背景:泌尿外科存在证据实践空白。我们先前调查了欧洲泌尿外科协会(EAU)指南,以高度确定性的证据为基础,这些证据会影响怀疑实践差异的患者体验。建议“不要在前列腺癌患者手术前提供新辅助雄激素剥夺治疗(ADT)”优先用于进一步研究。术前ADT既无临床疗效,也无成本效益,有严重的副作用。改进实施问题的第一步是了解其程度。在整个欧洲,没有关于手术前ADT的清晰实践。
目的:评估欧洲前列腺癌手术前ADT的使用现状。
方法:这是一项观察性横断面研究。我们在多中心国际环境中回顾性地审计了最近的ADT实践。我们使用了非概率目的抽样,以低量和高量的广度为目标,学术,相对于社区和公共与私人中心。
方法:我们的主要结果是遵守ADT建议。描述性统计和多层次模型被用来调查不同因素国家之间的差异(数量,中心类型,和资金类型)。对低,中间,高风险,以及局部晚期前列腺癌患者。我们还收集了不遵守的原因。
结论:我们纳入了2017年1月1日至2020年5月1日来自31个国家187家医院的6598名前列腺癌患者。总的来说,不依从性为2%,(范围0-32%)。大部分的变异性是在高危亚组中发现的,不依从率为4%(范围0-43%).不依从的原因包括试图改善肿瘤学结果或术前肿瘤参数;试图控制癌症,因为漫长的等待名单;和患者的偏好(在新辅助ADT开始后将想法从放疗改为手术或感觉副作用无法忍受)。虽然我们有目的地在国家(公共/私人,学术/社区,高/低音量),对具有指导方针意识的中心的选择偏见是可能的,所以依从率可能被高估了。
结论:EAU指南建议在前列腺癌手术前不要使用ADT,然而,一些指南不一致的ADT使用仍然是以患者体验和额外的支付者和提供者负担为代价的.应采取停止不适当的术前ADT使用的策略。
结果:雄激素剥夺疗法(ADT)有时用于无法从中受益的前列腺癌男性。ADT会导致体重增加和情绪变化等副作用,并增加患心血管疾病的风险,糖尿病,和骨质疏松症。指南强烈建议选择手术的男性不应该接受ADT,但尚不清楚该指南的遵循程度。我们询问了欧洲各地的泌尿科医师在过去几年中如何治疗其机构中的患者。大多数人在手术前不使用ADT,但这在某些地方仍然发生。需要更多的研究来帮助医生在无法从中受益的患者中停止使用ADT。
Evidence-practice gaps exist in urology. We previously surveyed European Association of Urology (EAU)
guidelines for strong recommendations underpinned by high-certainty evidence that impact patient experience for which practice variations were suspected. The recommendation \"Do not offer neoadjuvant androgen deprivation therapy (ADT) before surgery for patients with prostate cancer\" was prioritised for further investigation. ADT before surgery is neither clinically effective nor cost effective and has serious side effects. The first step in improving implementation problems is to understand their extent. A clear picture of practice regarding ADT before surgery across Europe is not available.
To assess current ADT use before prostate cancer surgery in Europe.
This was an observational cross-sectional study. We retrospectively audited recent ADT practices in a multicentre international setting. We used nonprobability purposive sampling, aiming for breadth in terms of low- versus high-volume, academic, versus community and public versus private centres.
Our primary outcome was adherence to the ADT recommendation. Descriptive statistics and a multilevel model were used to investigate differences between countries across different factors (volume, centre type, and funding type). Subgroup analyses were performed for patients with low, intermediate, and high risk, and for those with locally advanced prostate cancer. We also collected reasons for nonadherence.
We included 6598 patients with prostate cancer from 187 hospitals in 31 countries from January 1, 2017 to May 1, 2020. Overall, nonadherence was 2%, (range 0-32%). Most of the variability was found in the high-risk subgroup, for which nonadherence was 4% (range 0-43%). Reasons for nonadherence included attempts to improve oncological outcomes or preoperative tumour parameters; attempts to control the cancer because of long waiting lists; and patient preference (changing one\'s mind from radiotherapy to surgery after neoadjuvant ADT had commenced or feeling that the side effects were intolerable). Although we purposively sampled for variety within countries (public/private, academic/community, high/low-volume), a selection bias toward centres with awareness of
guidelines is possible, so adherence rates may be overestimated.
EAU
guidelines recommend against ADT use before prostate cancer surgery, yet some
guideline-discordant ADT use remains at the cost of patient experience and an additional payer and provider burden. Strategies towards discontinuation of inappropriate preoperative ADT use should be pursued.
Androgen deprivation therapy (ADT) is sometimes used in men with prostate cancer who will not benefit from it. ADT causes side effects such as weight gain and emotional changes and increases the risk of cardiovascular disease, diabetes, and osteoporosis.
Guidelines strongly recommend that men opting for surgery should not receive ADT, but it is unclear how well the guidance is followed. We asked urologists across Europe how patients in their institutions were treated over the past few years. Most do not use ADT before surgery, but this still happens in some places. More research is needed to help doctors to stop using ADT in patients who will not benefit from it.