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Urology

Cancer Narrative review 3 October 2022 Open Access

Modern paradigms for prostate cancer detection and management

Over the past decade, detection and management of prostate cancer have evolved, with the focus now placed on harm minimisation, reducing overdiagnosis and avoiding overtreatment

Isabella SC Williams · Aoife McVey · Sachin Perera · Jonathan S O’Brien · Louise Kostos · Kenneth Chen · Shankar Siva · Arun A Azad · Declan G Murphy · Veeru Kasivisvanathan · Nathan Lawrentschuk · Mark Frydenberg

Mja2 51722
Men's health Guidelines 19 September 2022 Free

Urological Society of Australia and New Zealand (USANZ) and Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) clinical guidelines on the management of erectile dysfunction

Modification of lifestyle behaviour, management of reversible risk factors and optimisation of existing medical conditions remain pivotal

Eric Chung · Michael Lowy · Michael Gillman · Chris Love · Darren Katz · Graham Neilsen

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Ophthalmology Letters 20 June 2022 Free

Taking a broader view of the health care needs of people with chronic kidney disease

To the Editor: We thank Polkinghorne and Kerr1 for their editorial on the health care needs of people with chronic kidney disease (CKD). We write to highlight the burden of visual loss suffered by people with CKD and its effects on quality of life and mortality. The prevalence of eye diseases associated with visual impairment (combined World Health Organization definitions of blindness and low vision) in people with CKD is about 36%, rising to about 60% in people with end‐stage renal disease.2 The commonest causes of visual impairment are diabetic retinopathy (prevalence in patients with CKD, 19–46%), cataract (prevalence, 33–75%) and age‐related macular degeneration (prevalence, 8–36%).2 Increased incidence of retinal vein occlusions and hypertensive retinopathy are also associated with CKD. Patients receiving haemodialysis have increased risk of additional ocular complications. A recent study of 121 patients found at least one ocular finding in over 89% cases, including conjunctival (32%) and corneal (32%) calcification, and optic atrophy (19%).3 Ectopic calcification has been a common cause of irritated eyes in patients receiving dialysis, but this may be decreasing with modern dialysis methods. Increased risk of optic atrophy may be related to chronic anaemia and an increased risk of non‐arteritic anterior ischaemic optic neuropathy. Uraemic optic neuropathy is now an uncommon event. People with CKD are recognised to have an increased risk of dying from heart disease (up to 20 times that of age and gender matched people for people on haemodialysis).4,5 Vision impairment may incrementally contribute to increased mortality; a recent meta‐analysis demonstrated an all‐cause mortality hazard ratio of 1.43 (95% CI, 1.22–1.68) for visual acuity worse than 6/18.6 Vision‐related quality of life is potentially reduced in people with CKD, affecting their ability to complete activities of daily living and their social, emotional and economic wellbeing. Vision loss is associated with increased risk of falls and increased mental health burden, typically anxiety and depression, and may limit the ability to live independently, including self‐medicating with insulin and performing home dialysis. Multiple studies show people rate losing vision as worse than losing hearing, memory, speech or a limb.7 We agree that supportive care clinics for people electing to not receive kidney replacement therapy are important, and suggest that these clinics include regular eye care services.

Heather G Mack · Deborah J Colville · Judith A Savige

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Urology Letters 7 June 2021 Free

Differences in treatment choices for localised prostate cancer diagnosed in private and public health services

To the Editor: Te Marvelde and colleagues1 report that patients with prostate cancer diagnosed in the private health system in Victoria are more likely to undergo radical treatment than patients in the public system. In particular, they report that patients in the private system undergo surgery more often than those in the public system (44% v 28%; odds ratio, 2.28; 95% CI, 2.13–2.44). The authors do not provide an explanation for this, but the inference is that private patients may be more likely to be overtreated in private hospitals. We respectfully point out two more plausible explanations. First, prostate‐specific antigen (PSA), local clinical staging, and cancer grading form the three essential parameters that define the risk groupings of low, intermediate and high risk prostate cancer. This risk categorisation forms the basis upon which evidence‐based clinical guidelines recommend treatment options, which unfortunately has not been accounted for in the article by te Marvelde et al. The suggestion that cancer grade alone is sufficient to inform on treatment choice is without evidence and is a limitation of this article. Much more granular risk stratification is already available to describe patterns of care of prostate cancer in Victoria from the Prostate Cancer Outcomes Registry (PCOR‐Vic), and these data have already reported that patients diagnosed in the private system in Victoria are actually less likely to undergo treatment than those diagnosed in the public system.2 The PCOR‐Vic data are in direct contradiction to this article, but are more robust as they are based on a granular registry across both public and private health systems, with many publications to validate patterns of care in Victoria.3,4,5 Second, patients in the public system are much less likely to access minimally invasive surgery than patients in the private system, which is likely also a deterrent to surgery in the public system. In 2019, 88% of prostatectomies performed in the private sector were performed using a robotic approach, compared with only 28% in the public sector.6 This ongoing inequity likely leads to underutilisation of surgery for patients in the public system. There is also a failure to contextualise major studies mentioned in the discussion to support the authors’ interpretation of their data. For example, the ProTect study is cited to highlight the lack of differences between treatment options for prostate cancer. This study was conceived and commenced well before active surveillance became accepted as the most appropriate treatment for low risk prostate cancer, where 77% of participants were categorised as such. Rates of utilisation of active surveillance in Australia, including in the private sector, are among the highest in the world and are not accounted for by the authors. In addition, the reference to 40% of overdiagnosis rates based on data collected from 1982 to 2012 bears no reflection on current practice.7 Te Marvelde and colleagues have also failed to consider the recent evidence that magnetic resonance imaging reduces the rates of overdiagnosis of low risk prostate cancer while improving the detection of clinically significant cancers.8 The authors assert that treatment of people with cancer should be high quality and evidence‐based. Nobody would disagree with this. Indeed, let us cite high quality randomised controlled trials to support the interpretation of the data we publish, but appropriate contextualisation is everything.

