Renal & Urology News - Winter 2022 Issue

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Skipping Pre-RP Biopsy Possible

BY JODY A. CHARNOW PERFORMING RADICAL prostatectomy (RP) based solely on radiographic findings and skipping conventional biopsies that are the standard of care for diagnosing prostate cancer may be a possible option for well-selected patients, according to a recent report.

In a study of 25 men with a high suspicion for significant prostate cancer based on imaging with multiparametric magnetic resonance imaging (mpMRI) of the prostate and prostate-specific membrane antigen positron emission tomography (PSMA-PET), all patients

had Grade Group 2 or higher prostate cancer on postoperative pathology.

On a per-patient basis, sensitivity and positive predictive value for identifying significant prostate cancer were 100% for both mpMRI and PSMA-PET, the investigators reported.

“Results of the current retrospective case series were promising and showed that, in patients with a high suspicion of [prostate cancer] in mpMRI and PSMA-PET, avoidance of prostate biopsy prior to RP might represent a valid option in well-counseled, selected patients,” Valentin H. Meissner, MD,

© ZEPHYR / SCIENCE SOURCE

Small study suggests promising new approach

RADIOGRAPHIC IMAGING alone may reliably identify clinically significant PCa, a study found.

of the Technical University of Munich School of Medicine, and colleagues reported in European Urology.

They also observed that this approach “should not be regarded as a standard procedure at the moment, and results illustrate the need for a prospective

Stone Rate Higher Than Expected PCSM Is Not SUBSTANTIALLY more new cases to a National Health and Nutrition Higher Among of kidney stones than anticipated are Examination Survey (NHANES) from occurring in the United States, accord- 2015 to 2018. Participants were asked Black Patients ing to nationally representative estimates. “In the past 12 months, have you Investigators led by Jonathan E. Shoag, MD, of University Hospitals Cleveland Medical Center, Case Western Reserve University in Cleveland, Ohio, analyzed data from 10,521 individuals aged 20 years or older who responded

Trend foreshadows possible rise in the number of emergency department visits.

passed a kidney stone?” and “Have you ever had a kidney stone?”

The rate of passing a symptomatic kidney stone in the last 12 months was 2.1% or 2054 stones per 100,000 adults, the investigators reported in The Journal of Urology. That incidence rate is much higher than previous reports, and it does not include asymptomatic stones.

In addition, 11.0% of participants reported ever having a kidney stone.

“Our findings have significant implications,” Dr Shoag’s team wrote. “If these findings are due to a persistent continued on page 4

BY JODY A. CHARNOW RECENT STUDIES OFFER more evidence challenging a widespread perception that the risk of dying from prostate cancer (PCa) is higher among Black men than White men.

One study included 51,530 men diagnosed with PCa in Canada from 1992 to 2010. Of these, 29,705 patients died, 7925 from PCa. Compared with White patients and those of selected other races and ethnicities (reference group), Black men had a 17% decreased risk of prostate cancer-specific mortality (PCSM), a difference that was not statistically significant.

Prior Studies Contradicted “Our results contradict earlier studies suggesting that Black men may have a biologically distinct form of aggressive prostate cancer,” Noah Stern, MD, MSc, of Western University in London, Ontario, Canada, and coauthors reported in JAMA Network Open. continued on page 4

evaluation within an ethically approved clinical trial to confirm these results.”

Dr Meissner’s team defined significant prostate cancer as an mpMRI Prostate Imaging Reporting and Data System (PI-RADS) score of 4 or higher and continued on page 4

IN THIS ISSUE 4

Thermal ablation for RCC in CKD patients preserves kidney function

6

Urologic practices need to adapt to a new normal

8

ADT-related cardiovascular risks may be lower than expected

11

Metformin use is associated with prostate cancer risk

14

Predictors of NMIBC pathologic upstaging identified

20

Extended PLND during RP may increase survival

26

Robotic cystectomy safe and feasible for octogenarians

Antibodies to COVID-19 vaccines wane quickly in dialysis patients PAGE 20

Contents

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WINTER

2022

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ONLINE

this month at renalandurologynews.com

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Clinical Quiz Test your knowledge by taking our latest quiz at renalandurologynews.com/ run-quiz

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HIPAA Compliance Read timely articles on various issues related to keeping protected health information secure.

Drug Information Search a comprehensive drug database for prescribing and other information on more than 4000 drugs.

Be sure to check our latest listings for professional openings across the United States.

Predictors of NMIBC Upstaging Identified Older age and lymphovascular invasion are risk factors for pathologic upstaging among patients with nonmuscle-invasive bladder cancer.

Extended PLND During RP May Up Survival In a study, removal of 10-19 lymph nodes vs fewer than 10 was significantly associated with a 14% lower risk for death.

Robotic Cystectomy Safe, Feasible for Octogenarians Robotic-assisted radical cystectomy is significantly associated with 54% decreased odds of in-hospital mortality compared with open surgery.

Nonalbuminuric DKD Ups CKD Progression Risk Diabetic kidney disease without albuminuria also is significantly associated with an increased risk for hospitalization for heart failure.

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Men Found to Be More Likely Than Women To Start Dialysis New finding helps interpret the preponderance of men in the dialysis population, researchers say.

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CKD Care Differs By Race, Ethnicity, Study Finds Black and Hispanic patients are less likely than White patients to have diabetes under control.

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CALENDAR Editor’s note: The 2022 conference listings below include information provided by the sponsoring organizations on their websites as this issue went to press.

Genitourinary Cancers Symposium San Francisco, CA February 17-19 42nd Annual Dialysis Conference Virtual Meeting March 5-6 European Association of Urology 37th Annual Congress Amsterdam, The Netherlands March 18-21 National Kidney Foundation Spring Clinical Meetings Boston, MA April 5-9 European Renal Association 59th Congress Paris, France, and Virtual May 19-22 American Transplant Congress Boston, MA June 4-8

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News Coverage Visit our website for daily reports on the latest developments in clinical research.

ADT-Related CV Risks May Be Lower Than Thought The rate of major adverse cardiovascular events was 3.7% during the first 4 years of treatment, a study found.

Nephrology

Job Board

Renal & Urology News 1

VOLUME 21, ISSUE NUMBER 1

Urology 8

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Antibodies to COVID-19 Vaccines Wane Quickly in Dialysis Patients Decline in SARS-CoV-2 antibodies is associated with an increased risk for breakthrough infection, investigators report.

This is the first study with real-world data to publish on a pretest video in a male population in the context of prostate cancer germline testing.

See our story on page 21

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Departments 2

From the Editor COVID-19 research is unprecedented

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News in Brief CKD severity affects likelihood of AF therapy

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Ethical Issues in Medicine Counseling patients on weighing risks and benefits of treatment

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Practice Management Establishing the value of a medical practice

2 Renal & Urology News

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FROM THE EDITOR EDITORIAL ADVISORY BOARD

COVID-19 Research Effort Unprecedented

T

he COVID-19 pandemic, the most devastating health crisis in more than a century, will be entering its third year in March. As of January 14, some 317 million COVID-19 cases and 5.5 million related deaths have occurred worldwide, according to the Johns Hopkins Coronavirus Research Center. The United States has tallied approximately 62.5 million COVID19 cases and 840,000 related deaths, according to the Centers for Disease Control and Prevention. The rapid spread of SARS-CoV-2, the novel coronavirus that causes COVID-19, and the resulting human toll and societal and economic disruption have led to an unprecedented worldwide marshalling of research efforts. SARS-CoV-2 has become perhaps the most studied virus in history. (See COVID-19 articles on pages 19 and 20.)

This is reflected in PubMed, the database maintained by the National Institutes of Health. A search of that database on January 14 using the term “COVID-19” retrieved 217,349 citations related to the disease.

That’s in just 2 years. By comparison, a search for “influenza” turned up 145,583 citations in the entire database. HIV had more entries (390,846), but that’s for research published during the approximately 4 decades since the virus was first recognized.

The COVID-19 research effort to date has identified risk factors for SARS-CoV-2 infection, characterized the spectrum of clinical manifestations of infection, and zeroed in on which treatments are effective and those that are not. Such knowledge could lead to improved infection control measures and therapeutics for SARS-CoV-2 and perhaps better prepare us for whatever epidemic or pandemic comes next.

The second year of the pandemic comes to an end with the emergence of a SARS-CoV-2 variant called Omicron. This variant is extremely transmissible, with experts saying they have never seen such a communicable virus. But it appears to cause milder disease than other variants. It remains unclear what the appearance of this less-virulent form of the virus means for the trajectory the pandemic.

Regardless, like pandemics before it, this one will end eventually.

The massive effort underway to vaccinate people against the virus has slowed its spread, but challenges remain in persuading millions of reluctant individuals to get their shots. SARS-CoV-2 could become endemic like seasonal influenza, with people learning to live with it, experts say. Meanwhile, researchers around the globe continue to probe COVID-19 from every scientific angle, and probably will do so for years to come.

Jody A. Charnow Editor

Medical Director, Urology

Medical Director, Nephrology

Robert G. Uzzo, MD, MBA, FACS G. Willing “Wing” Pepper Chair in Cancer Research Professor and Chairman Department of Surgery Fox Chase Cancer Center Temple University School of Medicine Philadelphia

Kamyar Kalantar-Zadeh, MD, PhD, MPH Professor & Chief, Division of Nephrology, Hypertension & Kidney Transplantation UC Irvine School of Medicine Orange, CA

Nephrologists Anthony J. Bleyer, MD, MS Professor of Internal Medicine/Nephrology Wake Forest University School of Medicine Winston-Salem, NC

Urologists Christopher S. Cooper, MD Director, Pediatric Urology Children’s Hospital of Iowa Iowa City

David S. Goldfarb, MD Professor, Department of Medicine Clinical Chief New York University Langone Medical Center Chief of Nephrology NY Harbor VA Medical Center

R. John Honey, MD Head, Division of Urology, Endourology/Kidney Stone Diseases St. Michael’s Hospital University of Toronto

Csaba P. Kovesdy, MD Chief of Nephrology Memphis VA Medical Center Fred Hatch Professor of Medicine University of Tennessee Health Science Center Memphis

Stanton Honig, MD Department of Urology Yale University School of Medicine New Haven, CT J. Stephen Jones, MD Chief Executive Officer Inova Health System Falls Church, VA Professor and Horvitz/Miller Distinguished Chair in Urologic Oncology (ret.)

Cleveland Clinic Lerner College of Medicine Cleveland Jaime Landman, MD Professor of Urology and Radiology Chairman, Department of Urology UC Irvine School of Medicine Orange, CA James M. McKiernan, MD John K. Lattimer Professor of Urology Chair, Department of Urology Director, Urologic Oncology Columbia University College of Physicians and Surgeons New York Kenneth Pace, MD, MSc Assistant Professor, Division of Urology St. Michael’s Hospital University of Toronto Vancouver, Canada

Edgar V. Lerma, MD Clinical Associate Professor of Medicine Section of Nephrology Department of Medicine University of Illinois at Chicago College of Medicine Chicago Allen Nissenson, MD Emeritus Professor of Medicine The David Geffen School of Medicine at UCLA Chief Medical Officer, DaVita Inc. Denver Rulan Parekh, MD, MS Associate Professor of Pediatrics and Medicine University of Toronto Robert Provenzano, MD Associate Professor of Medicine Wayne State University School of Medicine Detroit Vice President of Medical Affairs, DaVita Healthcare Denver

Renal & Urology News Staff Editor

Jody A. Charnow

Web editor

Natasha Persaud

Production editor Group creative director Production manager Vice president, sales operations and production National accounts manager Editorial director, Haymarket Oncology Vice president, content, medical communications Chief commercial officer President, medical communications Chairman & CEO, Haymarket Media Inc.

