Re: Discrepancies in Staging, Treatment, and Delays to Treatment May Explain Disparities in Bladder Cancer Outcomes: An Update from the National Cancer Data Base (2004-2013).

available at http://www.ncbi. nlm.nih. gov/pubmed/29338913 Editorial Comment: This review of the National Cancer Database examined 328,560 cases of bladder urothelial carcinoma, of which 7.6% involved advanced disease. Female gender, black race, Hispanic ethnicity, and living in a region of lower income and education were all associated with increased odds of advanced disease. Female gender (HR 1.16, 95% CI 1.12e1.20, p <0.001), black race (HR 1.10, 95% CI 1.04e1.18, p[ 0.002) and lower regional income levels (fourth quartile compared to first: HR 1.08, 95% CI 1.02e1.16, p [ 0.016) predicted worse overall survival. Importantly, and disturbingly, females, black patients, and patients from regions of lower income and education are less likely to receive timely treatment or any treatment at all. This study perhaps raises more questions than it answers, including the question regarding what is truly taking place with the vast number of patients who remain undiagnosed and untreated. One would reasonably conjecture that these same populations are receiving no diagnostic care or evaluation. However, within this large cohort with more advanced disease disparities exist that may be addressed by focusing on improved access to appropriate care without delay. Sam S. Chang, MD Reference 1. Klaassen Z, DiBianco JM, Jen RP et al: Female, black, and unmarried patients are more likely to present with metastatic bladder urothelial carcinoma. Clin Genitourin Cancer 2016; 14: e489. Suggested Reading Mallin K, David KA, Carroll PR et al: Transitional cell carcinoma of the bladder: racial and gender disparities in survival (1993 to 2002), stage and grade (1993 to 2007). J Urol 2011; 185: 1631. Lara J, Brunson A, Keegan TH et al: Determinants of survival for adolescents and young adults with urothelial bladder cancer: results from the California Cancer Registry. J Urol 2016; 196: 1378. Casey MF, Gross T, Wisnivesky J et al: The impact of regionalization of cystectomy on racial disparities in bladder cancer care. J Urol 2015; 194: 36. Urological Oncology: Prostate Cancer Re: Radical Prostatectomy or Watchful Waiting in Prostate Cancerd29-Year Follow-up A. Bill-Axelson, L. Holmberg, H. Garmo, K. Taari, C. Busch, S. Nordling, M. H€ aggman, S. O. Andersson, O. Andr en, G. Steineck, H. O. Adami and J. E. Johansson Department of Surgical Sciences, Regional Cancer Center Uppsala € Orebro and Department of Pathology, Uppsala University Hospital, Uppsala, School of Health and Medical Sciences, € Orebro University and Department of Urology, € Orebro University Hospital, € Orebro, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm and Division of Clinical Cancer Epidemiology, Sahlgrenska Academy, Gothenburg, Sweden, Division of Cancer Studies, School of Medicine, and School of Cancer and Pharmaceutical Sciences, King’s College London, London, United Kingdom, Department of Urology, Helsinki University Hospital and Department of Pathology, University of Helsinki, Helsinki, Finland, Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway, and Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts N Engl J Med 2018; 379: 2319e2329. doi: 10.1056/NEJMoa1807801 Abstract available at http://www.ncbi. nlm.nih. gov/pubmed/30575473 210 PROSTATE CANCERavailable at http://www.ncbi. nlm.nih. gov/pubmed/30575473 210 PROSTATE CANCER Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited. Editorial Comment: In this updated report of a Swedish randomized cohort comparing radical prostatectomy to watchful waiting the authors continue to demonstrate a survival benefit for men undergoing surgery. At a median followup of 23 years only 20.4% of men (142 of 695) remained alive. Of the deaths 32.7% were due to prostate cancer. The likelihood of dying of prostate cancer was greater in patients on watchful waiting, with an absolute difference of 12% compared to the prostatectomy cohort. This finding represents an increase in absolute overall survival benefit from 5% to 12% between years 10 and 23 of followup. Of men undergoing prostatectomy the risk of mortality was far greater for those with Gleason score 4 þ 3 or higher (RR 5.73) but was not greater for men with Gleason 3 þ 4 disease compared to those with Gleason 3 þ 3 disease. Men with Gleason score 4 þ 5 or higher had a tenfold increased risk of mortality. Men with extracapsular extension had a higher risk of mortality (RR 5.21) but this was not the case for men with positive margins (RR 1.16). Men included in this trial were enrolled from 1989 to 1999. As such, most men had detection by clinical examination and sextant biopsies, and were not representative of an earlier stage prostate specific antigen (PSA) screening detected cohort. For this reason it is not entirely clear whether observations are generalizable to contemporary cohorts. This is an important observation in that the absolute survival benefit at 19 years among men in PIVOT (Prostate Cancer Intervention versus Observation Trial) was only 4%, likely reflecting longer lead time to mortality in PSA detected cancer, inclusion of men with low risk cancers and high rates of death from competing causes within 10 years. The take home message is that when accounting for the lead time introduced by PSA based detection and the inclusion of lower Gleason score cases, the benefit of radical prostatectomy is diluted, and selection of such cases for surgery should account for this through expectation of very, very prolonged longevity. Samir S. Taneja, MD Suggested Reading Wilt TJ and Brawer MK: The Prostate Cancer Intervention versus Observation Trial: a randomized trial comparing radical prostatectomy versus expectant management for the treatment of clinically localized prostate cancer. J Urol 1994; 152: 1910. Liu D, Lehmann HP, Frick KD et al: Active surveillance versus surgery for low risk prostate cancer: a clinical decision analysis. J Urol 2012; 187: 1241. Re: Vitamin D Supplements and Prevention of Cancer and Cardiovascular Disease J. E. Manson, N. R. Cook, I. M. Lee, W. Christen, S. S. Bassuk, S. Mora, H. Gibson, D. Gordon, T. Copeland, D. D’Agostino, G. Friedenberg, C. Ridge, V. Bubes, E. L. Giovannucci, W. C. Willett and J. E. Buring; VITAL Research Group Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, and Departments of Epidemiology and Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts N Engl J Med 2019; 380: 33e44. doi: 10.1056/NEJMoa1809944 Abstract available at http://www.ncbi. nlm.nih. gov/pubmed/30415629available at http://www.ncbi. nlm.nih. gov/pubmed/30415629 Editorial Comment: In this report of VITAL (Vitamin D and Omega-3 Trial), a large randomized comparison of vitamin D and placebo as a preventive agent, the authors describe no decrease in the risk of prostate cancer with vitamin D supplementation. A total of 25,871 participants were randomized in a 2 by 2 design to receive 2,000 IU vitamin D daily or placebo, and then secondarily randomized within each arm to receive 1 gm omega-3 fatty acids. At a median followup of 5.3 years no difference in rate of invasive cancer of any type or cardiovascular event was noted. Specifically the odds ratio for development of prostate cancer was 0.88 (not significant) in men receiving vitamin D. Subset analyses for prostate cancer detection relative to recorded clinical parameters were not provided. This study adds to a growing number of observational and Mendelian genetic analysis series suggesting that the previously observed associations of vitamin D and prostate cancer risk do not hold true. The challenge of studying such associations is in optimizing dose and balancing the effects of variation in the remaining dietary intake. Samir S. Taneja, MD PROSTATE CANCER 211 Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.