 percent) and increasing parity and higher anxiety screening scores. Participants with urinary symptom bother also had significantly greater parity and higher anxiety screening scores.

"At 12 months postpartum, bothersome urinary symptoms and incontinence were quite common," the authors write. "Since these are treatable, postpartum screening for urinary complaints -- and associated anxiety and depression -- is essential, as is assisting patients in achieving a healthy weight."

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For patients undergoing urinary diversion for neurogenic bladder (NGB), the postoperative impact on urinary-related quality of life (UrQOL) is milder for spinal cord injury of congenital (C-SCI) etiology versus acquired (A-SCI) etiology, according to a study published online July 1 in PM&R.

João Pedro Emrich Accioly, M.D., from the Glickman Urological and Kidney Institute at the Cleveland Clinic Foundation, and colleagues compared decisional regret and UrQOL in patients undergoing urinary diversion for NGB arising from A-SCI (17 patients with traumatic spinal cord injury) and C-SCI (20 patients with spina bifida) etiologies. A-SCI was compared to C-SCI in terms of decisional regret, UrQOL, and postoperative changes in self-reported physical health, mental health, and pain.

The researchers found that compared with the C-SCI cohort, the A-SCI group displayed poorer preoperative physical health; after adjustment for baseline scores and follow-up time, absolute postoperative changes in this score and in the mental health score and pain level were not significant. When adjusted for other factors, a significantly worse impact of NGB in UrQOL was seen for A-SCI than C-SCI. Between the groups, there were no differences in decisional regret observed.

"We were able to demonstrate that patients with A-SCI report poorer physical health at baseline and lower UrQOL following reconstructive surgery when compared with a demographically and clinically similar C-SCI population," the authors write. "These findings may be a valuable addition to discussions between health care providers and patients when considering surgical management of NGB."

One author disclosed ties to Boston Scientific.

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From an economic perspective, first-line prostate-specific antigen (PSA) testing is favored over biparametric magnetic resonance imaging (bpMRI) for prostate cancer screening, mainly due to false-positive results and overdiagnosis, according to a study published online June 4 in the Annals of Internal Medicine.

Roman Gulati, from the Fred Hutchinson Cancer Center in Seattle, and colleagues examined the comparative effectiveness and cost-effectiveness of first-line bpMRI versus PSA-based screening in a decision analysis using a microsimulation model. The target population comprised U.S. men aged 55 years without prior screening or prostate cancer diagnosis.

The researchers found that first-line bpMRI versus PSA testing prevented two to three prostate cancer deaths and added 10 to 30 life-years per 1,000 men, but, depending on the biopsy imaging scheme, increased the number of biopsies by 1,506 to 4,174 and the number of overdiagnoses by 38 to 124. The greatest net monetary benefits were seen for first-line PSA testing with multiparametric MRI followed by either biopsy approach for Prostate Imaging Reporting and Data System 4 to 5 at conventional cost-effectiveness thresholds. In sensitivity analysis, even if bpMRI was free, all men with low-risk prostate cancer underwent surveillance, and screening was quadrennial, first-line PSA still remained cost-effective.

"Our analyses suggest that the economic value of a first-line screening test, such as bpMRI, is driven by false-positive results and overdiagnoses rather than the cost of the test," the authors write. "Accordingly, our results suggest that screening efforts should focus on strategies that reduce false-positive results and overdiagnoses to improve cost-effectiveness."

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MONDAY, July 10, 2023 (HealthDay News) -- Janus tyrosine kinase (JAK) signaling may be involved in the pathogenesis of polymyalgia rheumatica (PMR), and tofacitinib may be an effective treatment, according to a pilot study published online June 29 in PLOS Medicine.

Xinlei Ma, from Zhejiang University in Hangzhou, China, and colleagues examined pathogenetic features of PMR and assessed the efficacy and safety of the JAK inhibitor tofacitinib in patients with PMR. The analysis included 11 treatment-naive PMR patients and 20 healthy controls. In a second cohort, 76 patients with PMR were randomly assigned to tofacitinib or glucocorticoid treatment in an open-label trial, with 67 completing the 24-week intervention.

The researchers found that gene expression patterns of peripheral blood mononuclear cells in patients with newly diagnosed PMR were significantly different from 20 healthy controls using RNA sequencing. The most notable pathways affected were inflammatory response and cytokine-cytokine receptor interaction, with marked increases in expression of IL6R, IL1B, IL1R1, JAK2, TLR2, TLR4, TLR8, CCR1, CR1, S100A8, S100A12, and IL17RA, which could trigger JAK signaling. In vitro, tofacitinib suppressed the IL6R and JAK2 expression of CD4⁺T cells from patients with PMR. Among a second cohort of patients with newly diagnosed PMR randomly assigned to tofacitinib or glucocorticoid, all patients in both groups had PMR disease activity scores <10, and C-reactive protein and erythrocyte sedimentation rate were significantly decreased in both groups at weeks 12 and 24, with no severe adverse events.

"We think tofacitinib may have a high response rate in the new diagnosed PMR patients who were naive to glucocorticoid or biological agents," the authors write.

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FRIDAY, March 24, 2023 (HealthDay News) -- The environmental impact of prostate biopsies is considerable, according to a study recently published in European Urology.

Michael S. Leapman, M.D., from the Yale School of Medicine in New Haven, Connecticut, and colleagues estimated the environmental impact associated with prostate magnetic resonance imaging (MRI) and prostate biopsy. Environmental emissions were compared across five clinical scenarios: multiparametric MRI (mpMRI) of the prostate with targeted and systematic biopsies; mpMRI with targeted biopsy cores only; systematic biopsy without MRI; mpMRI with systematic biopsy; and biparametric MRI (bpMRI) with targeted and systematic biopsies.

The researchers noted that an estimated 80.7 kg carbon dioxide equivalents (CO2e) are emitted by a single transrectal prostate biopsy procedure including prostate MRI and targeted and systematic biopsies in the United States. A total of 76.2, 36.2, 70.5, and 42.7 kg CO2e were generated by an approach of MRI targeted cores alone without systematic biopsies, a systematic 12-core biopsy without mpMRI, bpMRI with targeted and systematic biopsies, and mpMRI alone, respectively. The largest contributor was energy, with an estimated 38.1 kg CO2e, followed by staff travel and supply production (20.7 and 11.4 kg CO2e, respectively). A total of 8.1 million kg CO2e could be avoided by performing 100,000 fewer unnecessary biopsies, which was equivalent to 4.1 million L of gasoline consumed. The use of prostate MRI to triage prostate biopsy and guide targeted biopsy cores would save the equivalent of 1.4 million kg CO2 emissions per 100,000 patients, which was equivalent to 700,000 L of gas consumed.

"We hope this work adds depth to the discussion by providing concrete estimates of health care pollution and environmental impact also incurred through these procedures," Leapman said in a statement.

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