Interested in writing an editorial for Renal & Urology News? Please email Jody A. Charnow, Editor, at jody.charnow@haymarketmedia.com

Kim Daigneau Jennifer Dvoretz Brian Wask Louise Morrin Boyle William Canning Lauren Burke Kathleen Walsh Tulley James Burke, RPh Michael Graziani Lee Maniscalco

Renal & Urology News (ISSN 1550-9478) Volume 21, Number 1. Published quarterly by Haymarket Media, Inc., 275 7th Avenue, 10th Floor, New York, NY 10001. For Advertising Sales & Editorial, call (646) 638-6000 (M–F, 9am–5pm, ET). For reprint/licensing requests, contact Customer Service at custserv@haymarketmedia.com. Postmaster: Send address changes to Renal & Urology News, c/o Direct Medical Data, 10255 W. Higgins Rd., Suite 280, Rosemont, IL 60018. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior written permission of Haymarket Media, Inc. Copyright © 2022.

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Renal & Urology News 3

News in Brief

Please visit us at www.renalandurologynews.com for the latest news updates from the fields of urology and nephrology

Short Takes Drug for Post-Transplant CMV Infection Approved

Urological and Kidney Institute at Cleveland Clinic in Ohio, reported in

Maribavir (Livtencity, Takeda Pharma-

the Journal of Urology. Users of 5ARIs

ceuticals) received FDA approval as

had significant 19% lower odds of

the first drug to treat adults and pedi-

infection compared with nonusers. In

atric patients aged 12 years or older

addition, 5ARI use was not associated

with post-transplant cytomegalovirus

with disease severity, they noted.

(CMV) infection that does not respond CMV. The drug prevents activity of hu-

Kidney Function Decline Predicts Death Risk in LN

man cytomegalovirus enzyme pUL97,

Kidney function decline is an indepen-

thereby blocking virus replication.

dent predictor of mortality among

to available antiviral treatment for

The drug received Breakthrough

patients with lupus nephritis (LN), ac-

Therapy and Priority Review designa-

cording to study published in Lupus.

tions for this indication. Approval was

Seung-Ki Kwok, MD, of Seoul St

based on data from the phase 3 open-

Mary’s Hospital, The Catholic Univer-

label SOLSTICE trial.

sity of Korea, and colleagues examined data from 401 Korean patients

5ARI Use Linked to Lower SARS-CoV-2 Infection Risk

diagnosed with LN from 1985 to

Use of 5-alpha-reductase inhibitors

131 months of follow-up.

(5ARIs) in men without prostate can-

2019, including 53 who died during On multivariate analysis, only final

cer was associated with a significantly

kidney function in the range of chron-

lower risk for community acquired

ic kidney disease stage 4 remained

SARS-CoV-2 infection in a study of

an independent predictor of mortality.

60,474 men tested for the novel

It was significantly associated with

coronavirus that causes COVID-19.

a 5.8-fold increased risk for early

The absolute risk for infection was 42.3% among users of 5ARIs

death, Dr Kwok’s team reported.

The top causes of death in the LN

compared with 47.2% among nonus-

cohort were infection, lupus flare, car-

ers, Madison Lyon, MD, of Glickman

diovascular disease, and malignancy.

Home Dialysis On the Rise The proportion of incident dialysis patients performing home dialysis (shown in green) and patients performing home dialysis at 1 year after dialysis initiation (shown in blue) increased in the United States from 2009 to 2019.

20

18.2%

15

12.6% 10.5%

10

6.8% 5

0

2009

Source: US Renal Data System 2021 Annual Data Report.

2019

Likelihood of AF Therapy Linked to CKD Severity C

hronic kidney disease (CKD) in patients with newly diagnosed atrial fibrillation (AF) is significantly associated with a lower likelihood of receiving treatment for AF, and that likelihood decreases as CKD severity increases, according to investigators.

In a study that included 115,564 patients with newly diagnosed AF receiving care in 2 large integrated health care delivery systems, those with an estimated glomerular filtration rate (eGFR, in mL/min/1.73 m2) of 30-44, 15-29, and less than 15 had a significant 9%, 22%, and 36% decreased likelihood of receiving any AF therapy, respectively, in adjusted analyses compared with those who had an eGFR greater than 60, Nisha Bansal, MD, of the Kidney Research Institute at the University of Washington in Seattle, and colleagues reported in the Journal of the American Society of Nephrology. The investigators defined CKD as an eGFR less than 60. Of the study cohort, 34% had CKD at baseline.

Larger RCC Tumors Predict Worse Post-CN Survival L

arger tumor size is an independent risk factor for poor survival after cytoreductive nephrectomy (CN) for renal cell carcinoma (RCC), investigators reported at the 22nd annual meeting of the Society of Urologic Oncology Among 360 patients (28% female; mean age 61 years) within the 2005-2019 International Marker Consortium for Renal Cancer (INMARC) who received CN and systemic therapy, primary clinical tumor size was 7 cm or greater in 249 patients (69.2%). During follow-up, 218 patients died (61%), including 50 (13.9%) from RCC. In multivariable analyses, clinical tumor size of 7 cm or greater was significantly associated with 2.6- and 1.5-fold increased risks for cancer-specific mortality and allcause mortality, respectively, Ryan Isaac Nasseri, MD, of the University of California, San Diego, reported in a poster presentation. Hypertension was significantly associated with a 3.7-fold increased risk for cancer-specific mortality.

Frailty May Affect Dialysis Vascular Access Maturation G

reater frailty among patients receiving dialysis is associated with longer times to vascular access functional use, according to study findings published in the American Journal of Kidney Diseases.

The finding is from a study of 41,471 patients, of whom 33,212 underwent fistula creation and 8259 who had graft placement. The investigators ascertained frailty using the claims-based frailty indicator (CFI). Higher scores on the CFI indicate greater frailty. Among patients receiving a fistula, 59% and 72.7% of those in the lowest frailty quartile were using their fistula within 6 and 12 months of creation, respectively, compared with 47.2% and 59.3% of those in the highest frailty quartile, Karen Woo, MD, PhD, of the David Geffen School of Medicine at UCLA, and colleagues reported. In the graft placement group, 67.5% and 71.6% were using their graft within 6 and 12 months of creation, respectively, compared with 66.3% and 69.3% of those in the highest frailty quartile.

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Skipping pre-RP biopsy continued from page 1

PET score of 4 or higher on a 5-point Likert scale and maximum standardized uptake value of 4 or higher.

The investigators acknowledged that their study is limited by the retrospective design and small sample size.

“In this small and very carefully selected group of patients, prostate MRI and PSMA-PET imaging were successful in identifying prostate cancer in all patients,” commented Michael Leapman, MD, assistant professor of urology at the Yale School of Medicine in New Haven, Connecticut, who was not involved with the study. “This work is intriguing because it may suggest the possibility of a diagnostic pathway that avoids prostate biopsy, an invasive procedure that is uncomfortable, costly, and does exposure patients to potential risks.”

Dr Leapman, who is clinical program leader of the Prostate & Urologic Cancers

PCSM among blacks continued from page 1

“These findings may have implications for future prostate cancer screening and treatment guidelines.”

Dr Stern and colleaegues noted that Black men are purported to have an increased risk for early and aggressive PCa, which has resulted in recommendations for earlier screening as well as evidence of distinctive treatment patterns. These recommendations, however, lack support by high-quality data, “rendering the validity of these conclusions uncertain.”

The investigators said their findings are consistent with recent pooled analyses of administrative data sets in which adjusting for non-biological differences, including socioeconomic status and health care access, almost eliminated the increased PCSM risk observed among Black men in the United States.

“Data from the Canadian health care system are well suited for studying the

Higher stone rate continued from page 1

increase in stone incidence over recent years, and this trend continues, there is the potential need for substantially increased resource utilization. This would mean an increase in the number of emergency department visits, urologic consults, and the need for interventions such as lithotripsy or placement of stents.”

Program at the Yale Cancer Center, said he interprets the findings with caution “as the consequences of exposing even 1 patient without cancer to prostatectomy is substantial, regardless of how they are counseled. Moreover, widespread use of PSMA-PET and prostate MRI raises questions about long-term cost effectiveness and sustainability.”

“While this is an interesting study, and all men were ultimately found to have treatable cancer, the results should be taken with caution given the variability of MRI reading and the concern for false positives,” observed Sanoj Punnen, MD, MAS, associate professor and vice chair of research in the department of urology at the Miller School of Medicine, University of Miami in Florida.

“Furthermore, the biopsy provides more information about the true grade and extent of tumor within the prostate, and without this we could underestimate or overestimate the burden of cancer, which could lead to misguided management.” ■

association of race and ethnicity and prostate cancer mortality, owing to Canada’s diverse population and universal health care model.”

Similar Findings in the US A recent study of men with PCa in the United States showed no significant difference in PCSM between Black men and White men in an equal-access health care system. The study, led by Brent S. Rose, MD, of the University of California San Diego, compared PCSM between Black and White men using data from the Surveillance, Epidemiology and End Results (SEER) national registry and the Veterans Health Administration (VHA), which provides veterans with equal-access to health care. The study included 311,691 men in the SEER database and 90,749 in the VHA system.

The median follow-up was 5.3 years in SEER and 4.7 years in the VHA. In the SEER group, Black men had significant 32% increased odds for PCSM in Further, this study underscores the critical need to learn what is driving these trends, as well as the importance of dietary and pharmacologic efforts to preventing stone recurrence, according to the investigators.

In multivariate Poisson regression analyses, hypertension and high cholesterol were significantly associated with 79% and 24% increased risks of passing a symptomatic kidney stone in the past 12 months, respectively. Compared

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Renal & Urology News 4

Ablation for RCC Preserves Kidney Function in CKD THERMAL ABLATION for localized

stable during the 12 months f­ollowing

renal cell carcinoma (RCC) preserves

ablation. The average baseline eGFR

kidney function in patients with chronic

was 42.6 mL/min/1.73 m2. At 6 and 12

kidney disease (CKD), according to data

months, the average eGFR was 41.2 and

presented at the 22nd annual meeting

42.2 mL/min/1.73 m2, respectively.

of the Society of Urologic Oncology.

Arighno Das, MD, of the University of

Patients with CKD stage 3a or higher had a significantly worse 5-year

Wisconsin in Madison, and colleagues

recurrence-free survival rate compared

studied 434 patients who underwent

with those who had CKD stage 1 or 2

a total of 520 thermal ablations (either

(73.3% vs 87.5%), but 5-year metas-

cryoablation or microwave ablation) for

tasis-free survival rates did not differ

localized RCC (average 1.3 per patient).

significantly (87.3% vs 91.4%), accord-

The patients had a median tumor size

ing to the investigators.

of 2.7 cm.

Among patients with CKD stage 3 or

Of the 434 patients, 54 (10.4%) had a solitary kidney and 50 (9.6%) had a prior

higher, the average estimated glo-

partial or radical nephrectomy. Patients

merular filtration rate (eGFR) remained

had a median age of 67 years. ■

adjusted analyses compared with White men, Dr Rose and colleagues reported in the Journal of the National Cancer Institute. In the VHA cohort, however, the investigators found no significant increase in risk. In the SEER group, Black men had 23% increased odds of presenting with metastatic disease compared with white men, whereas in

the VHA group, the races did not differ significantly in the odds of presenting with metastatic disease, according to the researchers.

