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Tang Y, Lin L, Xiao Y, Meng L, Yang Y, Li X. Predictors of trimodality therapy in patients with muscle-invasive bladder cancer and effect on survival. Clin Transl Oncol 2024; 26:446-455. [PMID: 37389736 DOI: 10.1007/s12094-023-03264-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Due to its unique advantages over radical cystectomy (RC), trimodality therapy (TMT) is increasingly being utilized by patients diagnosed with muscle-invasive bladder cancer (MIBC) who are not suitable for or refuse RC. However, achieving a satisfactory oncological outcome with TMT requires strict patient selection criteria, and the comparative oncological outcomes of TMT versus RC remain controversial. METHODS Patients diagnosed with non-metastatic MIBC who underwent TMT or RC were identified from the SEER database during 2004-2015. Before one-to-one propensity score matching (PSM), logistic regression was utilized to identify predictors of TMT. After matching, K-M curves were generated to estimate cancer-specific survival (CSS) and overall survival (OS) with log-rank to test the significance. Finally, we conducted univariate and multivariate Cox analyses to identify independent prognostic factors for CSS and OS. RESULTS The RC and TMT groups included 5812 and 1260 patients, respectively, and the TMT patients were significantly older than the RC patients. Patients with advanced age, separated, divorced, or widowed (SDW) or unmarried marital status (married as reference), and larger tumor size (< 40 mm as reference) were more likely to be treated with TMT. After PSM, TMT was found to be associated with worse CSS and OS, and it was identified as an independent risk factor for both CSS and OS. CONCLUSION MIBC patients may not be carefully evaluated prior to TMT, and some non-ideal candidates underwent TMT. TMT resulted in worse CSS and OS in the contemporary era, but these results may be biased. Strict TMT candidate criteria and TMT treatment modality should be required.
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Affiliation(s)
- Yaxiong Tang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Sichuan, 610041, China
| | - Lede Lin
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Sichuan, 610041, China
| | - Yunfei Xiao
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Sichuan, 610041, China
| | - Linghao Meng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Sichuan, 610041, China
| | - Yujia Yang
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Sichuan, 610041, China
| | - Xiang Li
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Sichuan, 610041, China.
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Al-Qudimat AR, Singh K, Ojha LK, Moustafa DA, Elaarag M, Al-Zoubi RM, Aboumarzouk OM. Comparing trimodal therapy with radical cystectomy in muscle-invasive bladder cancer: an updated meta-analysis. Front Surg 2023; 10:1276746. [PMID: 38130884 PMCID: PMC10733497 DOI: 10.3389/fsurg.2023.1276746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/16/2023] [Indexed: 12/23/2023] Open
Abstract
Background We conducted this meta-analysis to compare the two muscle-invasive bladder cancer (MIBC) treatment modalities in terms of cancer-specific survival (CSS) and other outcome indicators. Method A systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. The search was conducted using various academic databases including Scopus, PubMed, Cochrane database, EMBASE, Chinese biomedical literature database, Wan fang databases, and China National Knowledge Internet databases between 1966 and December 2023. This review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) No. (CRD42023398977). Result This study included a total of 54,816 patients diagnosed with bladder cancer from 14 studies, of which 6,228 patients were assigned to the trimodal therapy (TMT) group and 48,588 patients were assigned to the radical cystectomy (RC) group. Based on the results, the RC group exhibited a higher rate of survival than the TMT group [pooled hazard ratio (HR) = 1.23, 95% CI: 1.18-1.28, Z = 1.46, P < 0.001]. In terms of CSS, patients in the RC group had a longer CSS compared with those in the TMT group (pooled HR = 1.47, 95% CI: 1.29-1.67, Z = 5.893, P < 0.001). Compared with RC, TMT is significantly associated with an increased risk of both types of mortality (pooled HR: 1.30, P < 0.001). Conclusion Overall, the findings of this meta-analysis suggest that RC treatment may be associated with improved overall survival. Moreover, it was observed that cancer-specific survival was significantly prolonged among patients in the RC group as opposed to those who received TMT. In addition, it was shown that patients who received TMT exhibited a higher risk of all-cause mortality when compared with those who underwent RC.
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Affiliation(s)
- Ahmad R. Al-Qudimat
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
- Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar
| | - Kalpana Singh
- Department of Nursing Research, Hamad Medical Corporation, Doha, Qatar
| | - Laxmi K. Ojha
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Diala Alhaj Moustafa
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mai Elaarag
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Raed M. Al-Zoubi
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
- Department of Biomedical Sciences, College of Health Sciences, Qatar University, Doha, Qatar
- Department of Chemistry, College of Science, Jordan University of Science and Technology, Irbid, Jordan
| | - Omar M. Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
- School of Medicine, Dentistry and Nursing, The University of Glasgow, Glasgow, United Kingdom
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Waraich TA, Khalid SY, Ali A, Kathia UM. Comparative Outcomes of Radical Cystectomy in Muscle-Invasive Bladder Cancer: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e50646. [PMID: 38229790 PMCID: PMC10790112 DOI: 10.7759/cureus.50646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 01/18/2024] Open
Abstract
Muscle-invasive bladder cancer poses a significant clinical challenge that necessitates effective therapeutic interventions. Radical cystectomy is a primary treatment option, but a comprehensive understanding of its outcomes is crucial for informed clinical decision-making. This systematic review and meta-analysis aimed to investigate and summarize the outcomes associated with radical cystectomy as a primary treatment for muscle-invasive bladder cancer with a focus on survival rates, complications, and quality of life. A systematic search across databases-PubMed, Google Scholar, and others-covered studies from 2017 onwards. Included were studies reporting survival rates, complications, and quality of life post-radical cystectomy in muscle-invasive bladder cancer patients, including randomized controlled trials, cohort, and observational studies. Multidimensional analysis revealed promising findings regarding the efficacy of radical cystectomy in muscle-invasive bladder cancer. Survival outcomes, including overall survival and disease-specific mortality, have demonstrated significant improvements, particularly in recent randomized controlled trials and cohort studies. Complications associated with the surgical procedure, such as positive surgical margins and lymph node yields, were generally acceptable. Quality of life outcomes post-radical cystectomy exhibited positive trends, although variations were noted in the emotional and social domains. This review underscores radical cystectomy's role in enhancing overall survival and reducing disease-specific mortality in muscle-invasive bladder cancer. Despite reported complications, recent studies support its acceptable risk profile. Detailed examination of various factors contributes to a comprehensive understanding of the procedure. These findings emphasize the importance of individualized treatment approaches in the management of muscle-invasive bladder cancer, considering both oncological efficacy and perioperative outcomes. Radical cystectomy remains fundamental in urological oncology, with ongoing advancements refining its significance.
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Affiliation(s)
| | - Syed Yousaf Khalid
- Department of Urology, Letterkenny University Hospital, Letterkenny, IRL
| | - Azfar Ali
- Department of Urology & Kidney Transplantation, Lahore General Hospital, Lahore, PAK
| | - Usama Muhammad Kathia
- Department of Urology & Kidney Transplantation, Lahore General Hospital, Lahore, PAK
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4
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Zhou YX, Hu QC, Zhu YJ, Mu XL, Liu JY, Chen Y. Comparison of trimodality therapy and neoadjuvant chemotherapy combined with radical cystectomy for the survival of muscle-invasive bladder cancer: a population-based analysis. Eur J Med Res 2023; 28:422. [PMID: 37822001 PMCID: PMC10566126 DOI: 10.1186/s40001-023-01408-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Trimodality therapy (TMT) is a mature alternative to radical cystectomy (RC) for patients with muscle-invasive bladder cancer (MIBC) who seek to preserve their primary bladder or are inoperable due to comorbidities. To date, there has been increasing evidence of the effectiveness of TMT as an alternative to RC. In contrast, no literature has stated the effectiveness of neoadjuvant chemotherapy combined with RC (NAC + RC) compared with TMT. OBJECTIVE We aimed to compare the prognosis between patients receiving TMT and NAC + RC. METHODS The clinicopathological characteristics of patients with T2-4aN0M0 MIBC were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox proportional hazards regression models and Kaplan‒Meier survival curves were used for the survival analysis. Propensity-score matching (PSM) was applied to determine the differences between the two groups. The primary outcome was cancer-specific survival (CSS), and the secondary outcome was overall survival (OS). RESULTS In total, 1,175 patients with MIBC who underwent TMT (n = 822) or NAC + RC (n = 353) were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. After 1:1 PSM, the final patient sample included 303 pairs. The prognosis of patients receiving NAC + RC was significantly better than that of patients receiving TMT in both unmatched and matched cohorts (5-year CSS: before PSM, 75.4% vs. 50.6%, P < 0.0001; after PSM, 76.3% vs. 49.5%, P < 0.0001; 5-year OS: before PSM, 71.7% vs. 37.4%, P < 0.0001; after PSM, 71.7% vs. 31.4%, P < 0.0001). The survival advantages of NAC + RC remained remarkable in the stratified analysis of most factors after PSM. Multivariate Cox regression analysis showed that being older than 68 years old, unmarried, grade III/IV, T3-4a stage, and undergoing TMT independently correlated with poor OS. CONCLUSION Thus, in this study, patients with MIBC receiving NAC + RC presented with a better prognosis than those receiving TMT.
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Affiliation(s)
- Yi-Xin Zhou
- Department of Biotherapy, Cancer Centre, West China Hospital, Sichuan University, 37 Guoxue Xiang Street, Chengdu, 610041, Sichuan, China
| | - Qian-Cheng Hu
- Gastric Cancer Center, Division of Medical Oncology, Cancer Center, Laboratory of Gastric Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Ya-Juan Zhu
- Department of Biotherapy, Cancer Centre, West China Hospital, Sichuan University, 37 Guoxue Xiang Street, Chengdu, 610041, Sichuan, China
| | - Xiao-Li Mu
- Department of Biotherapy, Cancer Centre, West China Hospital, Sichuan University, 37 Guoxue Xiang Street, Chengdu, 610041, Sichuan, China
| | - Ji-Yan Liu
- Department of Biotherapy, Cancer Centre, West China Hospital, Sichuan University, 37 Guoxue Xiang Street, Chengdu, 610041, Sichuan, China.
| | - Ye Chen
- Division of Abdominal Tumor Multimodality Treatment, Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, 37 Guoxue Xiang Street, Chengdu, 610041, Sichuan, China.
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Fallatah M, Alkahtani AS, Alrumayyan M, Alotaibi MF, Alkhateeb S, Mokhtar AA, Altaweel W. Trimodal therapy versus radical cystectomy for cT2N0M0 urothelial muscle-invasive bladder cancer: Single-center experience. Urol Ann 2023; 15:406-411. [PMID: 38074180 PMCID: PMC10699176 DOI: 10.4103/ua.ua_50_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/10/2023] [Accepted: 08/21/2023] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Bladder cancer is ranked the ninth most common cancer in the world. Locally, the incidence of bladder cancer has increased tenfold over the past 26 years. Radical cystectomy (RC) is considered a gold standard management option for muscle-invasive bladder cancer (MIBC), but trimodal therapy (TMT) has shown comparable oncological outcomes in selected patients. MATERIALS AND METHODS This is a retrospective study in which we reviewed medical records of patients diagnosed with MIBC without nodal disease or distant metastasis (cT2N0M0) who underwent either RC or TMT. Demographic data, comorbidities, histopathological and clinical staging, neoadjuvant/adjuvant therapy, and follow-up were analyzed. RESULTS We included a total of 31 patients in the study, with 10 patients in the TMT group and 21 patients in the RC group. There was no significant difference in recurrence between the TMT and RC groups (P = 0.58). The TMT group had a higher percentage of local recurrence (40% vs. RC 5.2%, P = 0.018) but no significant difference in metastasis (0% vs. 10%, P = 0.420). The difference in overall survival between the TMT and RC groups was not significant (P = 0.25). CONCLUSION TMT may be considered an alternative option for patients unwilling to undergo RC due to related complications and prioritize a better quality of life. However, the decision should be made after considering the cost of extensive follow-ups and patient compliance with surveillance.
