Prostate cancer and kidney transplantation – exclusion or coexistence?
Bibliographic record
Abstract
Untreated prostate cancer is generally a contraindication to kidney transplantation. At our institution in Boston, we are often referred individuals with low-volume low-risk prostate cancer for treatment. For a cancer that would otherwise be managed with active surveillance, these kidney transplantation candidates will often be forced into some form of definitive therapy, generally radical prostatectomy, a procedure with a well-known long-term side-effect profile, and then have to wait for a period of time – generally 2 years – before being considered for transplantation. The basis for this approach stems from the theoretical higher risk of disease progression and ultimately mortality on immunosuppression. In this issue of BJU International, Bratt et al. [1] challenge these assumptions and report on the outcomes of kidney transplant recipients diagnosed with prostate cancer. First, they found no difference in prostate cancer incidence, suggesting that transplant recipients, despite being immunosuppressed, are not at higher risk of prostate cancer. Second, they found that the prostate cancer characteristics at diagnosis, overall and prostate cancer specific survival of kidney transplant recipients do not differ significantly from non-transplant patients. Furthermore, the probability of developing advanced prostate cancer over time was not higher among transplant recipients on immunosuppression. Taken together, these findings show that transplant patients are not at a higher risk of poor prostate cancer outcomes. Hypothesizing that many of the transplant recipients in this study already had prostate cancer when they underwent transplantation (based on assumptions about cancer screening practices in Sweden and time periods included), the authors aim to refute current transplantation guidelines contraindicating solid organ transplantation in those with a history of prostate cancer and requiring a minimum recurrence-free period before placing these patients on the organ waitlist [2, 3]. The findings of Bratt et al. corroborate previous case series including the largest study of cancer incidence among transplant recipients and a meta-analysis of six studies. Given the available data, is it still justifiable to deny low-risk prostate cancer patients the life-saving kidney transplantation? If the answer is 'no', what would be fair cutoffs in Gleason score, number of positive biopsy cores, PSA level, time from diagnosis, etc.? While this study does not definitely answer the question, it would seem reasonable that candidates for active surveillance, especially those with very low-risk prostate cancer, should be eligible for kidney transplantation without prior definitive therapy. Denying immediate placement on the waiting list represents not only a significant reduction of quality of life, but also leads to reduced survival due to longer dialysis time. Another concern often heard from those in favor of definitive therapy prior to transplantation is the added risks of prostatectomy in immunosuppressed individuals – this is understandable given that the incidence of definitive therapy on active surveillance is about 50% at 10 years after diagnosis [4]. However, the available data suggest that prostatectomy after transplantation is safe. For example, in a recent systematic review, only 1/35 patient experienced a Clavien ≥ 3 complication and graft function was maintained in all patients [5]. To summarize, this study, and others before that, suggests that immunosuppression after kidney transplantation is unlikely to adversely affect prostate cancer initiation or progression. Men with low-risk prostate cancer should be considered for transplantation without first undergoing definitive therapy. There is evidence around the world – and at our institution – that transplant specialists are finally starting to accept this pathway. This study will further reinforce this concept. QDT is supported by a Health Services Research pilot test grant from the Henry M Jackson Foundation for the Advancement of Military Medicine and a unrestricted educational grant from the Vattikuti Urology Institute. QDT reports personal fees from Astellas, Bayer, Janssen, Insightec, and Intuitive Surgical. The remaining authors have nothing to disclose.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.005 | 0.022 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.003 | 0.003 |
| Science and technology studies | 0.002 | 0.005 |
| Scholarly communication | 0.003 | 0.007 |
| Open science | 0.002 | 0.003 |
| Research integrity | 0.005 | 0.006 |
| Insufficient payload (model declined to judge) | 0.006 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".