After adjusting for extent of disease, PSA level, and Gleason score, Dr Rose’s team found no association between race and PCSM in the SEER cohort.

Radiotherapy Outcomes A meta-analysis of 7 randomized trials that included a total of 8814 men who received radiotherapy for PCa showed that Black patients have a lower risk for PCSM, biochemical recurrence (BCR), and distant metastases (DM), compared with White patients despite having more aggressive disease.

After adjusting for multiple variables, Black men had a significant 32% decreased risk for PCSM, 21% decreased risk for BCR, and 31% decreased risk for DM compared with White men even though the Black men were more likely to have high-risk disease features, a team led by Amar U. Kishan, MD, of the department of radiation oncology at the University of California, Los Angeles, reported in JAMA Network Open. They found no significant difference in allcause mortality.

The findings suggest that “other determinants of outcome, such as access to care, are important factors of achieving racial equity,” the authors concluded. ■

with White adults, Hispanic, Black, and Asian adults had significant 44%, 68%, and 41% lower risks of passing a kidney stone within the past 12 months, respectively. According to the investigators, historical risk factors for stone prevalence may play less of a role in stone incidence.

The risk of ever having a kidney stone significantly increased 1.4- to more than 2-fold with age categories older than 20-29 years. Compared with White adults, Hispanic, Black, and

Asian adults had significant 24%, 48%, and 49% lower risks for stone history, respectively. Adults in the overweight and obese categories of body mass index (BMI, 25-29.9 and 30 kg/m2 or higher, respectively) had a significant 26% and 44% increased risk for ever having a stone compared with those who had a BMI of 18.5-24.9 kg/m2.

Women had a significant 17% decreased risk for a history of stones compared with men. ■

Recent data may have implications for screening and treatment guidelines.

6 Renal & Urology News

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Urology’s ‘New Normal’ Requires Adaptability of your practices’ functionality,” he said.

“Adaptability, flexibility, and standardization within a practice are more important than ever,” said panelist Kim Ramsey, chief operating officer for Urology of Virginia. “It is an opportune time to change the ‘this is how we’ve always done it mentality.’”

BY JOHN SCHIESZER THE COVID-19 pandemic has dramatically changed how patients are managed. Telehealth platforms are rapidly evolving to allow for sharing of diagnostic imaging and interactive education about disease process and treatment options, according to a panel of experts who spoke at a session called “Re-imagining Our Independent Urology Practices: What’s the New Normal?” at the Large Urology Group Practice Association (LUGPA) 2021 annual meeting.

“Not all follow-up care needs to be done in person. Telepathology has enormous potential for remote testing of urinary and even finger stick blood samples, which can be sent to our labs via commercial parcel companies,” said panelist Thomas Rechtschaffen MD, a urologist with Advanced Urology Centers of New York, a division of Integrated Medical Professionals PLLC, New York, New York.

COVID-19 has forced physicians to reconsider how they provide care.

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true tertiary care centers; responding to nationwide staffing shortages with automation of both front and back office positions using robotic process automation (RPA) and new technology; and adopting collaborative platforms to allow instantaneous cross practice and cross position communication.

to reduce the risk of CV death plus hospitalization for heart failure

He added, “I have been advocating in Washington DC on behalf of the AUA [American Urological Association] for deregulation of telehealth legislation to allow for its expansion and broader access. The regulatory waivers implemented at the start of the pandemic were the proverbial crack in the door we’ve been asking for and has allowed Medicare to reimburse for telehealth services.”

In addition, clinicians should examine all the options for home testing to diagnose patients, Dr Rechtschaffen said. There are steps urologists can take to reduce the likelihood of emergency department visits or inpatient post-operative stays. Currently, many patients are still fearful of going to the hospital during infectious disease outbreaks.

The urology community has now seen what’s possible because of the pandemic. The new tools and modalities now being adopted, however, need to ensure that they benefit both physicians and patients, Dr Rechtschaffen said.

“Challenge your notions about delivery of care and consider all the ways remote care can improve your career satisfaction, your employees’ productivity, your patients’ experience, and the efficiencies 75

Another panelist, urologist Neal Patel, MD, Director of Robotic Surgery at the Advanced Urology Institute of Georgia in Atlanta, said for him “the new normal” of urology means further migration of more complex procedures like robotics and laparoscopy to the outpatient surgical setting, making hospitals

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“Some examples include our outpatient patient urologic robotic program which we established two years ago as the nation’s first non-hospital affiliated true outpatient program in a standalone ASC [ambulatory surgery center].

COVID enabled changes allowed this program to take off which aligned payor, patients and providers,” Dr Patel said.

RPA has allowed his team to develop a reliable automated workforce that

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allows the practice to have software especially in the arena of positions working 24/7 all year round, mimick- that have a large amount of repetitive ing human tasks in the EMR, practice and mundane tasks. “COVID has creadministration, billing, medical records, ated opportunities more than anything and insurance portals. “This allows us else,” Dr Patel said. “I’m a big believer to be less reliant on workforce staffing that quickly and sometimes drastically and talent acquisition costs and de- adapting to major events like COVID crease practice overhead,” Dr Patel said. results in interesting news processes His office experienced challenges in and innovative technology adoptions.” both indirect clinical and non-clinical This new environment resulted in staffing as a result of the pandemic, providers looking at alternatives Renal &many Urology News

Not actual patient.

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ways to run their business in the shortterm, but Dr Patel said it also opened urologists’ eyes to the fact that these same changes could protect and optimize their practice long-term. “What worked before will not work in the future,” Dr Patel said. “Reimbursement for services will stay the same or decline while overhead continues to rise. We need to increase our reliance on automation and less on staffing.” ■

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ADT-Related CV Risks May Be Lower Than Thought first 4 years, according to new real-world data presented at the Society of Urologic Oncology 22nd Annual Meeting.

“This study is what happens in real life,” said lead author Przemyslaw W. Twardowski, MD, from the departments of medical oncology and urologic oncology at Saint John’s Cancer

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The new study analyzed the US electronic medical records of 45,059 men with prostate cancer receiving a luteinizing hormone releasing hormone (LHRH) and News antagonist Renal &agonist Urology

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“The findings are somewhat more optimistic than what might be expected.”

Men with prostate cancer are known to be at an increased risk for cardiovascular (CV) events. A previous study published in BJU International suggested CV event rates over a 10-year

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BY JOHN SCHIESZER THE OVERALL risk for major adverse cardiovascular events (MACE) in men with prostate cancer treated with androgen deprivation therapy (ADT) may be lower than previously assumed, with a rate of 1% during the first year following ADT initiation and 3.7% during the

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i­njections. The team examined the rate of MACE within 6 months and 1 year of ADT initiation. The database contained 965 documented MACE events.

MACE was defined as myocardial infarction, stroke, and death from any cause. The first MACE experience was used for analysis, and events occurring on the day of ADT initiation were excluded. Rates of MACE were calculated for the entire cohort and also for race.

Only men with 6 months and 1 year data points were included in the general analysis.

Within each analysis set, 82% of men were White, 16% were Black, and 2% were Asian. The rate of MACE within 6 months of ADT initiation was 0.5% for the entire cohort, but it varied by race or ethnicity. It was 0.5% for White men, 0.2% for Black men, and 0.0% for Asian men.

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The rate of MACE within 1 year of ADT initiation was 0.8% for the entire cohort (0.9% for White men, 0.4% for Black men, and 0.3% for Asian men).

The risk of MACE was significantly higher in White men compared with Black men for both time periods. “It was against what was expected. It was surprising to me that White men had high rates. I think we need to look at more risk factors in a more granular

Renal & Urology News 9

way,” Dr Twardowski said, adding that future studies need to look at more than just MACE and factor in comorbidities. “The risk may not be as great as we thought,”Dr Twardowski said.”

Christopher Saigal, MD, MPH, professor and vice chair of urology at the David Geffen School of Medicine at the University of California in Los Angeles, said this study will need to be validated because it is uncertain how accurately

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ADT-related CV risks continued from page 9

this one individual health system captured all of the MACE events in this patient population. “It is possible that events occurred at nearby hospitals and were not recorded.”

Anthony V. D’Amico, MD, PhD, chief of the Division of Genitourinary Radiation Oncology at the D ­ ana-Farber

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Cancer Institute and professor of radiation oncology at Harvard Medical School in Massachusetts, said the MACE rates found in the current study are most likely on target as a consequence of improved medical management and new therapeutic agents. “I think the rates are lower because of increased awareness by treating physicians of the potential CV risks of ADT and as a result are proactive in ­assessing

CV risk before initiating ADT and correcting any CV issues,” Dr D’Amico said. “There also could be a shift toward LHRH antagonists, which have a lower risk of MACE.” Eiman Jahangir, MD, MPH, associate professor of medicine at Vanderbilt University in Nashville, Tennessee, said the findings are clinically relevant because they add to the current body of knowledge about how the shift toward

LHRH antagonists may be affecting MACE risk factors. The new findings, however, will need to be replicated in prospective studies, he said. Regardless, all men receiving ADT should be optimized from a cardiovascular risk standpoint, Dr Jahangir said. “Furthermore, as new ADTs are introduced, monitoring for cardiovascular effects is important. There is variability in what each treatment can cause.” ■

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Nonalbuminuric DKD Ups CKD Progression Risk DIABETIC KIDNEY disease (DKD) without albuminuria is significantly associated with higher risks for progression of chronic kidney disease (CKD), hospitalization for heart failure, and death, according to data published in the American Journal of Kidney Diseases.

The findings emerged from a study of 19,025 Chinese adults with type 2 diabetes enrolled in the Hong Kong Diabetes Biobank. Compared with patients who did not have DKD, those with a decreased estimated glomerular filtration rate (eGFR) only, albuminuria only, and albuminuria plus decreased

eGFR had 2.4-, 3.8-, and 14.0-fold increased risks for a composite renal outcome of incident end-stage kidney disease or sustained eGFR reduction of 40% or greater, respectively, after adjusting for confounders, Ronald C.W. Ma, MD, of The Chinese University of Hong Kong, and colleagues reported

in the American Journal of Kidney Diseases. They also had significant 3.1-, 3.1-, and 5.5-fold increased risks of hospitalization for heart failure, respectively, and 1.6-, 2.0-, and 3.3-fold increased risks for all-cause mortality.

In addition, compared with patients who did not have DKD, those with decreased eGFR only had a nonsignificant increased risk for cardiovascular disease and death when baseline eGFR was above 30 mL/min/1.73 m2, according to the investigators.

The study population had a mean age of 61.1 years. The mean duration of diabetes was 11.1 years. During 54,260 person-years of follow-up, 438 patients died and 298 hospitalizations for heart failure and 1161 episodes of CKD progression occurred. ■

Metformin May Affect PCa Risk METFORMIN EXPOSURE in the previous year may increase the risk for prostate cancer, but exposure in the previous 2 to 7 years may lower the risk, according to a recent study.

Rachel Dankner, MD, MPH, of Sheba Medical Center in Ramat Gan, Israel, and colleagues conducted a population-based study of 145,617 men aged 21 to 90 years with newly diagnosed diabetes. Of these, 1592 were diagnosed with prostate cancer over 666,553 person-years of follow-up.