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Affiliation(s)
- Moayid Fallatah
- Department of Urology, King Faisal Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Ali S. Alkahtani
- Department of Urology, King Faisal Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Majed Alrumayyan
- Department of Urology, King Faisal Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed F. Alotaibi
- Department of Urology, King Faisal Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Sultan Alkhateeb
- Department of Urology, King Faisal Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Alaa Ahmed Mokhtar
- Department of Urology, King Faisal Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Waleed Altaweel
- Department of Urology, King Faisal Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
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6
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Su X, Dong C, Liao W, Liu W. Oncological effectiveness of bladder-preserving trimodal therapy versus radical cystectomy for the treatment of muscle-invasive bladder cancer: a system review and meta-analysis. World J Surg Oncol 2023; 21:271. [PMID: 37641150 PMCID: PMC10464249 DOI: 10.1186/s12957-023-03161-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE Radical cystectomy (RC) is the gold standard treatment for muscle-invasive bladder cancer (MIBC). As a bladder-preservation option recommended in guidelines, trimodal therapy (TMT) has become increasingly popular in recent years. However, it is still uncertain whether TMT can provide comparable oncologic outcomes to RC. Therefore, it is imperative to evaluate whether TMT yields comparable outcomes to RC. METHODS We conducted a systematic search of Web of Science, MEDLINE, the Cochrane Library, and EMBASE databases up to June 2023 to identify studies that met our inclusion criteria. The primary outcome measures evaluated in this study were overall survival (OS) and cancer-specific survival (CSS). The study quality was evaluated independently by two authors, and data were extracted accordingly. RESULTS After excluding duplicates and ineligible articles, our meta-analysis included seven studies involving 3,489 and 13,877 patients in the TMT and RC groups, respectively. Short-term overall survival rates were comparable between the groups, but beyond 5 and > 10-years, the RC group had significantly higher overall survival rates compared to the TMT group. In terms of cancer-specific survival, there was no significant difference between the groups at 1-year follow-up, but from the second year onwards, including the 5-year and > 10-year nodes, the RC group had significantly better outcomes compared to the TMT group. CONCLUSION The treatment effect of RC is better than that of TMT. Unless the patient can't tolerate RC or has a strong desire to preserve the bladder, RC should be chosen over TMT in treatment, and patients undergoing TMT should be closely followed up.
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Affiliation(s)
- Xiaozhe Su
- Department of Urology, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Caitao Dong
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wenbiao Liao
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wentao Liu
- Department of Urology, The Second Xiangya Hospital of Central South University, Changsha, China.
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7
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Jiao H, Wang L, Zhou X, Wu J, Li T. Prognostic Ability of Nutritional Indices for Outcomes of Bladder Cancer: A Systematic Review and Meta-Analysis. Urol Int 2023; 107:886-894. [PMID: 37643581 DOI: 10.1159/000531884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Nutrition has become an important parameter influencing the prognosis of several cancers. However, its impact on outcomes for bladder cancer (BC) is still unclear. This review examines the association between three commonly used nutritional indices, namely, the prognostic nutritional index (PNI), controlling nutritional status (CONUT), and the geriatric nutritional risk index (GNRI) and outcomes of BC. METHODS PubMed, CENTRAL, Scopus, Web of Science, Embase, and Google Scholar were explored for studies published up to April 13, 2023. Data from studies were pooled to examine the association between PNI, CONUT, or GNRI and overall survival (OS) and recurrence-free survival (RFS). RESULTS Thirteen studies were included. Meta-analysis demonstrated significantly poor OS with low PNI versus high PNI in BC patients (hazard ratio [HR]: 1.71; 95% confidence interval [CI]: 1.37, 2.14; I2 = 0%). This result remained significant in various subgroup analyses. However, no association was noted between PNI and RFS (HR: 1.22; 95% CI: 0.67, 2.24; I2 = 84%). Meta-analysis showed that patients with high CONUT scores had significantly poor OS (HR: 2.43; 95% CI: 1.82, 3.25; I2 = 0%) as well as RFS (HR: 2.90; 95% CI: 2.10, 4.01; I2 = 0%). Data on GNRI were scarce and conflicting. CONCLUSION Limited data show that PNI and CONUT are predictive of outcomes in BC. Low PNI was associated with poor OS, while high CONUT was associated with poor OS and RFS. Data on GNRI are too scarce to obtain conclusions. Further studies are needed to supplement the results.
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Affiliation(s)
- Huijie Jiao
- Department of Urology, Affiliated Tumor Hospital of Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Lin Wang
- Department of Urology, Affiliated Tumor Hospital of Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Xiaomei Zhou
- Department of Urology, Affiliated Tumor Hospital of Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Jiacheng Wu
- Department of Urology, Affiliated Tumor Hospital of Nantong University & Nantong Tumor Hospital, Nantong, China
| | - Tiantian Li
- Department of Urology, Affiliated Tumor Hospital of Nantong University & Nantong Tumor Hospital, Nantong, China
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Koga F. Selective multimodal bladder-sparing therapy for muscle-invasive bladder cancer: the present and the future. Expert Rev Anticancer Ther 2023; 23:1127-1139. [PMID: 37753554 DOI: 10.1080/14737140.2023.2257389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/06/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION Despite the lack of level 1 evidence, selective bladder-sparing therapy using trimodal therapy is currently recommended by guidelines as a standard of care in patients with non-metastatic, muscle-invasive bladder cancer who are eligible for the treatment. AREAS COVERED This article reviews major studies of selective, bladder-sparing therapy utilizing multiple modalities for muscle-invasive bladder cancer and those comparing the oncological outcomes between bladder-sparing therapy and radical cystectomy. Also discussed are predictive biomarkers potentially capable of guiding treatment decisions by patients with muscle-invasive bladder cancer and a novel strategy for boosting the antitumor immune response in bladder-sparing therapy. PubMed databases were searched for records of 30 June 2023 or earlier. EXPERT OPINION Selective, bladder-sparing therapy appears to be underutilized at present. To promote its use, measures should be taken to facilitate the referral of eligible patients to specialist centers and broaden the number of facilities providing the therapy. Recent studies have suggested a prognostic benefit of radiotherapy for the primary lesion in patients with metastatic bladder cancer. Given that irradiation can induce the abscopal effect, particularly in combination with immune checkpoint inhibitors, demand for bladder-sparing therapies may increase in the context of treatments for metastases.
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Affiliation(s)
- Fumitaka Koga
- Department of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Bunkyo-ku, Tokyo, Japan
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9
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Kim KH, Lee HW, Ha HK, Seo HK. Perioperative systemic therapy in muscle invasive bladder cancer: Current standard method, biomarkers and emerging strategies. Investig Clin Urol 2023; 64:202-218. [PMID: 37341001 DOI: 10.4111/icu.20230006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/18/2023] [Indexed: 06/22/2023] Open
Abstract
Bladder cancer ranks as the 10th most common cancer type globally, and muscle-invasive disease accounts for approximately 25% of newly diagnosed bladder cancers. Despite definitive treatment, 50% of patients with muscle-invasive bladder cancer (MIBC) develop metastasis within 2 years, leading to death. Perioperative systemic therapy is generally recommended to control local relapse or distant metastasis after surgical resection for patients with MIBC. Cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy is the current standard treatment to improve oncologic control and survival outcomes. Adjuvant chemotherapy is recommended for patients with pathological T3-4 or positive lymph nodes after radical cystectomy if no neoadjuvant chemotherapy was given. Nonetheless, perioperative systemic therapy is not applied widely because of its toxicity, and less than 25% of patients receive cisplatin-based neoadjuvant chemotherapy. Therefore, the development of predictive biomarkers for neoadjuvant chemotherapy efficacy and alternative effective regimens for cisplatin-ineligible patients are important. Furthermore, recently, novel anticancer agents such as immune checkpoint inhibitors and antibody-drug conjugates have proven survival benefits in the metastatic setting, thereby expanding their therapeutic applications to the perioperative setting for non-metastatic MIBC. Herein, we discuss the current status and future perspectives of perioperative systemic strategies for MIBC.
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Affiliation(s)
- Kyung Hwan Kim
- Department of Urology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hye Won Lee
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, Korea
| | - Hong Koo Ha
- Department of Urology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Ho Kyung Seo
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, Korea
- Division of Tumor Immunology, Research Institute, National Cancer Center, Goyang, Korea
- Department of Cancer Biomedical Science, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea.
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10
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Cano Garcia C, Piccinelli ML, Tappero S, Panunzio A, Barletta F, Incesu RB, Tian Z, Saad F, Briganti A, Terrone C, Shariat SF, Graefen M, Tilki D, Antonelli A, De Cobelli O, Kosiba M, Banek S, Kluth LA, Chun FKH, Karakiewicz PI. Differences in overall survival of T2N0M0 bladder cancer patients vs. population-based controls according to treatment modalities. Int Urol Nephrol 2023; 55:1117-1123. [PMID: 36813873 DOI: 10.1007/s11255-023-03517-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/11/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE It is unknown to what extent overall survival (OS) of organ-confined (T2N0M0) urothelial carcinoma of the urinary bladder (UCUB) patients differs from age- and sex-matched population-based controls, especially when treatment modalities such as radical cystectomy (RC), trimodal therapy (TMT), or radiotherapy (RT) are considered. METHODS Relying on the Surveillance Epidemiology and End Results database (2004-2018), we identified newly diagnosed (2004-2013) T2N0M0 UCUB patients treated with either RC, TMT or RT. For each case, we simulated an age- and sex-matched control (Monte Carlo simulation), relying on Social Security Administration Life Tables with 5 years of follow-up, and compared OS with that of RC-, TMT-, and RT-treated cases. Additionally, we relied on smoothed cumulative incidence plots to display cancer-specific mortality (CSM) and other-cause mortality (OCM) rates for each treatment modality. RESULTS Of 7153 T2N0M0 UCUB patients, 4336 (61%) underwent RC, 1810 (25%) TMT, and 1007 (14%) RT. At 5 years, OS rate in RC cases was 65% vs. 86% in population-based controls (Δ = 21%); in TMT cases, 32% vs. 74% in population-based controls (Δ = 42%); and in RT, 13% vs. 60% in population-based control (Δ = 47%). Five-year CSM rates were highest in RT (57%), followed by TMT (46%) and RC (24%). Five-year OCM rates were the highest in RT (30%), followed by TMT (22%) and RC (12%). CONCLUSION OS of T2N0M0 UCUB patients is substantially less than that of age- and sex-matched population-based controls. The biggest difference affects RT, followed by TMT. A modest difference was recorded in RC and population-based controls.