Henry H Woo · Declan G Murphy

Cancer Research 15 March 2021 Free

Patterns of care for men with prostate cancer: the 45 and Up Study

Objectives: To describe patterns of care in New South Wales for men with prostate cancer, and to ascertain factors associated with receiving different types of treatment. Design: Individual patient data record linkage study. Setting, participants: 4003 New South Wales men aged 45 years or more enrolled in the population‐based 45 and Up Study in whom prostate cancer was first diagnosed during 2006–2013. Main outcome measures: Prostate cancer treatment type received; factors statistically associated with treatment received; proportions of patients who consulted radiation oncologists prior to treatment. Results: In total, 1619 of 4003 patients underwent radical prostatectomy (40%), 893 external beam radiotherapy (EBRT) (22%), 183 brachytherapy (5%), 87 chemotherapy (2%), 373 androgen deprivation therapy alone (9%), and 848 no active treatment (21%). 205 of 1628 patients who had radical prostatectomies (13%) had radiation oncology consultations prior to surgery. Radical prostatectomy was more likely for patients aged 45–59 years, with regional stage disease, living 100 km or more from the nearest radiotherapy centre, having partners, or having private health insurance, while lower physical functioning, obesity, and living in areas of greater socio‐economic disadvantage reduced the likelihood. EBRT was more likely for patients aged 70–79 years, with non‐localised or unknown stage disease, living less than 100 km from the nearest radiotherapy centre, or not having private health insurance, while the likelihood was lower for patients aged 45–59 years or more than 80 years and for those who had several comorbid conditions. Conclusions: Men with prostate cancer were twice as likely to have radical prostatectomy as to receive EBRT, and fewer than one in seven had consulted radiation oncologists prior to prostatectomy. The treatment received was influenced by several socio‐demographic factors. Given the treatment‐specific side effects and costs, policies that affect access to different treatments for prostate cancer should be reviewed.

Mei Ling Yap · Dianne L O'Connell · David E Goldsbury · Marianne F Weber · David P Smith · Michael B Barton

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Urology Research 12 October 2020 Free

Differences in treatment choices for localised prostate cancer diagnosed in private and public health services

Objective: To compare treatments for localised prostate cancer for men diagnosed in private and public health services in Victoria. Design: Retrospective analysis of Victorian Cancer Registry data linked to population‐based administrative health datasets. Setting, participants: 29 325 Victorian men diagnosed with prostate cancer during 2011–2017. Main outcome measures: Proportions of men in private and public health services receiving radical prostatectomy (with or without curative radiation therapy) or curative external beam radiation therapy alone within 12 months of diagnosis. Results: After adjusting for age, tumour classification and comorbidity, men diagnosed in private health services received radical treatment more frequently than men diagnosed in public health services (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.31–1.49). The proportion of private patients who underwent radical prostatectomy was larger than that for public patients (44% v 28%; OR, 2.28; 95% CI, 2.13–2.44) and the proportion of private patients who received curative external beam radiation therapy alone (excluding brachytherapy) was smaller (9% v 19%; OR, 0.45; 95% CI, 0.42–0.49). These differences were apparent for all International Society of Urological Pathology (ISUP) tumour grades. The magnitude of the difference for prostatectomy was greater for men aged 70 years or more; for radiation therapy alone, it was larger for those diagnosed before age 70. The differences between private and public services narrowed during 2011–2017 for men with ISUP grade 1 disease, but not ISUP grade 2–5 tumours. Conclusion: Prostate cancer treatment choices differ substantially between men diagnosed in private and public health services in Victoria. These differences are not explained by disease severity or comorbidity.

Luc te Marvelde · Roger L Milne · Colin J Hornby · Adam B Chapman · Graham G Giles · Ian E Haines

Mja2 50794

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