Patients exposed to metformin in the previous year had a significant 53% increased risk for a prostate cancer diagnosis per defined daily dose (DDD) before adjusting for glucose control and a significant 42% increased risk after adjusting for glucose control, Dr Dankner’s team reported in the American Journal of Epidemiology.

Patients exposed to metformin in the previous 2 to 7 years, however, had a significant 42% decreased risk for prostate cancer per DDD without adjusting for glucose control and a nonsignificant 40% decreased risk after adjustment. ■

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IKF Common in Adolescent Anorexia Impaired kidney function may offer a better way to judge anorexia severity, according to researchers IMPAIRED KIDNEY function (IKF) in adolescent patients with anorexia is common and transiently worsens during hospitalization, according to a recent study.

In a study of 395 patients with a mean age of 14.6 years (81.6% girls) recently hospitalized with the psychiatric disorder, IKF was present in 146 (36.8%), Evgenia Gurevich, MD, of Schneider Children’s Medical Center of Israel in Petach Tikva, and colleagues reported in JAMA Network Open. The investigators defined IKF as an estimated glomerular filtration rate (eGFR, in mL/ min/1.73 m2) less than 90.

Among patients with IKF, the mean eGFR decreased during hospitalization, declining from 83.0 at admission to a nadir of 79.1 during hospitalization. It rose to 97.7 at the most recent measurement.

The investigators observed no significant difference in body mass index (BMI) at admission between the patients with and without IKF. The maximal serum creatinine level during hospitalization was significantly higher in the patients with IKF (mean 83 vs 59 mg/dL).

Race Affects Role of SES In Use of PN

White patients, Black patients had significant 34% lower odds of undergoing PN. Compared with White patients in the lowest SES quartile (reference), Whites in the highest quartile had significant 1.2-fold higher odds of PN, whereas Blacks in the lowest and highest SES quartiles had significant 29% and 42% lower odds of PN, the investigators reported.

Within the highest neighborhood SES quartile, Black patients had significant 56% lower odds of receiving PN compared with White patients. In the other quartiles, the races did not differ significantly in the odds of PN, according to the investigators.

The authors acknowledged that their study had limitations. The New York State Cancer Registry database does not describe tumor location in the kidney or patients’ comorbid conditions. In addition, the database does not include information on the location and specific details about the treating hospitals.

Dr Anderson and colleagues pointed out that guidelines support PN as the preferred treatment for small localized renal masses when technically feasible because it offers similar oncologic outcomes to RN but with a lower risk for chronic kidney disease. Despite increasing use of PN for these renal masses, however, many patients who are eligible for PN but receive RN instead are disproportionately patients of color and those with low SES, they noted. ■

A STUDY OF patients in New York City showed that higher socioeconomic status (SES) is associated with a greater likelihood of undergoing partial nephrectomy (PN) for localized renal masses, and the effect of SES varies by race.

As neighborhood SES quartile increased, White patients were significantly more likely to undergo PN, whereas Black patients were not.

Using the New York State Cancer Registry (NYSCAPED), a team led by Christopher B. Anderson, MD, MPH, of Columbia University Irving Medical Center in New York, New York, identified 5,633 patients who underwent PN (61%) or radical nephrectomy (RN, 39%) for localized renal masses from 2004 to 2016. They identified patients’ home neighborhoods through Public Use Microdata Areas in NYSCAPED, which uses US Census-level socioeconomic and demographic data.

A significantly higher proportion of White patients than Black patients received PN (64.7% vs 57.4%), Dr Anderson and colleagues reported in Urologic Oncology. Compared with

Impaired kidney function observed in more than one third of patients.

During hospitalization, serum creatinine increased in those with IKF but remained unchanged in those without IKF. “Since proper hydration could be assured during hospitalization,

this ­finding suggests the presence of a unique yet undefined mechanism other than dehydration,” Dr Gurevich and colleagues wrote.

The patients with IKF had a significantly lower mean minimal eGFR (79.1 vs 112) and a significantly higher serum creatinine to BMI ratio (4.9% vs 3.6%).

Minimal heart rate and free triiodothyronine levels, both physiologic parameters of anorexia severity, correlated with eGFR but not with admission BMI, the investigators reported.

The median length of hospital stay was significantly longer in the IKF than noIKF group (13 vs 8 days).

“Results of this case-control study suggest that impaired kidney function may be a better parameter of anorexia nervosa severity than body mass index,” Dr Gurevich and colleagues concluded.

The investigators compared with anorexia group with a control group of 495 age- and sex-matched patients hospitalized during the same period with other diagnoses. The median BMI percentile at hospital admission was significantly lower in the anorexia group compared with controls (12.3 vs 49). The minimal eGFR was significantly lower in the anorexia than control group (99.8 vs 124).

The mean serum creatinine concentration was in the normal range for anorexia group as a whole, but was higher compared with controls (0.68 vs 0.54 mg/ dL), according to the investigators. The mean serum creatinine level increased significantly during hospitalization and then decreased to a lower than admission value in the anorexa group. The level was 0.66 mg/dL at admission and reached a maximum of 0.68 mg/dL, and was 0.60 mg/dL at hospital ­discharge. ■

Men Found to Be More Likely Than Women to Start Dialysis AMONG PATIENTS with chronic kidney

during the first 12 months after study

disease (CKD), men are more likely than

enrollment and first eGFR value after

women to start dialysis, a sex-related

enrollment. After adjusting for all of

difference not explained by CKD pro-

these variables, the investigators found

gression alone, a study found.

no significant difference between

“Although the causal mechanisms are

the sexes in the likelihood of kidney

uncertain, this finding helps interpret

transplantation or death prior to kidney

the preponderance of men in the dialy-

replacement therapy (KRT).

sis population,” Manfred Hecking, MD,

For the overall study population,

PhD, of the Medical University of Vienna

93% of KRT initiations among men and

in Austria, and colleagues reported in

women were dialysis. Interestingly, the

Kidney International Reports.

investigators noted, France had a mark-

Dr Hecking and colleagues studied

edly higher percentage of patients whose

8237 patients (4811 men and 3426

initial mode of KRT was kidney trans-

women) with CKD stages participating in

plantation (13% for both men and women)

the Chronic Kidney Disease Outcomes

compared with the other countries.

and Practice Patterns Study (CKDopps).

Dr Hecking’s team stressed that they

The patients were from the United

were unable to identify factors explain-

States, Brazil, France, and Germany.

ing why men and women differed in their

During a median follow-up duration

likelihood of starting KRT, “as all the

of 2.57 years, 23% of the men initiated

available variables adjusted for in the

KRT compared with 18% of women.

analysis did not explain this difference.”

Men had a significant 50% increased

They added, “Awareness that treat-

likelihood of starting dialysis compared

ment of women may differ from the

with women, after adjusting for age,

treatment of men is important for the

Black race, diabetes, cardiovascular

nephrological community and should

disease, albuminuria, and estimated

be openly discussed and further

glomerular filtration rate (eGFR) slope

investigated.” ■

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Renal & Urology News 13

How to Protect Your Online Reputation Medical practices need to ensure they show up in Google local search results with correct information

BY JOHN SCHIESZER IT IS TIME to show up and look good on the Internet just to protect your medical practice’s reputation, according to Brian Dooley, founder of Independence Digital of Niles, Michigan, a medical practice marketing agency specializing in reputation management and digital marketing.

Dooley led a session called “Reputation Management in 2021 and Beyond: 5 Keys to Standing Out on Google” at the LUGPA 2021 annual meeting.

Patient Reviews Important “Most patients looking for a new doctor start on Google. Making sure your practice shows up in Google’s local search results is critical for attracting these new patients,” Dooley said.

However, showing up in these results is only half the battle. Google also displays star ratings alongside these listings. “If your practice shows up but has a poor rating, you could be losing out on new patients. Getting more reviews from your patients will help increase your visibility and likelihood of attracting new patients,” Dooley said.

He presented an example of someone searching for a “urologist near me.” It

is not enough just to show up in the top 3 search results. Physicians also have to make sure their rating is high enough to attract new patients. Google listings are their own entity, separate from a website. Each doctor or practice should have full control over their listings. Once urologists have access, they need to update their listings with correct information. Most important are the name, address, and phone number.

“Google thinks it’s being helpful by creating listings and guessing [at] the information, but often that does more harm than good. Sometimes a doctor will have several listings that Google has created automatically, but only 1 or 2 have accurate information,” Dooley warned. He noted that a urologist in Minnesota had 8 different listings created by Google with different phone numbers and addresses. Only 1 phone number and 1 address were correct.

“We helped remove the bogus listings, so it was crystal clear to patients how to contact and find this doctor,” Dooley said.

Doctors need to optimize their Google listings by adding as much information as possible. This includes adding relevant keywords to their bio, uploading pictures, and posting more reviews, he said.

Most patients start their search for a new doctor using Google.

Removing Friction They also need to reduce friction, the unnecessary expenditure of time, effort, or money in performing a task.

Reducing friction in any process makes it more efficient and therefore more likely to happen, Dooley said. When asking for reviews for a medical practice, doctors should make the process as easy as possible for patients. “We’ve found email requests with direct links to be the most effective way to get more

reviews,” Dooley said. “We recommend personal-looking emails to increase the response rate. It also reduces the chances of an upset patient writing a bad review.”

If patients are upset, they will usually respond to this type of email because it gives them a chance to solve the problem before it turns into a bad review online.

One of the best ways to leverage reviews is on a medical provider’s website.

Testimonials can be a powerful form of persuasion. “This is especially true if the content is relevant to the reader.

Adding reviews to your website also adds additional content and keywords to your website, which can help people find you on Google searches,” Dooley said.

Reputation management, however, is more than just getting good reviews.

Accurately listing information improves patient access and reduces the no-show rate. By taking these simple steps a medical practice can have a good rating and hopefully attract new patients who can improve the payer mix, Dooley said.

“Leaving your online reputation up to chance usually means profiles filled with errors and ratings determined by your most unreasonable patients, not the happy majority,” he said. ■

Strategies for Recruiting Women Urologists

© PRYKHODOV / GETTY IMAGES

BY JOHN SCHIESZER MANY UROLOGY PRACTICES are actively recruiting women urologists, but tough competition for available candidates means practices need to do more than post a job listing.

During a panel session titled LUGPA Forward Session – Strategies to Recruit and Retain Female Urologists in Your Practice at the LUGPA 2021 annual meeting, urologists were told a great compensation package is mandatory, and due to higher amounts of educational debt for women, offering debt forgiveness as part of the package may be helpful. Further, all urology practices must to have a maternity/paternity leave policy.

What Census Data Show Data presented from the 2019 Resident & Fellow Census showed female residents took 6.4 weeks maternity leave on average compared with 1.6 weeks paternity leave among male residents. The data showed

that 85% of residents and 72% of fellows reported paid maternity/paternity leave.

Approximately 10.3% of practicing urologists and 30% of urology residents are women. The census showed that roughly

Practice websites that show a lack of physician diversity could be a turnoff.

23% of female urology residents planned on entering private practice compared with 39% of male residents.

Panel moderator Tim Richardson, MD, chair of LUGPA Forward, said there is high demand and a shortage of new urologists wanting to enter independent practice. “A growing proportion of urologists in training are women. However, very few of them

decide to enter into independent practice. We in independent urology need to adapt and conform to be a more attractive option for women coming out of training,” Dr Richardson said.