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Affiliation(s)
- Cristina Cano Garcia
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada. .,Department of Urology, Goethe University, University Hospital Frankfurt, Theodor- Stern Kai 7, 60590, Frankfurt, Germany.
| | - Mattia Luca Piccinelli
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Stefano Tappero
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Department of Urology, IRCCS Policlinico San Martino, Genoa, Italy.,Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genoa, Italy
| | - Andrea Panunzio
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Di Verona, Verona, Italy
| | - Francesco Barletta
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Reha-Baris Incesu
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Alberto Briganti
- Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Carlo Terrone
- Department of Urology, IRCCS Policlinico San Martino, Genoa, Italy.,Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genoa, Italy
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.,Department of Urology, Weill Cornell Medical College, New York, NY, USA.,Department of Urology, University of Texas Southwestern, Dallas, TX, USA.,Hourani Center of Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Di Verona, Verona, Italy
| | - Ottavio De Cobelli
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Marina Kosiba
- Department of Urology, Goethe University, University Hospital Frankfurt, Theodor- Stern Kai 7, 60590, Frankfurt, Germany
| | - Severine Banek
- Department of Urology, Goethe University, University Hospital Frankfurt, Theodor- Stern Kai 7, 60590, Frankfurt, Germany
| | - Luis A Kluth
- Department of Urology, Goethe University, University Hospital Frankfurt, Theodor- Stern Kai 7, 60590, Frankfurt, Germany
| | - Felix K H Chun
- Department of Urology, Goethe University, University Hospital Frankfurt, Theodor- Stern Kai 7, 60590, Frankfurt, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
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11
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Myths About Bladder Preservation in Muscle-Invasive Bladder Cancer. Semin Radiat Oncol 2023; 33:56-61. [PMID: 36517194 DOI: 10.1016/j.semradonc.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Radical cystectomy is long considered as the "gold standard" in the management of localized muscle-invasive bladder cancer (MIBC), and curative intent radiotherapy is relegated to those with either inoperable tumors or with multiple co-morbidities precluding surgery. This is despite a large volume of data showing equal survival between the two modalities of treatment in this setting. In this work we seek to dispel some common myths surrounding curative intent radiotherapy as part of a bladder preservation strategy in MIBC. Baseless claims of inferior outcomes and perceived contraindications for bladder preservation are debunked along with unfounded doubts relating to hypofractionation. Finally, we caution against using response to neoadjuvant chemotherapy as a predictive biomarker for treatment selection and conclude by recommending that trimodality bladder preservation be offered as a therapeutic option that is in clinical equipoise with radical cystectomy.
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12
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Chalfant V, Blute ML, Silberstein P. Treatment trends of muscle invasive bladder cancer: Evidence from the Surveillance, Epidemiology, and End Results database, 1988 to 2013. Asian J Urol 2023; 10:9-18. [PMID: 36721688 PMCID: PMC9875153 DOI: 10.1016/j.ajur.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 05/26/2021] [Accepted: 06/15/2021] [Indexed: 02/03/2023] Open
Abstract
Objective Guidelines for muscle-invasive bladder cancer (MIBC) recommend that patients receive neoadjuvant chemotherapy with radical cystectomy as treatment over radical cystectomy alone. Though trends and practice patterns of MIBC have been defined using the National Cancer Database, data using the Surveillance, Epidemiology, and End Results (SEER) program have been poorly described. Methods Using the SEER database, we collected data of MIBC according to the American Joint Commission on Cancer. We considered differences in patient demographics and tumor characteristics based on three treatment groups: chemotherapy (both adjuvant and neoadjuvant) with radical cystectomy, radical cystectomy, and chemoradiotherapy. Multinomial logistic regression was performed to compare likelihood ratios. Temporal trends were included for each treatment group. Kaplan-Meier curves were performed to compare cause-specific survival. A Cox proportional-hazards model was utilized to describe predictors of survival. Results Of 16 728 patients, 10 468 patients received radical cystectomy alone, 3236 received chemotherapy with radical cystectomy, and 3024 received chemoradiotherapy. Patients who received chemoradiotherapy over radical cystectomy were older and more likely to be African American; stage III patients tended to be divorced. Patients who received chemotherapy with radical cystectomy tended to be males; stage II patients were less likely to be Asian than Caucasian. Stage III patients were less likely to receive chemoradiotherapy as a treatment option than stage II. Chemotherapy with radical cystectomy and chemoradiotherapy are both underutilized treatment options, though increasingly utilized. Kaplan-Meier survival curves showed significant differences between stage II and III tumors at each interval. A Cox proportional-hazards model showed differences in gender, tumor stage, treatment modality, age, and marital status. Conclusion Radical cystectomy alone is still the most commonly used treatment for muscle-invasive bladder cancer based on temporal trends. Significant disparities exist in those who receive radical cystectomy over chemoradiotherapy for treatment.
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Affiliation(s)
- Victor Chalfant
- Urology at CHI Health Creighton University Medical Center Omaha, NE, USA,Corresponding author.
| | - Michael L. Blute
- Urology at CHI Health Creighton University Medical Center Omaha, NE, USA
| | - Peter Silberstein
- Hematology Oncology at CHI Health Creighton University Medical Center Omaha, NE, USA
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13
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Long-Term Outcome of Patients with Stage II and III Muscle-Invasive Urothelial Bladder Cancer after Multimodality Approach. Which Is the Best Option? Medicina (B Aires) 2022; 59:medicina59010050. [PMID: 36676675 PMCID: PMC9865683 DOI: 10.3390/medicina59010050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/18/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Background and Objectives: There is no consensus regarding the optimal therapy sequence in stage II and III bladder cancer. The study aimed to evaluate the long-term oncologic outcomes in patients with bladder cancer after a multimodality approach. Materials and methods: Medical files of 231 consecutive patients identified with stage II (46.8%), IIIA (30.3%), and IIIB (22.9%) transitional cell carcinoma of the bladder (BC) treated with a multimodality approach were retrospectively reviewed. The treatment consisted of transurethral resections or cystectomy, radiotherapy alone or concurrent chemoradiotherapy as definitive treatment, or neoadjuvant chemotherapy using platinum salt regimens. Results: Median age at diagnosis was 65 ± 10.98 years. Radical or partial cystectomy was performed in 88 patients (37.1%), and trans-urethral resection of bladder tumor (TURBT) alone was performed in 143 (61.9%) patients. Overall, 40 patients (17.3%) received neoadjuvant chemotherapy and 82 (35.5%) received definitive chemoradiotherapy. After a median follow-up of 30.6 months (range 3-146 months), the median disease-free survival (DFS) for an entire lot of patients was 32 months, and the percentage of patients without recurrence at 12, 24, and 36 months was 86%, 58%, and 45%, respectively. Patients receiving neoadjuvant chemotherapy had a better oncologic outcome compared to patients without neoadjuvant chemotherapy (median DFS not reached vs. 31 months, p = 0.038, HR = 0.55, 95% CI 0.310-0.951). There was a trend for better 3-year DFS with radical cystectomy vs. TURBT (60 months vs. 31 months, p = 0.064). Definitive chemoradiotherapy 3-year DFS was 58% compared to 44% in patients who received radiotherapy or chemotherapy alone. Conclusions: In patients with stages II and III, both neoadjuvant chemotherapy and concurrent radio-chemotherapy are valid options for treatment and must be part of a multidisciplinary approach.
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14
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Kool R, Yanev I, Hijal T, Vanhuyse M, Cury FL, Souhami L, Kassouf W, Dragomir A. Trimodal therapy vs. radical cystectomy for muscle-invasive bladder cancer: A Canadian cost-effectiveness analysis. Can Urol Assoc J 2022; 16:189-198. [PMID: 35099381 PMCID: PMC9245963 DOI: 10.5489/cuaj.7430] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2024]
Abstract
INTRODUCTION Trimodal therapy (TMT) is a suitable alternative to neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) for patients with muscle-invasive bladder cancer (MIBC). In this study, we conducted a cost-effectiveness evaluation of RC±NAC vs. TMT for MIBC in the universal and publicly funded Canadian healthcare system. METHODS We developed a Markov model with Monte-Carlo microsimulations. Rates and probabilities of transitioning within different health states (e.g., cure, locoregional recurrence, distant metastasis, death) were input in the model after a scoped literature review. Two main scenarios were considered: 1) academic center; and 2) populational-level. Results were reported in life-years gained (LYG), quality-adjusted life years (QALY), and incremental cost-effectiveness ratio (ICER). A sensitivity analysis was performed. RESULTS A total of 20 000 patients were simulated. For the academic center model, TMT was associated with increased effectiveness (both in LYG and QALY) at a higher cost compared to RC±NAC at five and 10 years. This resulted in an ICER of $19 746/QALY per patient undergoing the TMT strategy at 10 years of followup. For the populational-level model, RC±NAC was associated with higher effectiveness at 10 years, with an ICER of $3319/QALY per patient. This study was limited by heterogeneity within the studies used to build the model. CONCLUSIONS In this study, TMT performed in academic centers was cost-effective compared to RC±NAC, with higher effectiveness at a higher cost. On the other hand, RC±NAC was considered cost-effective compared to TMT at the populational-level. Further studies are needed to confirm these results.
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Affiliation(s)
- Ronald Kool
- Division of Urology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Ivan Yanev
- Division of Urology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Tarek Hijal
- Division of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Marie Vanhuyse
- Division of Medical Oncology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Fabio L. Cury
- Division of Urology, McGill University Health Centre, McGill University, Montreal, QC, Canada
- Division of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Luis Souhami
- Division of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Wassim Kassouf
- Division of Urology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Alice Dragomir
- Division of Urology, McGill University Health Centre, McGill University, Montreal, QC, Canada
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15
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Long term cost comparisons of radical cystectomy versus trimodal therapy for muscle-invasive bladder cancer. Urol Oncol 2022; 40:273.e1-273.e9. [DOI: 10.1016/j.urolonc.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 11/20/2022]
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16
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Effects of treatments on gender differences in patients with localized muscle-invasive bladder cancer. Int Urol Nephrol 2022; 54:1845-1855. [PMID: 35608804 DOI: 10.1007/s11255-022-03200-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/27/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE To explore the gender differences in survival under different treatments in localized muscle-invasive bladder cancer (MIBC), and to find clinical strategies to improve the poor prognosis of female with bladder cancer (BC). METHODS Patients with localized MIBC were collected in the SEER database from 2010 to 2016 to analyze the gender differences in clinical characteristics. Propensity score matching was used to balance the effects of confounding factors. Kaplan-Meier method and Cox proportional hazards regression model were performed to compare the overall survival (OS) and cancer-specific survival (CSS) of patients between different treatment subgroups. RESULTS The entire cohort included 13,272 T2N0M0 MIBC patients, with a male-to-female incidence of 3:1. Compared with male patients, females had a higher age of onset and more blacks. There were more female patients undergoing bladder-sparing surgery (BSS) alone, and the OS and CSS were worse than those in males. The gender difference showed statistical significance in the BSS group, but not in the radical cystectomy (RC) group. CONCLUSION The survival of localized MIBC patients can be affected by treatments. Multi-modality treatment and RC may improve the survival prognosis of female patients.
