6 minute read
CKD Care Differs By Race, Ethnicity, Study Finds
ROBOTIC-ASSISTED radical cystectomy (RARC) for bladder cancer is safe and feasible for octogenarians, investigators concluded.
Advertisement
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
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.”
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 encouraging patients who are at increased risk to get tested.
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.
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. ■
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.
“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.
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 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.
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 important 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. ■