Having a maternity leave policy is extremely important, and often a paid maternity leave policy is required to entice a woman urologist to join a group. “Be open-minded and if possible, reach out to women urologists in training and find out what is important to them and what is needed to be an attractive option for them entering a practice,” Dr Richardson said.

‘Not a Vacation’ Panelist Jennifer Miles-Thomas, MD, president of Urology of Virginia, agrees, noting that maternity leave is a much bigger factor today than it was 10 years ago.

“Maternity leave is important,” Dr MilesThomas said. “We should not require one gender to be penalized professionally

or economically for biological differences.

Policies matter. Maternity leave is not a vacation. The world is constantly changing and urology will need to adapt.”

Most women residents are not interested in becoming the first woman to join a medical practice. Panelists said it may be easier to recruit and retain women if the group already has women urologists. Surveys suggest that the culture of a medical practice is paramount for women candidates. It was noted that the “frat boy culture” is a turn-off.

Recruitment of women urologists should begin with practices’ websites, panelists said. This is where women candidates will usually start when sizing up a practice. Urology practice websites that show no signs of diversity among physicians could be a turnoff.

The panelists recommend having an “about our providers” section on the website to highlight the culture and diversity of an organization. ■

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Predictors of NMIBC Upstaging Identified Risk factors include advanced age and lymphovascular invasion, and other histologic features PATHOLOGIC UPSTAGING among patients with nonmuscle-invasive bladder cancer (NMIBC) is more likely among older patients and those with lymphovascular invasion (LVI) and other histologic features, according to recent study findings presented at the 22nd Annual Meeting of the Society of Urologic Oncology.

The findings are from a study of 8620 patients with NMIBC who underwent radical cystectomy (RC), of whom 3100 (36%) were upstaged. Age 80 years or older was significantly associated with 1.6-fold greater odds of upstaging compared with age less than 60 years, Ahmed Elshabrawy, MD, and colleagues from UT Health San Antonio in Texas, reported in a poster presentation. LVI was significantly associated with 7.7-fold greater odds of upstaging compared with no LVI. Sarcomatoid and squamous histologies were signifi-

LN Remission Lowers Fetal Loss Risk Rate WOMEN WITH LUPUS nephritis (LN) who have a complete renal remission prior to pregnancy tend to experience good fetal outcomes and less LN relapse, a new study finds.

Investigators analyzed the pregnancy outcomes of 158 pregnancies in 155 Chinese patients with LN. Of these, 130 patients had achieved complete renal remission (CRR) and a systemic lupus erythematosus disease activity index 2000 (SLEDAI-2K) of 4 or lower prior to pregnancy, and 25 patients had not. CRR was defined as proteinuria less than 0.5 g/24 h, no active urinary sediment, serum albumin 35 g/L or higher, and normal serum creatinine.

The remission group had significantly lower rates of LN relapse (11.3% vs 72.0%), LN relapse in early pregnancy (3.0% vs 44.0%), fetal loss (5.3% vs 20.0%), and premature birth (23.3% vs 48.0%) compared with the control group.

The odds of LN relapse significantly increased 11.2- and 5.2-fold in patients with a pre-pregnancy CRR duration of less than 18 months and anti-C1q antibody positivity, respectively, Weixin

cantly associated with 1.4- and 6.4-fold greater odds of upstaging, respectively, compared with urothelial disease.

The study also identified predictors of RC, which included younger age, male gender, treatment at academic medical centers, and the presence of LVI and

Pathologic upstaging is associated with significantly worse survival, data show. ­ istologic variants. Compared with h patients younger than 60 years, those aged 80 years or older had 76% lower odds of RC. Male vs female sex was significantly associated with 22% greater odds of RC. Treatment at academic medical centers was significantly ­associated

Hu, MD, and colleagues from Jinling Hospital, Nanjing University School of Medicine in China, reported in Nephrology Dialysis Transplantation.

The odds of fetal loss significantly increased 9.3-fold with anti-phospholipid antibody positivity, and the odds of premature birth significantly increased 3.9-fold with a prednisone dosage of 12.5 mg/d or higher during pregnancy. Age older than 30 years was an independent risk factor for both preeclampsia and premature birth.

Current guidelines for the management of pregnancy in LN patients are mostly based on patients with SLE, but the risk of LN relapse during pregnancy is 2- to 3-fold higher in LN, the investigators noted.

According to Dr Hu’s team, “our study showed that LN patients with complete renal remission for more than 18 months were associated with good pregnancy outcomes and lower LN relapse during pregnancy.”

For immunosuppression during pregnancy, the remission group received prednisone (82.7%), prednisone plus a calcineurin inhibitor (7.5%), or prednisone plus azathioprine (4.5%). Fewer patients in the control group received prednisone alone (28.0%), and more received prednisone plus a calcineurin inhibitor (56.0%) or plus azathioprine (12.0%). Medications contraindicated in pregnancy were discontinued. ■

with 7.2-fold greater odds of RC. The presence of LVI, compared with its absence, was significantly associated with 4.0-fold greater odds of RC. Pure urothelial vs variant histology was significantly associated with 60% lower odds of RC. Upstaged patients had significantly lower 5-year overall survival compared with patients who were not upstaged (40% vs 71%). Positive surgical margins and neuroendocrine or sarcomatoid variants were significantly associated with higher death risks.

“On a nationwide level, predictable adverse pathological features are associated with pathological upstaging,” the investigators concluded in their poster.

This upstaging is associated with significantly poor overall survival, especially in patients with non-organ-confined disease, they noted.

“These features should be considered when counseling patients regarding

early radical cystectomy,” they wrote.

The lower odds of RC among older patients observed in the current study can be attributed to multiple factors, said senior author Ahmed M. Mansour, MD. For example, the procedure is associated with greater morbidity among older patients, he explained.

Thus, older patients might opt for other treatment.

In a paper published recently in Urologic Oncology (2021;39:236.e9-236. e20), he and his colleagues reported findings from a study of 74,159 patients with muscle-invasive bladder cancer showing that 5.4% refused RC despite physician recommendations. On multivariate analysis, predictors of RC refusal included advanced age (80 years or older vs younger than 60 years), Black race, and female sex. Median survival after RC was 40.4 vs 12.5 months in refusal group, according to the investigators. ■

Dyskalemias Before Hemodialysis Sessions May Increase Mortality LOW AND HIGH serum potassium levels

The study included 1117 incident

before hemodialysis (HD) sessions are

HD patients older than 18 years from

associated with an increased risk for

the Netherlands Cooperative Study on

death, according to a recent prospec-

the Adequacy of Dialysis. Researchers

tive study of adult patients new to HD.

followed up patients from their first

Predialysis levels of 4.0 mmol/L or

HD treatment until death, transplanta-

lower and levels higher than 6.0 mmol/L

tion, switch to peritoneal dialysis, or a

are associated with 1.4- and 1.3-fold

maximum of 10 years.

increased risks for 6-month all-cause

At baseline, the study population

mortality, respectively, in adjusted analy-

had a mean age of 63 years; 58% of

ses compared with an optimum level

patients were men, 26% smoked, 24%

of about 5.1 mmol/L, Esther N.M. de

had diabetes, and 32% had cardiovas-

Rooijj, MD, of Leiden University Medical

cular disease. The mean serum potas-

Center in Leiden, The Netherlands, and

sium level was 5.0 mmol/L. In addition,

colleagues reported in Kidney Medicine.

7% had low subjective global assess-

“If proven causal, the clinical implica-

ment scores. The median residual kid-

tion of these results is that potassium-

ney function was 3.5 mL/min/1.73m2.

lowering therapy should be used

A total of 555 deaths occurred during

with caution in hemodialysis patients

10 years of follow-up.

with normal or low serum potassium

The authors noted that, to their knowl-

level before the dialysis session,” the

edge, their study is the first to include

investigators reported. “Furthermore,

only incident HD. “All previous studies

as low predialysis serum potassium

investigating the relation between

could result from malnourishment, the

predialysis serum potassium and death

associated mortality risk emphasizes

included mainly prevalent hemodialysis

the importance of preventing nutritional

patients, thus being susceptible to

disorders in hemodialysis patients.”

survivor bias,” they wrote. ■

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RFA Found Safe, Effective for Refractory SHPT MINIMALLY invasive radiofrequency ablation (RFA) can treat refractory secondary hyperparathyroidism (SHPT) with relative safety and efficacy compared with surgery, according to investigators.

In a retrospective study, 80 patients on dialysis who had parathyroid h ­ ormone (PTH) levels exceeding 800 ng/mL

underwent ultrasound-guided RFA or parathyroidectomy with autotransplantation (PTx + AT) from January 2018 to February 2021. Compared with baseline, PTH levels had significantly declined at day 1 (160.7 and 226.6 ng/ mL), day 7 (184.6 and 122.3 ng/mL), and 6 months (272.1 and 488.2 ng/mL) in

the RFA and PTx + AT groups, respectively. Serum calcium, serum phosphorus, and visual analog scale scores also significantly declined from baseline in both groups, according to findings published by Song-Song Wu, MD, of Fujian Provincial Hospital in China, and ­colleagues in Kidney International

Reports. Significant between-group differences in these biochemical parameters largely diminished by 3 months.

Recurrent laryngeal nerve injury occurred in more patients in the RFA than PTx + AT group (26.7% vs 16.7%, respectively) but the difference was nonsignificant. However, RFA significantly decreased the risk of severe hypocalcemia (20% vs 46.7%) and led to a significantly shorter hospital stay (7.53 vs 12.13 days) compared with PTx + AT, the researchers reported.

At 6 months, SHPT recurrence rates were comparable between groups: 23.3% RFA vs 30% PTX + AT group.

“Taken together, RFA is associated with less injury, faster recovery, fewer complications, and a significantly lower risk of postoperative [severe hypocalcemia] compared with PTX + AT, while achieving similar clinical efficacy, improvement in clinical symptoms, and long-term recurrence rate,” the investigators concluded. ■

High-Dose IV Iron in HD Cuts MI Risk HIGH-DOSE intravenous (IV) iron reduces the risk for acute myocardial infarction (MI) in patients receiving maintenance hemodialysis compared with low-dose IV iron, researchers reported in Cardiovascular Research.

The findings are from both a prespecified and post hoc analysis of the Proactive IV Iron Therapy in Hemodialysis Patients (PIVOTAL) randomized trial, which included 2141 patients with a ferritin concentration less than 400 µg per liter and a transferrin saturation less than 30%. Over a median 2.1 years, 8.4% of patients experienced a fatal or nonfatal MI. In time-to-first event analyses, proactive high-dose IV iron reduced the risk for nonfatal and fatal MI by a significant 31% compared with reactive low-dose IV iron, Mark C Petrie, MD, of the University of Glasgow in Glasgow, UK, and colleagues reported. High-dose IV iron reduced the risk for type 1 MI by a significant 29% but did not reduce the risk for nonfatal type 2 MIs. ■

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KT Candidates Hit Hard by COVID-19 Waitlisted kidney transplant candidates and kidney transplant recipients experienced excess deaths

BY NATASHA PERSAUD Kidney transplant (KT) candidates and recipients in the United States experienced excess deaths in 2020 related to COVID-19, with a disproportionate number of those deaths occurring among minorities, according to a study of nationwide registry data from the United Network for Organ Sharing.