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17
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Wu J, Xie RY, Cao CZ, Shang BQ, Shi HZ, Shou JZ. Disease Management of Clinical Complete Responders to Neoadjuvant Chemotherapy of Muscle-Invasive Bladder Cancer: A Review of Literature. Front Oncol 2022; 12:816444. [PMID: 35494010 PMCID: PMC9043546 DOI: 10.3389/fonc.2022.816444] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Muscle-invasive bladder cancer (MIBC) is an aggressive disease requiring active management. Neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is considered the standard treatment paradigm for MIBC patients, which could result in significant perioperative mortality and morbidity, as well as the significant alteration of the quality of life (QOL). Notably, multimodal bladder-preserving treatment strategies have been recommended for highly selected patients. Pathologic complete response (pCR) after NAC is a powerful prognostic indicator of survival for patients with MIBC. Clinical complete response (cCR) is then introduced as a complementary endpoint for pCR to assess disease status preoperatively. Bladder preservation strategy for patients who achieve cCR following NAC is emerging as a new treatment concept. However, the efficiency of the conservative strategy remains controversial. In this state-of-the-art review, we discuss the advantages and limitations of cCR and the feasibility and safety of bladder preservation strategy in highly selected MIBC patients who achieve cCR following NAC. We conclude that a conservative strategy can be considered a reasonable alternative to RC in carefully selected cCR MIBC patients, leading to acceptable oncological outcomes.
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Affiliation(s)
- Jie Wu
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui-Yang Xie
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chuan-Zhen Cao
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing-Qing Shang
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong-Zhe Shi
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Zhong Shou
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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18
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Treatment disparities in muscle-invasive bladder cancer: Evidence from a large statewide cancer registry. Urol Oncol 2022; 40:164.e17-164.e23. [DOI: 10.1016/j.urolonc.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/18/2021] [Accepted: 12/09/2021] [Indexed: 11/19/2022]
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19
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Nik Ab Kadir MN, Hairon SM, Yaacob NM, Ab Manan A, Ali N. Prognostic Factors for Bladder Cancer Patients in Malaysia: A Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19053029. [PMID: 35270721 PMCID: PMC8910605 DOI: 10.3390/ijerph19053029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 12/24/2022]
Abstract
Background: Malaysia has the third highest crude mortality rates of bladder cancer within Southeast Asia. We aimed to identify the prognostic factors for bladder cancer patients in Malaysia. Methods: A retrospective population-based study was conducted among patients diagnosed between 2007 and 2011. Death date until 31 December 2016 was updated. Cox proportional hazard regression analysis was performed to examine clinical variables as prognostic factors of death. Results: Identified prognostic factors of 1828 analyzed patients were age groups, ethnicity, morphology, stage, and surgery. As compared to patients aged 15–44, the adjusted Hazard Ratio for those aged 45–54, 55–64, 65–74, and ≥75 were 1.59, 1.87, 2.46, and 3.47, respectively. Malay and other ethnic groups had 1.22- and 1.40-times the risk of death compared to Chinese. Patients with squamous cell carcinoma were at 1.47-times the hazard of death compared to urothelial carcinoma patients. Stages II, III and IV patients had 2.20-, 2.98-, and 4.12-times the risk of death as compared to stage I. Patients who did not receive surgery were at 50% increased hazard of death. Conclusion: Early detection and/or surgery, especially for those more than 75 years old, Malay, and squamous cell carcinoma could potentially improve survival. The findings could inform national cancer control programs.
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Affiliation(s)
- Mohd Nasrullah Nik Ab Kadir
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
| | - Suhaily Mohd Hairon
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
- Correspondence:
| | - Najib Majdi Yaacob
- Biostatistics and Research Methodology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia;
| | - Azizah Ab Manan
- Timur Laut District Health Office, Penang State Health Department, Ministry of Health Malaysia, Georgetown 11600, Penang, Malaysia;
- Malaysian National Cancer Registry Department, National Cancer Institute, Ministry of Health Malaysia, Putrajaya 62250, Selangor, Malaysia;
| | - Nabihah Ali
- Malaysian National Cancer Registry Department, National Cancer Institute, Ministry of Health Malaysia, Putrajaya 62250, Selangor, Malaysia;
- Public Health Medicine Department, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu 88400, Sabah, Malaysia
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20
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Hatakeyama S, Narita S, Okita K, Narita T, Iwamura H, Fujita N, Inokuchi J, Matsui Y, Kitamura H, Ohyama C. Management of bladder cancer in older patients. Jpn J Clin Oncol 2021; 52:203-213. [PMID: 34905776 DOI: 10.1093/jjco/hyab187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/13/2021] [Indexed: 11/14/2022] Open
Abstract
Evidence has shown that patients with bladder cancer are diagnosed at a much older age compared with those with other cancers. Given that co-morbidities and frailty are prevalent in older patients with advanced bladder cancer, they are easily excluded from randomized controlled trials. As little evidence has been available regarding assessment tools for frailty, the management of those patients remains challenging. This weakness is strongly manifested in muscle-invasive bladder cancer. Despite radical cystectomy is the standard of care for bladder cancer, there is an extensive undertreatment of older adult patients with potentially curative muscle-invasive bladder cancer. However, it is also true that radical cystectomy is often unsuitable for vulnerable or frail patients. Bladder preservation using trimodality therapy has been utilized as an alternative option, but the appropriate selection criteria for trimodality therapy remain unclear. Cisplatin-based regimens have been the first choice for advanced disease among eligible patients. Moreover, immunotherapy appears to have similar benefits and tolerability in both older and younger patients. Furthermore, palliative or supportive interventions need to be initiated earlier in patients with metastatic disease. Accumulating evidence suggests that frailty may play a key role in the selection of treatment modalities. Older patients should be considered for standard treatment based on frailty and not chronological age. Moreover, older patients with bladder cancer need to undergo geriatric assessment for proper decision-making.
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Affiliation(s)
- Shingo Hatakeyama
- Department of Advanced Blood Purification Therapy, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shintaro Narita
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Kazutaka Okita
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takuma Narita
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hiromichi Iwamura
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Naoki Fujita
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Junichi Inokuchi
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshiyuki Matsui
- Department of Urology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Kitamura
- Department of Urology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Chikara Ohyama
- Department of Advanced Blood Purification Therapy, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.,Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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21
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Horlemann B, Würnschimmel C, Hoeh B, Sorce G, Chierigo F, Flammia RS, Tian Z, Saad F, Briganti A, Shariat SF, Galucci M, Chun FKH, Graefen M, Karakiewicz PI. Radical Cystectomy vs. Radiotherapy in Urothelial Bladder Cancer in Elderly and Very Elderly Patients. Clin Genitourin Cancer 2021; 20:93.e1-93.e9. [PMID: 34620567 DOI: 10.1016/j.clgc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Controversy regarding cancer-specific mortality (CSM) of elderly and very elderly patients with muscle-invasive, non-metastatic, urothelial carcinoma of the urinary bladder (UCUB) undergoing radical cystectomy (RC) vs radiotherapy (RT) still exists. MATERIALS AND METHODS In the 2004-2016 Surveillance, Epidemiology and End Results (SEER) database, we identified 2663 UCUB patients aged 75-79 (1808 RC vs 855 RT) and 3569 UCUB patients aged 80-89 (1551 RC vs 2018 RT). After stratification for concomitant chemotherapy, propensity score matching (PSM) between RC and RT was applied and competing-risks regression models addressed CSM and OCM. RESULTS In the cohort aged 75-79, five-year CSM rates were 22.0 vs 49.0% for RC only vs RT only and yielded a HR of 0.41 (95% confidence interval (CI) 0.30-0.57, p<0.001) favoring RC only. Five-year CSM rates were 28.3 vs 44.3% for RC with chemotherapy vs trimodal therapy (TMT) and yielded a HR of 0.48 (95% CI 0.35-0.65, p<0.001) favoring RC with chemotherapy. In the cohort aged 80-89, five-year CSM rates were 24.2 vs 48.9% for RC only vs RT only and yielded a HR of 0.42 (95% CI 0.33-0.52, p<0.001) favoring RC only. Five-year CSM rates were 19.6 vs 43.2% for RC with chemotherapy vs TMT and yielded a HR of 0.43 (95% CI 0.28-0.67, p<0.001) favoring RC with chemotherapy. CONCLUSIONS In elderly and very elderly patients, radical cystectomy is associated with virtually half the CSM rate than radiotherapy, regardless of concomitant chemotherapy administration.
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Affiliation(s)
- Benedikt Horlemann
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.
| | - Christoph Würnschimmel
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada; Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt Hoeh
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada; Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Gabriele Sorce
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada; Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Chierigo
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada; Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Rocco Simone Flammia
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada; Department of Maternal-Child and Urological Sciences, Sapienza Rome University, Policlinico Umberto I Hospital, Rome, Italy
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Alberto Briganti
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sharokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY; Department of Urology, University of Texas Southwestern, Dallas, TX; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Michele Galucci
- Department of Maternal-Child and Urological Sciences, Sapienza Rome University, Policlinico Umberto I Hospital, Rome, Italy
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada
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22
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Rouprêt M, Pignot G, Masson-Lecomte A, Compérat E, Audenet F, Roumiguié M, Houédé N, Larré S, Brunelle S, Xylinas E, Neuzillet Y, Méjean A. [French ccAFU guidelines - update 2020-2022: bladder cancer]. Prog Urol 2021; 30:S78-S135. [PMID: 33349431 DOI: 10.1016/s1166-7087(20)30751-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE - To update French guidelines for the management of bladder cancer specifically non-muscle invasive (NMIBC) and muscle-invasive bladder cancers (MIBC). METHODS - A Medline search was achieved between 2018 and 2020, notably regarding diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence. RESULTS - Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS <1) and renal function (creatinine clearance >60 mL/min) allow it (only in 50% of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival. CONCLUSION - These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment of patients diagnosed with NMIBC and MIBC.
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Affiliation(s)
- M Rouprêt
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Sorbonne Université, GRC n° 5, Predictive onco-uro, AP-HP, hôpital Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - G Pignot
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, Institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - A Masson-Lecomte
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital Saint-Louis, Université Paris-Diderot, 10, avenue de Verdun, 75010 Paris, France
| | - E Compérat
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'anatomie pathologique, hôpital Tenon, HUEP, Sorbonne Université, GRC n° 5, ONCOTYPE-URO, 4, rue de la Chine, 75020 Paris, France
| | - F Audenet
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital Foch, Université de Versailles - Saint-Quentin-en-Yvelines, 40, rue Worth, 92150 Suresnes, France
| | - M Roumiguié
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Département d'urologie, CHU Rangueil, 1, avenue du Professeur-Jean-Poulhès, 31400 Toulouse, France
| | - N Houédé
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Département d'oncologie médicale, CHU Carémeau, Université de Montpellier, rue du Professeur-Robert-Debré, 30900 Nîmes, France
| | - S Larré
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Reims, rue du Général Koenig, 51100 Reims, France
| | - S Brunelle
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de radiologie, Institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - E Xylinas
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, Université Paris-Descartes, 46, rue Henri-Huchard, 75018 Paris, France
| | - Y Neuzillet
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Reims, rue du Général Koenig, 51100 Reims, France
| | - A Méjean
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital européen Georges-Pompidou, AP-HP, Université de Paris, 20, rue Leblanc, 75015 Paris, France
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23
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Varughese M. Overcoming the Chasm Between Evidence and Routine Practice for Bladder Cancer; Just a Quixotic Notion? Clin Oncol (R Coll Radiol) 2021; 33:e274-e284. [PMID: 33840534 DOI: 10.1016/j.clon.2021.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/16/2021] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Abstract
There has been a failure to improve outcomes in bladder cancer over the last 30 years. This is despite clinical trial evidence showing a benefit of interventions such as neoadjuvant chemotherapy or concurrent radiosensitisation for non-metastatic muscle-invasive bladder cancer. The bladder cancer population is characteristically elderly, who typically suffer from multiple comorbidities. Historically, radical cystectomy has been heralded as the treatment of choice, with radiotherapy being reserved for those with inoperable tumours or those unfit for major pelvic surgery, despite a lack of robust comparative or quality of life data to support one treatment recommendation over the other. Although patients with non-metastatic muscle-invasive bladder cancer have potentially curable disease, a growing body of population-based analyses persistently highlights that most patients do not undergo curative-intent treatments - a trend that remains static. The causes for the disparity between evidence and routine practice is not clearly understood. Here, the facets of patient-centred evidence-based care, with respect to bladder conservation therapy, are examined, with proposals to reverse this unacceptable status quo.
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Affiliation(s)
- M Varughese
- Department of Oncology, Royal Devon & Exeter Hospital, Exeter, UK.
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24
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Deuker M, Krimphove MJ, Stolzenbach LF, Collà Ruvolo C, Nocera L, Mansour M, Tian Z, Roos FC, Becker A, Kluth LA, Shariat SF, Black PC, Kassouf W, Tilki D, Saad F, Chun FKH, Karakiewicz PI. Radical Cystectomy vs. Multimodality Treatment in T2N0M0 Bladder Cancer: A Population-based, Age-matched Analysis. Clin Genitourin Cancer 2021; 19:e264-e271. [PMID: 33972185 DOI: 10.1016/j.clgc.2021.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/07/2021] [Accepted: 03/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Controversy still exists regarding efficacy of multimodality treatment (MMT) vs. radical cystectomy (RC) for urothelial carcinoma of the urinary bladder (UCUB). METHODS Within the SEER database (2004-2016), we retrospectively identified patients with stage T2N0M0 UCUB. Competing risks regression (CRR) tested cancer-specific mortality (CSM) and adjusted for other-cause mortality after MMT vs. RC. Exact matching for age was applied. Subgroup analyses focused on differences in chemotherapy or lymph node dissection rates. In sensitivity analyses, we accounted for 40% understaging rate in patients who underwent MMT. RESULTS Of 9862 patients with T2N0M0 UCUB, 2675 (27.1%) underwent MMT vs. 5751 (58.3%) RC vs. 1436 (14.6%) radiotherapy (RT) without chemotherapy. MMT rate increased (annually +3.0%, P < .01) and MMT patient age was significantly higher (median 77 years) than RC patient age (68 years). In exact age-matched analyses, 10-year CSM rates were 44.3% vs. 25.9% for MMT vs. RC (multivariate hazard ratio [HR] 0.48); 44.1% vs. 22.8% for MMT vs. RC with chemotherapy (HR 0.43); 40.5% vs. 31.1% for MMT vs. RC without lymph node dissection (HR 0.66), and 55.6% vs. 27.3% for RT without chemotherapy vs. RC (HR 0.37, all P < .001). Sensitivity analyses that addressed understaging of patients who underwent MMT resulted in virtually the same CSM rates. CONCLUSION In patents with T2N0M0, MMT or even more so RT alone may be associated with higher CSM than RC, even in exact age-matched multivariate CRR analyses, which adjust for other-cause mortality. In consequence, patients with T2 UCUB should be informed of this possible CSM disadvantage outside of highly specialized centers.
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Affiliation(s)
- Marina Deuker
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany; Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.
| | - Marieke J Krimphove
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - L Franziska Stolzenbach
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Collà Ruvolo
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, University of Naples Federico II, Naples, Italy
| | - Luigi Nocera
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, San Raffaele Scientific Institute, Milan, Italy
| | - Mila Mansour
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Frederik C Roos
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Andreas Becker
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Department of Urology, University of Jordan, Amman, Jordan
| | - Peter C Black
- Department of Urologic Sciences, Vancouver Prostate Centre, University of British Columbia, Vancouver, British Colombia, Canada
| | - Wassim Kassouf
- Department of Urology, McGill University Health Centre, Montréal, Québec, Canada
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
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25
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Bladder preservation therapy in combination with atezolizumab and radiation therapy for invasive bladder cancer (BPT-ART) - A study protocol for an open-label, phase II, multicenter study. Contemp Clin Trials Commun 2021; 21:100724. [PMID: 33615035 PMCID: PMC7878176 DOI: 10.1016/j.conctc.2021.100724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/09/2020] [Accepted: 01/11/2021] [Indexed: 01/05/2023] Open
Abstract
Radical cystectomy (RC) is recommended for muscle-invasive bladder cancer (MIBC) or highest-risk non-muscle-invasive bladder cancer (NMIBC). Trimodal therapy (TMT) is the most favorable strategy among bladder preservation therapies (BPT) for patients who are ineligible for or refuse RC. However, referrals for TMT, especially following chemotherapy, are limited by the patient's condition. Therefore, new BPT approaches are needed. Atezolizumab inhibits programmed death-ligand 1, is well-tolerated in patient populations heavily dominated by renal insufficiency, and is expected to have synergistic anti-tumor effects in combination with radiation therapy (RT). Therefore, we have conducted this open-label phase II multicenter study to evaluate the efficacy and safety of RT in combination with atezolizumab for T2-3 MIBC and highest-risk T1 NMIBC patients. This study was initiated in January 2019, and we aimed to enroll a total of 45 patients. The study is registered in the Japan Registry of Clinical Trials (Identifier: RCT2031180060).
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26
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Polo-Alonso E, Kuk C, Guruli G, Paul AK, Thalmann G, Kamat A, Solsona E, Thalmann G, Urdaneta AI, Zlotta AR, Mir MC. Trimodal therapy in muscle invasive bladder cancer management. MINERVA UROL NEFROL 2020; 72:650-662. [PMID: 33263367 DOI: 10.23736/s0393-2249.20.04018-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Radical cystectomy (RC) is the current mainstay for muscle-invasive bladder cancer (MIBC). Concerns regarding morbidity, mortality and quality of life have favored the introduction of bladder sparing strategies. Trimodal therapy, combining transurethral resection, chemotherapy and radiotherapy is the current standard of care for bladder preservation strategies in selected patients with MIBC. EVIDENCE ACQUISITION A comprehensive search of the Medline and Embase databases was performed. A total of 19 studies were included in a systematic review of bladder sparing strategies in MIBC management was carried out following the preferred reporting items for systematic reviews and meta-analysis (PRISMA). EVIDENCE SYNTHESIS The overall median complete response rate after trimodal therapy (TMT) was 77% (55-93). Salvage cystectomy rate with TMT was 17% on average (8-30). For TMT, the 5-year cancer-specific survival and overall survival rates range from 42-82% and 32-74%, respectively. Currently data supporting neoadjuvant or adjuvant chemotherapy in bladder sparing approaches are emerging, but robust definitive conclusions are still lacking. Gastrointestinal toxicity rates are low around 4% (0.5-16), whereas genitourinary toxicity rates reached 8% (1-24). Quality of life outcomes are still underreported. CONCLUSIONS Published data and clinical experience strongly support trimodal therapy as an acceptable bladder sparing strategy in terms of oncological outcomes and quality of life in selected patients with MIBC. A strong need exists for specialized centers, to increase awareness among urologists, to discuss these options with patients and to stress the increased participation of patients and their families in treatment path decision-making.
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Affiliation(s)
- Elvira Polo-Alonso
- Department of Urology, Instituto Valenciano de Oncologia (IVO), Valencia, Spain
| | - Cynthia Kuk
- Division of Urology, Departments of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada.,Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Georgi Guruli
- Division of Urology, Virginia Commonwealth University, Richmond, VA, USA
| | - Asit K Paul
- Division of Hematology, Oncology and Palliative Care Unit, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - George Thalmann
- Division of Hematology, Oncology and Palliative Care Unit, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ashish Kamat
- Department of Urology, Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Solsona
- Department of Urology, Instituto Valenciano de Oncologia (IVO), Valencia, Spain
| | - George Thalmann
- Department of Urology, University Hospital of Bern, Bern, Switzerland
| | - Alfredo I Urdaneta
- Division of Hematology, Oncology and Palliative Care Unit, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Alexandre R Zlotta
- Division of Urology, Departments of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada.,Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Maria C Mir
- Department of Urology, Instituto Valenciano de Oncologia (IVO), Valencia, Spain -
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27
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Tholomier C, Souhami L, Kassouf W. Bladder-sparing protocols in the treatment of muscle-invasive bladder cancer. Transl Androl Urol 2020; 9:2920-2937. [PMID: 33457265 PMCID: PMC7807363 DOI: 10.21037/tau.2020.02.10] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/29/2019] [Indexed: 01/06/2023] Open
Abstract
Bladder-sparing protocols (BSP) have been gaining widespread popularity as an attractive alternative to radical cystectomy (RC) for muscle-invasive bladder cancer. Unimodal therapies are inferior to multimodal regimens. The most promising regimen is trimodal therapy (TMT), which is a combination of maximal transurethral resection of bladder tumor (TURBT), radiotherapy, and chemotherapy. In appropriately selected patients (low volume unifocal T2 disease, complete TURBT, no hydronephrosis and no carcinoma-in-situ), comparable oncological outcomes to RC have been reported in large retrospective studies, with a potential improvement in overall quality of life (QOL). TMT also offers the possibility for definitive therapy for patients who are not surgically fit to undergo RC. Routine biopsy of previous tumor resection is recommended to assess response. Prompt salvage RC is required in non-responders and for recurrent muscle-invasive disease, while non-muscle-invasive recurrence can be managed conservatively with TURBT +/- intravesical BCG. Long-term follow-up consisting of routine cystoscopy, urine cytology, and cross-section imaging is required. Further studies are warranted to better define the role of neoadjuvant or adjuvant chemotherapy in the setting of TMT. Finally, future research on predictive markers of response to TMT and on the integration of immunotherapy in bladder sparing protocols is ongoing and is highly promising.