Together, Black and Hispanic patients accounted for 72% of COVID-19related deaths among waitlisted candidates and 62% of COVID-19-related deaths among kidney transplant recipients, Sumit Mohan, MD, PhD, of the Columbia University Vagelos College of Physicians and Surgeons in New York, New York, and colleagues reported in the Clinical Journal of the American Society of Nephrology.

“The excess risk of COVID-19 mortality for both candidates and recipients may alter the amount of benefit associated with transplantation and impact clinical decision-making,” Dr Mohan’s team wrote.

Waitlisted Patients Of 134,948 patients on a kidney transplant waitlist in 2020, a total of 4774 died, including 516 (11%) from COVID19-related causes. The ­investigators

Death While on a Waiting List Kidney transplant candidates who died from COVID-19 in 2020 were significantly more likely to be male, obese, and belong to a racial/ethnic minority.

100 80 60

n Male n Obese candidates n Racial/ethnic minority

85%

72% 53%

40

65% 45%

60%

20 0

COVID-19-related death

Death from other causes

Source: Mohan S, et al. COVID-19-associated mortality among kidney transplant recipients and candidates in the United States. Clin J Am Soc Nephrol. Published online ahead of print October 21, 2021.

found that a greater proportion of male waitlist candidates died from COVID-19-related causes than from other causes (72% vs 65%) and at a higher rate compared with the same period in 2019 (63%). Racial and ethnic minorities were more likely to die from COVID-19 than from other causes (85% vs 60%), as were obese candidates (53% vs 45%), according to the investigators.

Among White transplant candidates, 15% died from COVID-19-related causes and 40% died from other causes in 2020, and 39% died from any causes

in 2019. By comparison, the death rates were 34%, 31%, and 32% among Black candidates, respectively, and 37%, 19%, and 19% among Hispanic candidates, respectively.

Transplant Recipients Among 190,481 transplant recipients in 2020, a total of 5435 died, including 893 (16%) from COVID-19-related causes.

Recipients who died from COVID-19 were younger than recipients who died from other causes (median age 65 vs 68 years). They also were more likely to be obese (body mass index of 30 kg/m2

or higher). In 2020, 44% died from COVID-19-associated causes and 36% died from non-COVID-19 causes. In 2019, prior to the COVID-19 pandemic, 36% died from all causes, Dr Mohan and colleagues reported.

Among White recipients, 30% and 54% died from COVID-19-associated complications and causes not related to COVID-19, respectively, in 2020, and 59% died from any cause in 2019, the researchers reported. Among Black recipients, 31% died from COVID19-associated causes and 25% died from causes not related to COVID-19 in 2020, and 24% died from any cause in 2019. The rates were 31%, 13%, and 11% among Hispanic recipients.

Dr Mohan’s team found that the allcause mortality rate in 2020 was higher among waitlisted candidates (24%) than among kidney transplant recipients (20%) compared with 2019.

“Although 11% of deaths on the waitlist in 2020 were attributed to COVID19, the remainder of the difference in mortality observed is also likely to be COVID-19 related to the extent that the pandemic has adversely impacted access to and delivery of health care, particularly during the peak of the initial surge,” the investigators wrote. ■

CKD Care Differs by Race, Ethnicity, Study Finds AMONG PATIENTS with nondialysis-dependent chronic kidney disease (CKD), racial and ethnic minorities are more likely than White individuals to receive guideline-directed care in several key areas, a new study finds. Black and Hispanic patients, however, are less likely to have their high blood pressure and diabetes under control.

Of 452,238 commercially insured and Medicare Advantage patients with CKD who received care during 2012 to 2019, 1.7% were categorized as Asian, 11.0% Black, 3.4% Hispanic, and 83.8% White.

Investigators led by Chi D. Chu, MD, MAS, of the University of California, San Francisco, identified CKD care delivery measures based on Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines. Use of ACE inhibitors and angiotensin II receptor blockers was higher among Black (76.7%), Hispanic (79.9%), and Asian (79.8%) patients compared with White

patients (72.3%) in 2018-2019, they reported in JAMA Network Open. Statin use was also higher among minority groups — Black (69.1%), Asian (72.6%), and Hispanic (74.1%) — compared with White patients (61.5%). Avoidance of long-term prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) was consistently greater than 80% across all racial groups. Predialysis nephrology care was received by greater proportions of non-White (64.8% Asian, 69.4% Hispanic, and 72.9% Black) compared with White patients (58.3%), the investigators reported. Albuminuria testing occurred in 41.0%, 52.6%, and 53.9% of Black, Hispanic, and Asian patients, respectively, but only 30.7% of White patients. Compared with White patients, Black, Hispanic, and Asian patients with an estimated glomerular filtration rate less than 30 mL/min/1.73 m2 had significant 73%, 61%, and 32% increased odds of receiving nephrology care,

r­ espectively, in a fully adjusted model.

Black, Hispanic, and Asian patients also had 14%, 63%, and 113% increased odds of albuminuria testing, respectively.

Although minority groups received guideline-recommended care in key areas, a lower proportion of Black patients

Black and Hispanic patients are less likely to have their diabetes under control.

(63.3%) achieved blood pressure control to less than 140/90 mm Hg, compared with Hispanic (69.8%), Asian (71.8%), and White patients (72.9%). Diabetes control to a hemoglobin A1c target of less than 7.0% occurred in 46.0% and 49.3% of Hispanic and Black patients, respectively, compared with 50.1% and 50.3%

of Asian and White patients, respectively. Using White patients as the reference group, Black, Hispanic, and Asian patients had significant 30%, 16%, and 14% decreased odds of blood pressure control and 6%, 21%, and 7% decreased odds of glycemic control, respectively.

“Lower achievement of blood pressure and glycemic targets despite better performance on process-type care delivery measures suggests that more aggressive health care — testing, prescribing, and referring to match guideline recommendations — is likely inadequate in isolation for narrowing health disparities,” Dr Chu’s team concluded.

“An alternative might be exploring how interventions addressing social determinants of health (eg, food insecurity, housing instability, and health literacy) may help mitigate the burden of CKD risk factors and health consequences among non-White individuals, including Black and Hispanic persons.” ■

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Antibodies to COVID-19 Vaccines Wane Quickly in Dialysis Patients Decline is associated with a higher risk for breakthrough infection ANTIBODY RESPONSES to vaccination against SARS-CoV-2, the coronavirus that causes COVID-19, wane quickly in patients receiving dialysis, and this decline is associated with an increased risk for breakthrough infection, new data suggest.

The findings are from a prospective case-control study of a nationwide sample of 4791 patients in which investigators examined the relationship between levels of vaccine-induced antibodies to the receptor-binding domain (RBD) of SARS-CoV-2 and development of breakthrough infection. They matched each breakthrough case patient to 5 control patients by age, sex, and vaccination month and adjusted for diabetes status and region of residence. The study population had a mean age of 63.4 years. The racial or ethnic composition was 29.7% nonHispanic White, 23.4% non-Hispanic Black, 13.3% Hispanic, and 14.3% non-Hispanic “other.” Information on race or ethnicity was missing for 19.4% of patients.

Among the 2563 fully vaccinated patients, the estimated proportion with an undetectable antibody response

Investigators studied 4791 dialysis patients vaccinated against SARS-CoV-2.

increased from 6.6% 14-30 days after vaccination to 20.2% 5-6 months after vaccination, Shuchi Anand, MD, of Stanford University in Palo Alto, California, and colleagues reported in Annals of Internal Medicine. Estimated median index values decreased from 91.9 14-30 days after vaccination to 8.4 5-6 months after vaccination.

During a median follow-up period of 152 days, clinically documented

COVID-19 developed in 56 (2%) of the fully vaccinated patients.

Compared with pre-breakthrough index RBD antibody values of 23 or higher (equivalent to 506 binding antibody units [BAU]/mL or greater), prebreakthrough RBD values less than 10 (equivalent to 218 BAU/mL) and values from 10 to less than 23 were significantly associated with an 11.6- and 6.0fold greater likelihood of breakthrough infection, respectively, Dr Anand and colleagues reported.

“Our analysis suggests that a majority of vaccinated patients have circulating antibody levels 5 months after vaccination that render them vulnerable to a breakthrough infection,” the authors wrote. “Although the overall number of breakthrough infections was low, even in the group with low antibody levels, exposure to SARS-CoV-2 is not uniform and patients are likely to have used other mitigation strategies, such as masking and social distancing.”

The investigators acknowledged that reliance on a single measure of vaccine response and ascertainment of COVID19 diagnoses from electronic medical records were study limitations. ■

Extended PLND During RP May Up Survival EXTENDED PELVIC lymph node dissection (PLND) during radical prostatectomy for intermediate- and highrisk prostate cancer (PCa) is associated with improved survival, according to data presented at the 22nd annual meeting of the Society of Urologic Oncology.

Study demonstrates benefit of removing 10 to 19 lymph nodes vs less than 10.

In a propensity score analysis, removal of 10 to 19 lymph nodes was significantly associated with a 14% decreased risk for death compared with removal of less than 10 lymph nodes among patients with intermediate-risk PCa, Furkan Dursun, MD, of the University

of Texas Health San Antonio, reported on behalf of his research team. Removal of 20 or more lymph nodes was significantly associated with a 39% decreased risk for death among patients with high-risk PCa. The study included 103,250 patients identified using the National Cancer Database. Of these, 74.2% and 25.8% had intermediate- and high-risk PCa. The number of excised lymph nodes was less than 10 for 80.5% of patients, 10 to 19 for 15.9%, and 20 or more for 3.6%. In both the intermediate- and high-risk groups, pathologically proven lymph node-­ positive disease rates were significantly higher among patients with 20 or more excised lymph nodes compared with those who had fewer than 10 and 10-19 excised lymph nodes (9.25% vs 1.53% and 4.45% for intermediate-risk patients and 25.25% vs 5.65% and 15.53%, respectively, for high-risk patients).

Dr Dursun and colleagues defined intermediate-risk PCa as cT2b-2c and/or PSA level 10-20 ng/mL and/or Grade Group 2 or 3 disease and highrisk PCa as cT3 or higher and/or PSA level greater than 20 ng/mL, and/or Grade Group 4 or 5.

The study adds to the literature on the value of performing extended PLND during radical prostatectomy.

For example, results of a randomized controlled trial published in European Urology (2021;79:595-604) showed that while extended vs limited PLND improved pathologic staging, it did not improve early oncologic outcomes, including the primary endpoint of biochemical recurrence-free survival.

The trial included 300 patients with intermediate- or high-risk prostate cancer randomly assigned to undergo limited or extended PLND (150 patients in each group). ■

Long-Term PCa Mortality Described MORE THAN half of deaths from prostate cancer (PCa) in the United States occur among men initially diagnosed with low-grade disease, according to the findings of a large populationbased study presented at the Society of Urologic Oncology 22nd annual meeting.

Using data from the US Surveillance, Epidemiology and End Results (SEER) program, Roderick Clark, MSc, of the University Health Network in Toronto, Ontario, Canada, and Steven Narod, MD, of the Familial Breast Cancer Research Unit at Women’s College Hospital, also in Toronto, analyzed long-term prostate cancer mortality rates in a population-based study that included 116,796 men diagnosed with PCa during 1992-1997.

Of the 116,796 men, 21,896 died from PCa. Most of these deaths (55.6%) occurred among men initially diagnosed with low-grade disease, with most deaths occurring more than 5 years after diagnosis, the investigators reported. Among men initially diagnosed with high-grade disease, most PCa deaths (54.3%) occurred within the first 5 years of diagnosis.