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Affiliation(s)
- Côme Tholomier
- Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Wassim Kassouf
- Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
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28
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Ding H, Fan N, Ning Z, Ma D. Trimodal Therapy vs. Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Meta-Analysis. Front Oncol 2020; 10:564779. [PMID: 33154943 PMCID: PMC7591759 DOI: 10.3389/fonc.2020.564779] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/27/2020] [Indexed: 11/13/2022] Open
Abstract
Background: To compare the difference between trimodal therapy (TMT) and radical cystectomy (RC) in treating muscle-invasive bladder cancer, we performed a meta-analysis for data from the following database. Methods: We searched PubMed, Chinese biomedicine literature database, the Cochrane Library, China National Knowledge Internet databases, Wanfang databases, and Google Scholar up to December 2019. The main outcome measures assessed were overall survival (OS), cancer-specific survival (CSS), mortality, and Charlson comorbidity score (CCS). Two authors independently evaluated the study quality and extracted data. All data were analyzed using Review Manager (version 5.3). Results: After database retrieval, article selection, data extraction, and quality assessment, nine articles comprising 5,721 cases from the TMT group and 48,262 cases from the RC group were included in this study. The data showed that there was no statistical difference between TMT and RC at <10 years OS [pooled hazard ratio (HR) = 1.26, 95% confidence interval (CI): 0.92–1.73, Z = 1.46, P = 0.14], while OS of the RC group was higher than that of the TMT group at more than 10 years (pooled HR = 1.34, 95% CI: 1.18–1.54, Z = 4.33, P < 0.0001). As for CSS, compared with the TMT group, the patients in the RC group had longer CSS (pooled HR = 1.50, 95% CI: 1.29–1.76, Z = 5.15, P < 0.00001). Compared with RC, TMT is linked to an obvious increase in all-cause mortality and bladder-specific cancer mortality (pooled HR = 1.30, 95% CI: 1.16–1.46, Z = 4.55, P < 0.00001; pooled HR = 1.32, 95% CI: 1.15–1.51, Z = 3.92, P < 0.0001). The bladder cancer patients belonging to CCS “0” score preferred RC [pooled relative risk (OR) = 0.94, 95% CI: 0.89–0.98, Z = 2.79, P = 0.005], while CCS “2” score's patients were prone to TMT (pooled OR = 1.40, 95% CI: 1.29–1.53, Z = 7.73, P < 0.00001). Conclusions: Overall, this meta-analysis suggests that the efficacy of TMT is non-inferior to that of RC at <10-year OS, and RC is superior to TMT at more than 10-year OS. Therefore, TMT may be a reasonable treatment option in well-selected patients who are unsuitable for surgery or are not willing to experience surgery. In the future, more high-quality, large-sample randomized controlled trials (RCTs) are needed to verify the results.
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Affiliation(s)
- Hui Ding
- Key Laboratory of Diseases of Urological System Gansu Province, Department of Urology, Gansu Nephro-Urological Clinical Center, Lanzhou University Second Hospital, Lanzhou, China.,Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Ning Fan
- Key Laboratory of Diseases of Urological System Gansu Province, Department of Urology, Gansu Nephro-Urological Clinical Center, Lanzhou University Second Hospital, Lanzhou, China
| | - Zhongyun Ning
- Key Laboratory of Diseases of Urological System Gansu Province, Department of Urology, Gansu Nephro-Urological Clinical Center, Lanzhou University Second Hospital, Lanzhou, China
| | - Deyuan Ma
- The Second Clinical College of Lanzhou University, Lanzhou, China
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29
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Gofrit ON, Meirovitz A, Frank S, Rabinovich I, Luwisch H, Yutkin V, Neuman T, Hidas G, Duvdevani M, Wygoda M. Trimodal therapy in T2-4aN0M0 bladder cancer--How to select the best candidate? Cancer Med 2020; 9:8491-8497. [PMID: 32960495 PMCID: PMC7666756 DOI: 10.1002/cam4.3478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 12/24/2022] Open
Abstract
The reported results of trimodal treatment (TMT) in muscle-invasive bladder cancer vary widely. We attempted to characterize the profile of ideal candidates for this approach. Between 2000 and 2019, 105 patients (median age 78 years) with T2-4aN0M0 bladder cancer were treated with TMT and analyzed retrospectively. Mean radiotherapy dose was 62 Gy (SD 8.4). Ten pretreatment prognostic parameters were evaluated including tumor diameter on pre-TURBT CT. Multivariate analyses was performed and combination of parameters was studied. After a median follow-up of 29 months, 53 patients (50.5%) developed recurrence and 70 patients (67.7%) died. Death was disease-specific in 46 patients (65.7%). Tumor diameter was the most significant prognostic parameter with p < 0.0001 for overall, disease-specific and recurrence-free survivals. For every 1 cm increase in tumor diameter, the risk of disease-specific mortality increased by 1.57. Age, cisplatin eligibility and the Charlson Comorbidity Index were significant predictors of overall survival but not of disease-specific or recurrence-free survival. Patients who were cisplatin-eligible with a tumor diameter ≤3 cm had a 5-year disease-specific survival rate of 79.2% as opposed to 33.9% in patients without one of these features (p < 0.001). When tumor diameter exceeded 5 cm (irrelevant of all other parameters), 5-year disease-specific survival rate was only 28.2%. Patient profiles can accurately predict response to TMT. In cisplatin-eligible patients with a tumor diameter ≤3 cm, TMT provides an excellent disease-specific survival rate. In patients with a tumor diameter >5 cm TMT renders unacceptably poor treatment outcomes.
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Affiliation(s)
- Ofer N. Gofrit
- Department of UrologyHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Amichay Meirovitz
- Department of OncologyHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Stephen Frank
- Department of OncologyHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Igal Rabinovich
- Department of UrologyHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Hemda Luwisch
- Department of UrologyHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Vladimir Yutkin
- Department of UrologyHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Tzahi Neuman
- Department of PathologyHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Guy Hidas
- Department of UrologyHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Mordechai Duvdevani
- Department of UrologyHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Marc Wygoda
- Department of OncologyHadassah Hebrew University Medical CenterJerusalemIsrael
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30
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Black PC, Efstathiou J. Setting the stage for bladder preservation. Urol Oncol 2020; 39:209-212. [PMID: 33008753 DOI: 10.1016/j.urolonc.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/02/2020] [Indexed: 01/05/2023]
Abstract
There is an underutilization of potentially curative treatments for patients with muscle-invasive bladder cancer. Contemporary trimodality bladder-preservation therapy - which includes a maximally safe transurethral resection of the bladder tumor followed by concurrent chemoradiation and close cystoscopic surveillance with salvage cystectomy reserved for invasive tumor recurrence - can help fulfill this unmet need. Over the past few decades, cumulative published data from prospective clinical trials and large institutional series have established trimodality therapy (TMT) for select patients as a safe and effective alternative to upfront cystectomy. Indeed, TMT is now supported as an accepted option for muscle-invasive bladder cancer patients by numerous clinical guidelines. Following TMT, the vast majority of long-term survivors maintain their native bladders, which tend to function well with relatively low rates of long-term toxicity and good long-term quality of life. There is the potential to further improve outcomes by optimizing systemic therapy integration and by validating predictive biomarkers for improved patient and treatment selection. TMT offers a unique opportunity for urologic surgeons, radiation oncologists and medical oncologists to work hand-in-hand in a multidisciplinary effort to deliver such therapy optimally, to support its research, to promote informed decision-making and ultimately to preserve the autonomy of patients with bladder cancer. The third annual meeting of the Johns Hopkins Greenberg Bladder Cancer Institute/American Urological Association Translational Research Collaboration allowed bladder cancer experts to meet and advance this mission.
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Affiliation(s)
- Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, Canada.
| | - Jason Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Vassantachart A, Daneshmand S, Cai J, Miranda G, Ghodoussipour S, Schuckman AK, Djaladat H, Ballas L. Feasibility and Outcomes of Orthotopic Ileal Neobladder Reconstruction Following Pelvic Irradiation. Urology 2020; 148:198-202. [PMID: 32979377 DOI: 10.1016/j.urology.2020.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the complications and oncologic outcomes of orthotopic ileal neobladder reconstruction (ONB) following pelvic radiotherapy (RT) compared to patients with no prior pelvic RT. METHODS Our institutional database was queried for all patients with pT0-4bN0-3M0 urothelial carcinoma of the bladder who underwent radical cystectomy with curative intent and ONB between 1990 and 2018. We then queried this cohort for patients who had prior pelvic RT (>3900 cGy) and compared baseline characteristics, perioperative complications, and recurrence free survival between patients with and without prior pelvic RT. RESULTS One thousand eight hundred and forty-six patients matched our inclusion criteria; 34 had prior pelvic RT with a median dose of 6280 cGy. Prior RT targeted the bladder, prostate, and cervix in 27, 6, and 1 patient, respectively. Median time from RT to cystectomy was 15.5 months. Patients with prior RT had a longer time from diagnosis to cystectomy, more frequently had ≥5 TURBT and neoadjuvant chemo, and less frequently had multifocal disease. Perioperative complications including operative time, estimated blood loss, days hospitalized, as well as 30- and 90-day complication rates, were not statistically different. There was no statistical difference in recurrence free survival between the 2 groups (P = .48). CONCLUSION ONB in highly selected patients with prior pelvic RT is feasible with statistically similar perioperative complication rates compared to ONB without prior RT.
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Affiliation(s)
| | - Siamak Daneshmand
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Jie Cai
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Gus Miranda
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Saum Ghodoussipour
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Anne K Schuckman
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Hooman Djaladat
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Leslie Ballas
- Department of Radiation Oncology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
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Jiang DM, North SA, Canil C, Kolinsky M, Wood LA, Gray S, Eigl BJ, Basappa NS, Blais N, Winquist E, Mukherjee SD, Booth CM, Alimohamed NS, Czaykowski P, Kulkarni GS, Black PC, Chung PW, Kassouf W, van der Kwast T, Sridhar SS. Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada. Bladder Cancer 2020. [DOI: 10.3233/blc-200291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND: Despite recent advances in the management of muscle-invasive bladder cancer (MIBC), treatment outcomes remain suboptimal, and variability exists across current practice patterns. OBJECTIVE: To promote standardization of care for MIBC in Canada by developing a consensus guidelines using a multidisciplinary, evidence-based, patient-centered approach who specialize in bladder cancer. METHODS: A comprehensive literature search of PubMed, Medline, and Embase was performed; and most recent guidelines from national and international organizations were reviewed. Recommendations were made based on best available evidence, and strength of recommendations were graded based on quality of the evidence. RESULTS: Overall, 17 recommendations were made covering a broad range of topics including pathology review, staging investigations, systemic therapy, local definitive therapy and surveillance. Of these, 10 (59% ) were level 1 or 2, 7 (41% ) were level 3 or 4 recommendations. There were 2 recommendations which did not reach full consensus, and were based on majority opinion. This guideline also provides guidance for the management of cisplatin-ineligible patients, variant histologies, and bladder-sparing trimodality therapy. Potential biomarkers, ongoing clinical trials, and future directions are highlighted. CONCLUSIONS: This guideline embodies the collaborative expertise from all disciplines involved, and provides guidance to further optimize and standardize the management of MIBC.
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Affiliation(s)
- Di Maria Jiang
- Department of Medicine, Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Scott A. North
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Christina Canil
- Department of Internal Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON, Canada
| | - Michael Kolinsky
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Lori A. Wood
- Department of Medicine, Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Samantha Gray
- Department of Oncology, Saint John Regional Hospital, Department of Medicine, Dalhousie University, Saint John, NB, Canada
| | - Bernhard J. Eigl
- Department of Medicine, Division of Medical Oncology, BC Cancer - Vancouver, University of British Columbia, Vancouver, BC, Canada
| | - Naveen S. Basappa
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Normand Blais
- Department of Medicine, Division of Medical Oncology and Hematology, Centre Hospitalier de l’Université de Montréal; Université de Montréal, Montreal, QC, Canada
| | - Eric Winquist
- Department of Oncology, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Som D. Mukherjee
- Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | - Nimira S. Alimohamed
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Piotr Czaykowski
- Department of Medical Oncology and Hematology, Cancer Care Manitoba, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Girish S. Kulkarni
- Departments of Surgery and Surgical Oncology, Division of Urology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Peter C. Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Peter W. Chung
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Wassim Kassouf
- Department of Urology, McGill University Health Centre, Montreal, QC, Canada
| | | | - Srikala S. Sridhar
- Department of Medicine, Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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Abstract
Bladder cancer accounts for nearly 170,000 deaths worldwide annually. For over 4 decades, the systemic management of muscle-invasive and advanced bladder cancer has primarily consisted of platinum-based chemotherapy. Over the past 10 years, innovations in sequencing technologies have led to rapid genomic characterization of bladder cancer, deepening our understanding of bladder cancer pathogenesis and exposing potential therapeutic vulnerabilities. On the basis of its high mutational burden, immune checkpoint inhibitors were investigated in advanced bladder cancer, revealing durable responses in a subset of patients. These agents are now approved for several indications and highlight the changing treatment landscape of advanced bladder cancer. In addition, commonly expressed molecular targets were leveraged to develop targeted therapies, such as fibroblast growth factor receptor inhibitors and antibody-drug conjugates. The molecular characterization of bladder cancer and the development of novel therapies also have stimulated investigations into optimizing treatment approaches for muscle-invasive bladder cancer. Herein, the authors review the history of muscle-invasive and advanced bladder cancer management, highlight the important molecular characteristics of bladder cancer, describe the major advances in treatment, and offer future directions for therapeutic development.
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Affiliation(s)
- Vaibhav G Patel
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - William K Oh
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthew D Galsky
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Drakaki A, Pantuck A, Mhatre SK, Dhillon PK, Davarpanah N, Degaonkar V, Surinach A, Chamie K, Grivas P. "Real-world" outcomes and prognostic indicators among patients with high-risk muscle-invasive urothelial carcinoma. Urol Oncol 2020; 39:76.e15-76.e22. [PMID: 32778476 DOI: 10.1016/j.urolonc.2020.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/25/2020] [Accepted: 07/08/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION There is no current standard of care for patients with high-risk muscle-invasive urothelial carcinoma (MIUC) after neoadjuvant chemotherapy and surgical resection or for those who cannot receive or decline cisplatin-based perioperative chemotherapy. Understanding current, real-world treatment patterns may help inform decisions from clinical, research, and population health management perspectives. We examined real-world treatment patterns, survival outcomes, and prognostic factors among Medicare beneficiaries with high-risk MIUC who did not receive adjuvant treatment after surgical resection. METHODS We identified patients with high-risk MIUC in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database who underwent surgical resection (radical cystectomy and/or radical nephroureterectomy). Eligible patients had indicators of high-risk MIUC and surgical resection between 2001 and 2013. Demographic and clinical characteristics, including comorbidities, American Joint Commission on Cancer (AJCC) stage, tumor stage/grade and nodal status, and distribution of neoadjuvant treatment by the year of surgical resection were evaluated. Overall survival (OS) and disease-free survival (DFS) were assessed for the full cohort and by subgroups using Kaplan-Meier survival analysis. Adjusted Cox proportional hazards models were used to evaluate patient demographics and clinical characteristics associated with OS and DFS. RESULTS A total of 665 patients were included in the analysis, with a mean age of 75.5 years; most were men (61%) and had AJCC stage IIIA disease (69%). Neoadjuvant treatment increased over the entire study period, both overall (from 12% to 46%) and cisplatin based (from 5% to 38%). Median OS for the entire cohort was 23.1 months (95% confidence interval: 18, 27); median DFS was 13.5 months (95% confidence interval: 11.3, 16.8). AJCC stage IIIB/IVA was the most significant predictor of poor prognosis for both OS and DFS, followed by non-white race and comorbidity burden. CONCLUSION The prognosis for high-risk patients with MIUC remains poor, with significant risk of mortality within 2 years of radical cystectomy despite increasing use of neoadjuvant treatment. Unmet treatment needs persist for this difficult-to-treat patient population despite the increasing use of cisplatin-based neoadjuvant chemotherapy.
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Affiliation(s)
| | - Allan Pantuck
- University of California Los Angeles, Los Angeles, CA
| | | | | | | | | | | | - Karim Chamie
- University of California Los Angeles, Los Angeles, CA
| | - Petros Grivas
- University of Washington, Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, Seattle, WA
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Psutka SP. Introduction: Personalizing risk stratification in bladder cancer: Moving away from "the eyeball test" and embracing objective quantification of risk. Urol Oncol 2020; 38:695-697. [PMID: 32600927 DOI: 10.1016/j.urolonc.2020.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 05/15/2020] [Accepted: 05/28/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Sarah P Psutka
- Department of Urology, Seattle Cancer Care Alliance, University of Washington, Seattle, WA.
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Golla V, Shan Y, Mehta HB, Klaassen Z, Tyler DS, Baillargeon J, Kamat AM, Freedland SJ, Gore JL, Chamie K, Kuo YF, Williams SB. Impact of Diagnosing Urologists and Hospitals on the Use of Radical Cystectomy. EUR UROL SUPPL 2020; 19:27-36. [PMID: 34337452 PMCID: PMC8317809 DOI: 10.1016/j.euros.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2020] [Indexed: 11/22/2022] Open
Abstract
Background One out of five patients with muscle-invasive bladder cancer undergo radical cystectomy—a guideline-recommended treatment. Previous studies have primarily evaluated patient characteristics associated with the use of radical cystectomy, ignoring potential nesting of data. Objective To determine the impact of patient, diagnosing urologist, and hospital characteristics on the variation in the use of radical cystectomy. Design, setting, and participants This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results Registry (SEER)-Medicare linked database. Outcome measurements and statistical analysis A total of 7097 muscle-invasive bladder cancer patients and 4601 diagnosing urologists affiliated to 822 hospitals from January 1, 2002 to December 31, 2012 were analyzed. Multilevel logistic regression analyses were used to determine variation and factors associated with the use of radical cystectomy. Results and limitations Of the 7097 patients, only 27% underwent radical cystectomy. The intraclass correlation coefficient for variation in the use of radical cystectomy attributed to the hospital level was 4.3%. Higher radical cystectomy volume by diagnosing urologists (more than five vs zero to one surgery: odds ratio [OR], 1.27; 95% confidence interval [CI], 1.00–1.62) and hospitals (more than five vs zero to four surgeries: OR,1.48; 95% CI, 1.14–1.93) was associated with increased use of radical cystectomy. Patients diagnosed by female rather than male urologists were more likely to undergo radical cystectomy (OR, 1.32; 95% CI, 1.07–1.62). Conclusions We found that 4.3% variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. We identified significantly increased use among higher-volume and female diagnosing urologists. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy. Patient summary In this large population-based study, we found that 4.3% of variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. Higher radical cystectomy volume of diagnosing urologists and female urologists were independently associated with increased use of radical cystectomy. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy.
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Affiliation(s)
- Vishnukamal Golla
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Yong Shan
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hemalkumar B. Mehta
- Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
| | - Zachary Klaassen
- Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
| | - Douglas S. Tyler
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Ashish M. Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - John L. Gore
- Department of Urology, The University of Washington, Seattle, WA, USA
| | - Karim Chamie
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Stephen B. Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
- Corresponding author. Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA. Tel.: +1-409-747-7333; Fax: +1-409-772-0088.
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Lin T, Zhang Q, Yuan A, Wang B, Zhang F, Ding Y, Cao W, Chen W, Guo H. Synergy of Tumor Microenvironment Remodeling and Autophagy Inhibition to Sensitize Radiation for Bladder Cancer Treatment. Am J Cancer Res 2020; 10:7683-7696. [PMID: 32685013 PMCID: PMC7359086 DOI: 10.7150/thno.45358] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/07/2020] [Indexed: 01/23/2023] Open
Abstract
Tumor hypoxia, acidosis, and excessive reactive oxygen species (ROS) were the main characteristics of the bladder tumor microenvironment (TME), and abnormal TME led to autophagy activation, which facilitated cancer cell proliferation. The therapeutic efficacy of autophagy inhibitors might also be impeded by abnormal TME. To address these issues, we proposed a new strategy that utilized manganese dioxide (MnO2) nanoparticles to optimize the abnormal TME and revitalize autophagy inhibitors, and both oxygenation and autophagy inhibition may sensitize the tumor cells to radiation therapy. Methods: By taking advantage of the strong affinity between negatively charged MnO2 and positively charged chloroquine (CQ), the nanoparticles were fabricated by integrating MnO2 and CQ in human serum albumin (HSA)-based nanoplatform (HSA-MnO2-CQ NPs). Results: HSA-MnO2-CQ NPs NPs efficiently generated O2 and increased pH in vitro after reaction with H+/H2O2 and then released the encapsulated CQ in a H+/H2O2 concentration-dependent manner. The NPs restored the autophagy-inhibiting activity of chloroquine in acidic conditions by increasing its intracellular uptake, and markedly blocked hypoxia-induced autophagic flux. In vivo studies showed the NPs improved pharmacokinetic behavior of chloroquine and effectively accumulated in tumor tissues. The NPs exhibited significantly decreased tumor hypoxia areas and increased tumor pH, and had remarkable autophagy inhibition efficacy on bladder tumors. Finally, a significant anti-tumor effect achieved by the enhanced autophagy inhibition and radiation sensitization. Conclusions: HSA-MnO2-CQ NPs synergistically regulated the abnormal TME and inhibited autophagic flux, and effectively sensitized radiation therapy to treat bladder cancers.
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Witjes JA, Bruins HM, Cathomas R, Compérat EM, Cowan NC, Gakis G, Hernández V, Linares Espinós E, Lorch A, Neuzillet Y, Rouanne M, Thalmann GN, Veskimäe E, Ribal MJ, van der Heijden AG. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines. Eur Urol 2020; 79:82-104. [PMID: 32360052 DOI: 10.1016/j.eururo.2020.03.055] [Citation(s) in RCA: 1017] [Impact Index Per Article: 254.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 01/11/2023]
Abstract
CONTEXT This overview presents the updated European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC). OBJECTIVE To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the MMIBC guideline has been performed annually since its 2017 publication (based on the 2016 guideline). Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries, resulting in yearly guideline updates. A level of evidence and a grade of recommendation were assigned. Additionally, the results of a collaborative multistakeholder consensus project on advanced bladder cancer (BC) have been incorporated in the 2020 guidelines, addressing those areas where it is unlikely that prospective comparative studies will be conducted. EVIDENCE SYNTHESIS Variant histologies are increasingly reported in invasive BC and are relevant for treatment and prognosis. Staging is preferably done with (enhanced) computerised tomography scanning. Treatment decisions are still largely based on clinical factors. Radical cystectomy (RC) with lymph node dissection remains the recommended treatment in highest-risk non-muscle-invasive and muscle-invasive nonmetastatic BC, preceded by cisplatin-based neoadjuvant chemotherapy (NAC) for invasive tumours in "fit" patients. Selected men and women benefit from sexuality sparing RC, although this is not recommended as standard therapy. Open and robotic RC show comparable outcomes, provided the procedure is performed in experienced centres. For open RC 10, the minimum selected case load is 10 procedures per year. If bladder preservation is considered, chemoradiation is an alternative in well-selected patients without carcinoma in situ and after maximal resection. Adjuvant chemotherapy should be considered if no NAC was given. Perioperative immunotherapy can be offered in clinical trial setting. For fit metastatic patients, cisplatin-based chemotherapy remains the first choice. In cisplatin-ineligible patients, immunotherapy in Programmed Death Ligand 1 (PD-L1)-positive patients or carboplatin in PD-L1-negative patients is recommended. For second-line treatment in metastatic disease, pembrolizumab is recommended. Postchemotherapy surgery may prolong survival in responders. Quality of life should be monitored in all phases of treatment and follow-up. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/. CONCLUSIONS This summary of the 2020 EAU MMIBC guideline provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology Muscle-invasive and Metastatic Bladder Cancer (MMIBC) Panel has released an updated version of their guideline, which contains information on histology, staging, prognostic factors, and treatment of MMIBC. The recommendations are based on the current literature (until the end of 2019), with emphasis on high-level data from randomised clinical trials and meta-analyses and on the findings of an international consensus meeting. Surgical removal of the bladder and bladder preservation are discussed, as well as the use of chemotherapy and immunotherapy in localised and metastatic disease.