Overall, the annual PCa-specific mortality (PCSM) rate was 1.5%, but the rate increased with age at diagnosis, from 0.9% among men younger than 60 years to 1.2% and 2.1% for those 60-70 and older than 70 years, respectively.

Among men older than 60 years with low-grade PCa, annual diseasespecific mortality rates increase continuously with time from diagnosis, according to the investigators.

The overall 10- and 20-year PCaspecific survival rates were 84.6% and 74.5%, respectively. The proportion of PCa deaths during years 1-10 and 10-20 after diagnosis were 69.3 and 25.6%, respectively. These figures varied by age. The 10- and 20-year PCa-specific survival rates were 90.2% and 83.7%, respectively.

The proportion of PCa deaths during years 1-10 and 10-20 were 60.3% and 33.1%, respectively. ■

© MARKO GEBER / GETTY IMAGES

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Case Finding Better for CKD Detection Targeting at-risk individuals is more efficient than population-based screening, study confirms

BY JODY A. CHARNOW Case finding is more efficient and cost-effective than population-based screening for early detection of chronic kidney disease (CKD), recent study findings suggest.

“Case finding was associated with a significant decrease in the number of individuals who required [estimated glomerular filtration rate (eGFR)] testing and increase in the proportion of individuals with CKD for whom a treatment change was indicated,” Marcello Tonelli, MD, MSc, of the University of Calgary in Calgary, Canada, and colleagues concluded in JAMA Network Open.

For the study, Dr Tonelli’s team analyzed data from population-based samples from China, India, Mexico, Senegal, and the United States. A total of 126,242 adults were screened for CKD. The investigators defined screening as measuring eGFR in all participants and case finding as measuring eGFR in a subset of participants at elevated risk for CKD (those with a self-reported history of hypertension, diabetes, or CKD, or with BP levels of 140/90 or higher or with laboratory evidence of diabetes, hemoglobin A1c [HbA1c] levels of

6.5% or higher, or fasting blood glucose levels of 126.1 mg/dL or higher depending on the cohort). For individuals with CKD, the need for a treatment change was defined as not taking an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) or having BP of 140/90 mm Hg or higher. For participants with CKD who also had diabetes, the need for a treatment change was also defined as having HbA1c levels of 8% or higher or fasting glucose levels of 178.4 mg/dL or greater.

Screening vs Case Finding The prevalence of CKD, as defined by an eGFR less than 60 mL/min/ 1.73 m2, was 2.5%, 2.3%, 10.6%, 13.1%, and 6.8% in the China, India, Mexico, Senegal, and US cohorts, respectively, Dr Tonelli and colleagues reported.

Screening for CKD was associated with the identification of additional adults whose treatment would change (beyond those identified by measuring BP and glycemia) per 1000 adults, according to the investigators. In all cohorts, fewer than 15% of participants with CKD were aware that they had it. Among those with CKD, treatment gaps were relatively c­ ommon, ranging from 68.7% to 97.8% of cases.

In contrast, case finding was associated with the identification of 46.2% to 86.4% of individuals with CKD depending on the country, an increase in the proportion of individuals requiring a treatment change by as much as 89.6% in the US, and a decrease in the proportion of individuals needing eGFR measurements by as much as 57.8% in the US. “Measuring eGFR or albuminuria was not associated with frequent identification of an indication for a treatment change, suggesting that CKD screening programs may not be associated with a benefit for most participants,” the authors wrote.

The investigators ascertained use of ACEI and ARBs, medications known to prevent progressive loss of kidney function in patients with CKD. The investigators defined adequate BP control as levels less than 140/90 mm Hg, but noted that American College of Cardiology and American Heart Association (ACC/AHA) guidelines recommend a BP target of less than 130/80 mm Hg for nearly all adults, including those with CKD. “If blood pressure control were defined as in this guideline, a smaller number of individuals would have con-

trolled BP and the potential benefit associated with screening for CKD would be smaller than we estimated in this study.”

“These findings suggest that measuring eGFR or albuminuria in population-based screening programs may not be associated with more frequent identification of an indication for a change in treatment in comparison with simply

Researchers analyzed data from the US, India, China, Mexico, and Senegal. measuring blood pressure, inquiring about antihypertension medication use, assessing glycemic control, and first-line use of ACEI or ARB therapy among individuals with diabetes or hypertension.”

SGLT2 Inhibitor Use Not Considered Dr Tonelli’s team acknowledged that they did not consider the use of statins and sodium-glucose cotransporter-2 (SGLT2) inhibitors, which continued on page 26

Video May Improve Precision Medicine for PCa

BY JOHN SCHIESZER AN EDUCATIONAL video that informs men about genetic testing may provide an attractive alternative to genetic counseling (GC), according to findings from a recent study.

Thousands of men are eligible for prostate cancer genetic testing to

More men chose to watch an educational video than receive genetic counseling. inform precision therapy, screening, and hereditary cancer risk, but a shortage of trained genetic counselors is a barrier to testing. Counseling patients with an educational video could address this issue.

First Real-World Study “This is the first study with real-world data to publish on a pretest video in a male population in the context of prostate cancer germline testing,” said lead investigator Veda N. Giri, MD, a medical oncologist at the Sidney Kimmel Cancer Center at Thomas Jefferson University in Philadelphia, Pennsylvania, where she is director of Cancer Risk Assessment and Clinical Cancer Genetics. “Results are supportive of practice change for alternate delivery of pretest information for men to make an informed decision for genetic testing.”

The findings, published in JCO Precision Oncology, are from the Evaluation and Management for Prostate Oncology, Wellness, and Risk (EMPOWER) Study, which included 127 men asked to choose between pretest video-based genetic education

(VBGE) or GC. Of these, 90.6% had prostate cancer and 85.7% had a family history of cancer. Study participants had a mean age of 65.5 years. The cohort was 85.8% White, 67% had at bachelor’s degree or higher, and 78% were married or living with a partner.

The 11-minute video addressed cancer inheritance, purpose of testing, risks and benefits of testing, multigene panel options, and types of potential results. It also included implications of results for treatment, screening, and cancer management, implications of hereditary cancer risk for blood relatives, genetic discrimination laws, and possible reproductive implications. A link to the video was sent to men who chose it. The men had an opportunity to ask questions of a study investigator before proceeding with genetic testing.

A higher proportion of patients chose VBGE over GC (71% vs 29%).

The VBGE group had a higher proportion of patients who intended to share genetic testing results (96.4% vs 86.4%), Dr. Giri’s team reported.

Both the VBGE and GC groups had high rates of genetic testing (94.4% and 92.0%). Cancer genetics knowledge improved to a similar extent in both groups.

Factors Affecting Choice Major reasons for choosing the video included greater convenience (62.2%), less time commitment (37.8%), and absence of waiting time to view the video (20.2%). Individuals in the GC arm received personalized counseling by telehealth or telephone. Major reasons for choosing GC included ability to ask questions to a genetics provider (62.2%) and preference or ability to do the visit from home. continued on page 26

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Robotic Cystectomy Safe, Feasible for Octogenarians ROBOTIC-ASSISTED radical cystectomy (RARC) for bladder cancer is safe and feasible for octogenarians, investigators concluded.

In a study of 1988 patients aged 80 years or older, Alice Yu, MD, MPH, of H. Lee Moffitt Cancer Center in Tampa, Florida, and colleagues found that the perioperative mortality rate was 2.2% among patients who underwent RARC compared with 4.6% among those who had open surgery.

On multivariable analysis, RARC

was significantly associated with 54% decreased odds of in-hospital mortality compared with open surgery after controlling for patient and hospital characteristics, Dr Yu’s team reported online ahead of print in Urologic Oncology.

The RARC group also had a significantly shorter hospital length of stay compared with the open surgery group (8 vs 9 days) and had a higher proportion of patients discharged home or to self-care (62.3% vs 56.6%). The RARC

group, however, had a higher proportion of patients readmitted within 90 days after discharge (42.3% vs 36.5%).

The authors noted that the early discharge observed in the RARC group may have contributed to the higher readmission rate in that group. The RARC and open surgery groups had similar rates of major, minor, and overall 90-day complication rates, according to the investigators.

“The benefits of robotic surgery may have a more pronounced effect

in octogenarians and may explain the improved early perioperative outcomes observed in this study,” Dr Yu and colleagues wrote.

The study population, which was 22.1% female, included 416 patients who underwent RARC and 1572 who had open surgery. Both groups had a median age of 82 years.

As far as the investigators are aware, their study is the first to examine the role of RARC “in a meaningful sample of octogenarians.” ■

CKD Detection

Paul M. Palevsky, MD, president of the National Kidney Foundation (NKF) and professor of medicine at the University of Pittsburgh in Pittsburgh, Pennsylvania, said the new study “confirms what we already know, that screening a low-risk population provides little yield.”

He added that the US Preventive Services Task Force in 2012 did not recommend broad-based population screening for CKD. The NKF estimates that 1 in 3 American adults are at risk for the ­development of kidney disease. In March 2020, the NKF launched a campaign called “Are You the 33%?” aimed at increasing awareness of the risk factors for kidney disease and encourag-

ing patients who are at increased risk to get tested.

Dr Palevsky also noted that the study did not look at other relevant outcomes, such as patients’ behavioral changes.

For example, patients with CKD may try to lose weight if they are obese or be more adherent to dietary restrictions, such as reducing sodium intake for BP control. They also may try to avoid medications that can worsen kidney function, such as nonsteroidal antiinflammatory drugs.

Further, the study only defined kidney disease based on blood testing and did not consider albuminuria, which can affect the rate of disease progression, he said. “The full assessment for kidney disease includes assessment of both eGFR and urine albumin excretion,” he said. ■

“Urology practice is now a critical doorway into hereditary cancer information for men and their families, and genetic testing is essential to consider for men due to the impact on precision medicine, emerging impact on active surveillance, and prostate cancer screening,” Dr Giri said.

prostate cancer who have progressed on initial lines of therapy,” Dr Giri said, “and clinical activity is seen in those men who have BRCA mutations and possibly mutations in other DNA repair genes.”

Daniel A Barocas, MD, MPH, associate professor of urology and executive vice chair for the department of urology at Vanderbilt University in Nashville, Tennessee, said genetic testing and counseling are more important than ever in the management of men diagnosed with prostate cancer. “It helps us identify potentially aggressive or lethal disease, enables patients to inform family members about harmful mutations, and, in some cases, helps determine what medications a patient will be responsive to,” Dr Barocas said.

continued from page 21

are ­ associated with improved outcomes among patients with CKD. “However, the high cost of SGLT2 inhibitors suggests that they will be infrequently used in [low- and middle-income countries] at present and reinforces the opportunity cost associated with detecting additional cases of CKD as opposed to treating known cases.”

“These data add to evidence suggesting that population-based CKD screening is not a wise use of resources but may warrant re-evaluation if SGLT2 inhibitors become less expensive and more widely available, especially in LMICs.”

Video aid for PCa continued from page 21

With regard to study strengths, Dr Giri observed: “The sample size was robust enough to deliver ­meaningful results on key patient-reported outcomes, such as decisional conflict for genetic testing and satisfaction with the process. Importantly, there was no difference in uptake of genetic testing among men who chose pretest video versus genetic counseling.”

She and her colleagues acknowledged limitations to their study, including a lack of racial or ethnic diversity. “The majority of study participants were White and college-educated; therefore, it is imperative to study digital solutions to pretest genetic delivery across diverse populations to ensure generalizability,” the investigators wrote.

Precision Medicine Genetic testing has become important in prostate cancer because it can provide information that enables more precise therapy.

PARP Inhibitors Genetic testing may identify pathologic variants that predict therapeutic response. For example, pathogenic variants in BRCA1 and BRCA2 may determine which men may respond to poly (ADP-ribose) polymerase (PARP) inhibitors. In 2020, the PARP inhibitors olaparib and rucaparib were approved for men with metastatic castration-resistant prostate cancer (mCRPC) who carry BRCA pathogenic variants after progression on standard therapy. Olaparib also is approved for men with pathogenic variants in several additional DNA repair genes.

“There are now 2 PARP inhibitors that are FDA-approved to treat men with metastatic castration-resistant

Study Limitations Dr Palevsky pointed out that the study had limitations, which the investigators acknowledged. These include the use of a BP target of 140/90 mm Hg rather than the ACC/AHA recommended level of 130/80 mm Hg. Had the lower target been used, Dr Palevsky said, fewer individuals would have been identified as having adequately controlled BP. What’s more, some of the conclusions are based on the lack of intervention for indications for which intervention now would be considered part of optimal care, such as the use of SGLT2 inhibitors to slow disease progression, he said.

Supported by Guidelines Brock O’Neil, MD, an assistant professor in the division of urology at the University of Utah Hospital in Salt Lake City, said guidelines support that a growing number of men should be offered genetic testing because of increasing understanding of the impor-

tant role germline genetic defects play in the development of prostate cancer.

“While we are able to identify such defects in only a minority of men, the implications for treatment and screening in family members has a potentially large impact,” Dr O’Neil said.

“Additionally, we are regularly learning of new potential germline mutations and the role that they play in prostate cancer, increasing the benefit of this knowledge with time.”

Awareness of the importance of genetic testing for men with prostate cancer has grown in recent years, said Todd Morgan, MD, professor of urology and chief of the division of urologic oncology at the University of Michigan Rogel Cancer Center in Ann Arbor.

“There are a number of excellent guidelines on this topic, including from the [National Comprehensive Cancer Network] as well as the Philadelphia Consensus Conference, and it is critical that urologists are familiar with these guidelines since we are the primary oncology providers for so many of these patients,” Dr Morgan said. ■

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Ethical Issues in Medicine Physicians often need to tease out how patients weigh the risks and benefits of medical treatments BY DAVID J. ALFANDRE, MD, MSPH The key to understanding our decision (which may have been different than yours) was by recognizing the ratio of the potential harms and benefits, not simply thinking of them in isolation.

Changing some of the conditions also could have changed the calculus of the relative harms and benefits and therefore our decision. What if the spare tire I had installed had no tread left and it was snowing out? What if we decided that the probability of getting another flat was remote? What if rather than visiting friends, we wanted to see a family member we had not seen in 2 years because of COVID-19? Our dynamic appreciation of those harms and benefits affects our willingness to use the car without a spare.

Principle of Proportionality This is where the ethical principle of proportionality can help us understand both how to make hard decisions as well as how our patients make them.

People weigh not just the absolute risks of harm or benefit, but whether or not they are proportional. Large risks of harm are generally balanced by large potential benefits. The risks of dialysis are acceptable to patients because of the tremendous benefit of life-saving treatment. The risks of a ureteroscopy for a patient with significant pain from a

When patients are able to articulate their beliefs, it can help them move from making what may have been an unconscious choice into a conscious one. towed to a service station where on a Sunday we might not be able to have the tire fixed or replaced. At the same time, the benefits of getting groceries were significant—we had nothing for lunch or dinner for the week. Seeing friends, while lovely, was lower down on our Maslow’s hierarchy of needs.

For us at that particular time, the harms to benefits ratio clearly favored feeding our family but not for seeing faraway friends.

­ reteral stone are often acceptable to both u patient and surgeon if it promotes the promise of better and faster pain control.

At the time of this writing, both the new-case and death rate from COVID-19 are rising, likely from the Omicron variant, the holiday season, and persistent lower vaccination rates in some communities. Your patients might be asking if they should get vaccinated now.

From a medical perspective, the answer has always been an unqualified yes, but

© SASHA WALLIS / GETTY IMAGES

I

recently woke up on a Sunday morning to a flat tire. Although I was able to install the spare tire (were the lugnuts this tight when I was younger?) and plan to have the flat fixed at the service station in town during the work week, we had some decisions to make about using the car without a spare tire.

When my spouse asked if the car was OK to drive to get groceries in town a mile away, I said there was no problem.

Later in the day when we wanted to visit some friends 45 minutes away, we decided we should not use the car for that. Our decision lay in our personal tolerance for risk and reminded me of the ever-present similar calculations we and our patients have been making about COVID-19.

Let’s break down the flat tire problem and then I’ll apply it to risk assessment in disease. Risk of harm is never taken in isolation but rather as a larger assessment in the context of a benefit. With our flat tire, the primary risk was that if we got another flat tire (albeit a low probability event), we wouldn’t have a spare to get us back on the road. A trip to a nearby grocery store probably wouldn’t leave us stranded, but for a flat 25 miles from our house, the consequences would be more significant.

We would likely have to have the car

Large risks of harm are generally balanced by large potential benefits.

if we try to understand the patient’s appreciation of the harms and benefits (and their ratio to one another), it might become easier to understand why they have previously chosen not to get vaccinated. When patients decline vaccination, they may have a different appreciation of what is considered a harm or a benefit. They may not believe reducing their risk of hospitalization or death from COVID-19 or that contributing to reducing the risk of hospitals becoming overwhelmed are significant benefits, especially in light of their appreciation of the risks of vaccination. When the proportionality condition is not met for them, they may be less likely to be vaccinated. How do we manage this problem?

Ultimately, patients’ health care decisions stem from their appreciation of harms and benefits and their relationship to one another, even if they have not considered or articulated them explicitly. The clinician can help by eliciting the patient’s understanding of both the harms and benefits and how they relate to one another. Asking how the risks and benefits could change based on new information can help to isolate the inflection point in their decision-making. “OK, so you’re saying that if the risk of serious bleeding were

lower, you would be willing to consider the operation?”

Get Patients to Articulate Beliefs Although it may be difficult to change the mind of patients with firmly held beliefs, at least helping them to articulate their thoughts and beliefs can open the door to more effective counseling.

When patients are able to articulate their beliefs, it can help them move from making what may have been an unconscious choice into a conscious one: Clinicians can work with conscious choices much more easily. In the best-case scenario, this might help them change their mind. In other situations, simply improving the transparency of the decision provides a roadmap for future discussions and reduces clinicians’ distress when patients make choices that don’t necessarily promote their health. ■ David J. Alfandre, MD, MSPH, is a health care ethicist and an associate professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.

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Practice Management Physicians planning to retire need to establish the value of their practices to facilitate their sale BY JOHN SCHIESZER

Pandemic’s Effect on Value The pandemic may have led to changes in the value of medical practices, which have had to increase the number of exam room cleanings and the time required for each cleaning, he said. The pandemic also has made it more difficult to maintain adequate staffing lev-

strategic decisions regarding the path of the practice. “With so many doctors looking to retire, private practices may start consolidating even more so than before the pandemic,” Brinly said.

Understanding the objective value of a medical practice can put it in a better position to create a fair exit strategy for partners who are transitioning, leaving, or retiring, said Kearin Schulte, Vice President for Physician Enterprise Advisory Services at Premier, a health care improvement company based in Charlotte, North Carolina. If the practice is considering selling to a health system, a larger physician practice group, or venture capital group, this gives the practice better negotiating power when valuing or negotiating an offer.

Review Fee Schedules and Codes Sandy Coffta, Vice President of Client Services at Healthcare Administrative Partners in Philadelphia, Pennsylvania, said a practice analysis can be highly beneficial in identifying problems with fee schedules and coding. An outdated fee schedule could mean that claims being filed with third-party payers are less than allowed amounts, drastically affecting revenue. “We are seeing more of a focus on fee schedule maintenance in terms of consistency and transpar-

Physicians need to maintain up-to-date fee schedules and review their use of billing codes to optimize their practice’s value. els. “If new cleaning procedures reduce the number of patients a doctor can see in a day, the bottom line of the practice will be affected as will the value of the practice. If staffing shortages affect patient flow, the same effect will be felt by the practice,” he said.

For doctors not at their retirement age, but starting to plan for the future, it may be an ideal time to appraise their practice’s value when the pandemic ends. This would allow them to make

ency, making sure charges are reasonable and there is a consistent plan for setting new procedure fees,” Coffta said.

An analysis of reimbursement by procedure code needs to include breakouts by payer and modifier combination.

These steps help identify areas that can be improved in the pre-authorization, coding, or denial management process. “It will also show any codes where reimbursement is out of line with other similar procedures, and opportunities

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hysicians planning to retire need to determine the value of their medical practice, which in many cases is their largest asset, and analyze factors that might affect what their practice is worth. Such a medical practice analysis can identify areas that could increase the value of a medical practice, said Vincent M. Brinly, Director of Valuation Services at Practice Valuation Group in Washington DC. “It is always costeffective,” Brinly said. “Since a proper valuation can possibly save or benefit a doctor by tens or hundreds of thousands of dollars, or even a million, the appropriate fee is not a barrier to a peace of mind.”

Potential buyers rely on practice valuations to negotiate a reasonable purchase price. Practice analyses provide information buyers need to make sure they don’t buy “a broken practice,” Brinly said.

The COVID-19 pandemic may have led to changes in the value of medical practices.

to strategically re-negotiate fees on high volume CPT codes,” Coffta said. “The biggest benefit of a medical practice analysis is the ability to identify issues across the billing process and ensure that the practice is capturing all revenue it is entitled to, and ensuring that as many claims as possible are paid on their first submission.”

Nelson Lowman, a managing director in the Healthcare Performance Improvement practice at Berkeley Research Group, a global consulting firm based in Emeryville, California, said fee schedule maintenance is paramount and should be part of managing reimbursement for all specialties. “All payers generally pay based on their reimbursement schedule or the billed charges, whichever is the lowest,” Lowman said. “Often physician groups don’t have a lot of market power to demand higher rates.” Setting slightly higher fees than called for contractually “creates an environment where payers are obligated to pay rates as contracted.”

Coding Audits Conducting periodic coding audits is always a good idea. Coding rules vary by specialty, and they are often quite complex, Lowman said. Particular

attention should be paid to surgical procedure codes. “The coding of surgical procedures often requires the application of multiple modifiers and typically represents the most reimbursement for a practice group,” Lowman said. “Concentrating on surgical codes will give you the best [return on investment].”

Periodic operational and physician contracting assessments conducted by a third party can provide an unbiased set of improvement opportunities, he said. This can allow a medical group to proactively protect revenue and eliminate costs. “These assessments also are valuable as practices weigh external equity valuations and investments,” Lowman said.

It is important to understand the proper use of modifiers with procedural codes. By optimizing use of modifiers, a medical practice can submit “clean invoices the first time for the fastest payment,” Schulte said. “The more time you have to invest in addressing denials and rebilling slows down your payment process significantly and can impact cash flow.” ■ John Schieszer is a freelance medical writer based in Seattle, Washington.