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Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | - Harman Max Bruins
- Department of Urology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, The Netherlands
| | - Richard Cathomas
- Department of Medical Oncology, Kantonsspital Graubünden, Chur, Switzerland
| | - Eva M Compérat
- Department of Pathology, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hopital Tenon, Paris, France
| | - Nigel C Cowan
- Department of Radiology, The Queen Alexandra Hospital, Portsmouth, UK
| | - Georgios Gakis
- Department of Urology and Pediatric Urology, University of Würzburg, Würzburg, Germany
| | - Virginia Hernández
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Anja Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Yann Neuzillet
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Mathieu Rouanne
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - George N Thalmann
- Department of Urology, Inselspital, University Hospital Bern, Switzerland
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Maria J Ribal
- Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Fedeli U, De Paoli A, Corti MC, Cacciamani GE, Gill IS, Zattoni F, Novara G, Porreca A, Artibani W. Perioperative Mortality and Long-Term Survival after Radical Cystectomy: A Population-Based Study in a Southern European Country on 4,389 Patients. Urol Int 2020; 104:559-566. [PMID: 32272471 DOI: 10.1159/000506240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 01/27/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE Population-based data on survival after radical cystectomy (RC) are lacking from Southern Europe. The aim of this study was to assess trends and determinants of perioperative mortality and long-term survival in the Veneto region (Northeastern Italy). METHODS All patients submitted to RC for bladder cancer from January 2004 to December 2016 were identified from the regional archive of hospital discharge records. Age at surgery, gender, comorbidities, hospital volume, calendar period of surgery, and type of urinary diversion were retrieved; vital status and cause of death were obtained by linkage with mortality records. Determinants of 90-day mortality were assessed by multilevel logistic regression; long-term survival was investigated by the Kaplan-Meier method and Cox regression. RESULTS Among 4,389 included patients, an increase in the share of patients aged ≥80 years (from 13% in 2004-2008 to 24% in 2013-2016, p < 0.001) and a decline in performing continent diversion (from 34.9 to 23.4%, p < 0.001) were observed across the study period. Ninety-day mortality did not change over time and was 4% for patients aged <70 years and 13.7% for those aged ≥80 years. Age- and comorbidities-adjusted mortality was significantly lower in hospitals performing >30 RCs/year (odds ratio 0.67, 95% confidence interval 0.48-0.93). At a median follow-up of 67 months, overall survival at 1 year and 5 years was 72 and 40%, respectively, with a higher rate among younger patients treated in high-volume hospitals. CONCLUSION The population of patients treated with RC is rapidly ageing, with a high risk of perioperative and long-term mortality; this changing epidemiological scenario and better outcomes observed in high-volume hospitals support regionalization of the procedure.
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Affiliation(s)
- Ugo Fedeli
- Epidemiological Department, Azienda Zero, Padova, Italy
| | | | | | - Giovanni Enrico Cacciamani
- Department of Urology, University of Verona, Verona, Italy.,USC Institute of Urology and the Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, Los Angeles, California, USA
| | - Inderbir S Gill
- USC Institute of Urology and the Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, Los Angeles, California, USA
| | - Filiberto Zattoni
- Urologic Unit, Department of Oncologic, Surgical and Gastrointestinal Sciences, University of Padua, Padua, Italy
| | - Giacomo Novara
- Urologic Unit, Department of Oncologic, Surgical and Gastrointestinal Sciences, University of Padua, Padua, Italy
| | - Angelo Porreca
- Department of Urology, Policlinico Abano Terme, Abano Terme, Italy
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Abstract
PURPOSE OF REVIEW This review examines both trimodality therapy (TMT) in the definitive management of bladder cancer as well as the use of adjuvant radiotherapy for bladder cancer with a specific focus on publications from the last 2 years. RECENT FINDINGS TMT is an effective management strategy for muscle invasive bladder cancer with outcomes similar to radical cystectomy. Effectiveness of this strategy exists in variant histologies and can be personalized with use of biomarkers. There is a role for adjuvant radiotherapy in locally advanced bladder cancer, especially in the age of improved imaging and modern radiotherapy techniques. SUMMARY This review should provide the reader data necessary to support use of TMT and adjuvant radiation therapy in their clinic.
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Gakis G. Management of Muscle-invasive Bladder Cancer in the 2020s: Challenges and Perspectives. Eur Urol Focus 2020; 6:632-638. [PMID: 31987763 DOI: 10.1016/j.euf.2020.01.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/30/2019] [Accepted: 01/16/2020] [Indexed: 12/16/2022]
Abstract
Despite an increased use of neoadjuvant and adjuvant chemotherapy, the long-term survival rates after radical cystectomy or trimodal therapy (TMT) for muscle-invasive bladder cancer (MIBC) remain basically unchanged for decades. Detection and effective treatment of micrometastatic disease are still a clinical dilemma. Assessment of circulating tumor DNA in combination with improved imaging modalities may improve the prediction of micrometastatic disease. Different genetic subtypes of MIBC show varying degrees of chemosensitivity. Further progress needs to be made in order to develop a common molecular classifier that can be used easily for daily clinical decision making. With the advent on immuno-oncology, bladder-sparing protocols are on the rise as an alternative to surgery. The extent of transurethral bladder tumor resection has a marked impact on the response rates to TMT and neoadjuvant chemotherapy. This review focuses on strategies regarding how to integrate surgery, radiotherapy, and molecular-based systemic treatment for improved oncological outcomes of patients with MIBC. PATIENT SUMMARY: Effective treatment of micrometastatic disease is the key to improved oncological outcomes in muscle-invasive bladder cancer and requires a multidisciplinary approach.
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Affiliation(s)
- Georgios Gakis
- Department of Urology and Pediatric Urology, Julius Maximillians University, Würzburg, Germany.
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Guo Y, Jie X, Zhang A, Zhang W, Wang R, Zhang J, Mao S, Wu Y, Wang L, Zhang Z, Yan Y, Wang P, Yao X. Evaluation of Survival Outcomes With Trimodal Therapy as Primary Therapy for Non-organ-confined Bladder Cancer. Front Oncol 2019; 9:1315. [PMID: 31867271 PMCID: PMC6909817 DOI: 10.3389/fonc.2019.01315] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 11/12/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Currently, the diagnosis of non-organ-confined bladder cancer (NOCBCa) has a very poor prognosis. For patients with NOCBCa, treatments such as radical cystectomy (RC) and systemic chemotherapy have shown survival benefits. However, the relative survival benefits of trimodal therapy (TMT) are unclear. Methods: Patients diagnosed with NOCBCa (cT4bN0M0, cTxN1-3M0, or TxNxM1) were identified in the Surveillance, Epidemiology, and End Results (SEER) database (2004–2015). Patients were grouped based on their definitive treatment for bladder cancer (RC or TMT with maximal transurethral resection, chemotherapy, or radiotherapy). All-cause mortality (ACM) and bladder cancer-specific mortality (BCSM) were assessed by Cox proportional hazard regression and competitive risk models. Results: A total of 2,988 patients met the inclusion criteria and were treated with RC (83.5%) or TMT (16.5%). Patients who underwent TMT had higher 5-year ACM (91.3%) and BCSM (88.8%) results compared to patients who underwent RC (82.6 and 75.0%, respectively) (P < 0.001). Adjusted hazard rate (AHR) analysis showed that TMT was associated with higher ACM (AHR: 1.33, 95% CI: 1.15–1.54, P < 0.001) and higher BCSM (AHR: 1.32, 95% CI: 1.13–1.54, P = 0.001). Subgroup analysis revealed not statistically significant between RC and TMT among patients aged ≥80 years (P > 0.05). Conclusions: Compared with TMT, RC is associated with a significant reduction in ACM and BCSM. However, the risks and survival benefits of RC should be weighed, especially in older patients, and our results further suggest that there may be no difference in the prognosis of RC and TMT in patients ≥80 years of age. These results are preliminary and emphasize the need for randomized controlled trials to compare TMT and RC.
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Affiliation(s)
- Yadong Guo
- Shanghai Clinical Medical College, Anhui Medical University, Hefei, China.,Shanghai Tenth People's Hospital, Tongji University, Shanghai, China.,Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xiaoliang Jie
- Shanghai Clinical Medical College, Anhui Medical University, Hefei, China.,Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Aihong Zhang
- Department of Medical Statistics, Tongji University School of Medicine, Shanghai, China
| | - Wentao Zhang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ruiliang Wang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Junfeng Zhang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Shiyu Mao
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Yuan Wu
- Shanghai Clinical Medical College, Anhui Medical University, Hefei, China.,Shanghai Tenth People's Hospital, Tongji University, Shanghai, China.,Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Longsheng Wang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ziwei Zhang
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Yang Yan
- Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ping Wang
- Shanghai Clinical Medical College, Anhui Medical University, Hefei, China.,Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xudong Yao
- Shanghai Clinical Medical College, Anhui Medical University, Hefei, China.,Shanghai Tenth People's Hospital, Tongji University, Shanghai, China.,Department of Urology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
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Solanki AA, Liauw SL. The perils of using registry data to compare the survival and cost of radical cystectomy and trimodality therapy in bladder cancer. Transl Androl Urol 2019; 8:S533-S537. [PMID: 32042640 DOI: 10.21037/tau.2019.12.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
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Screening logs from a pilot randomized controlled trial of radical cystectomy versus chemoradiation therapy for muscle-invasive bladder cancer. Urol Oncol 2019; 38:4.e1-4.e6. [PMID: 31676280 DOI: 10.1016/j.urolonc.2019.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/18/2019] [Accepted: 09/07/2019] [Indexed: 01/09/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is growing interest in a bladder preservation approach using chemoradiation therapy with transurethral resection of bladder tumor (TURBT), i.e., combined modality treatment (CMT), for muscle-invasive bladder cancer (MIBC). We have initiated a pilot study to determine feasibility of conducting a larger-scale clinical trial comparing CMT to radical cystectomy (RC) in patients with MIBC. Here we present the screening logs from the recruitment phase of this trial. METHODS Patients who were diagnosed to have MIBC after TURBT between April 2016 and August 2017 and considered to be candidates for surgery were enrolled in this prospective, single center, randomized controlled pilot feasibility trial and scheduled to undergo RC (with neoadjuvant chemotherapy if appropriate) or CMT. RESULTS Of 62 patients screened during the recruitment phase, only 5 were found to be suitable candidates for either treatment modality hence eligible for randomization. The reasons for exclusion were as follows: multifocal disease (n = 24, 40%), variant histology (n = 15, 25%), previous pelvic radiation (n = 6, 10%), severe lower urinary tract symptoms (n = 5, 8.3%), unwillingness to be enrolled (n = 8, 13.3%), and receipt of neoadjuvant chemotherapy (n = 2, 3.3%). One of the 5 eligible patients was randomized to CMT but was subsequently switched to RC because of a high tumor burden, 1 was randomized to RC, 2 were randomized to CMT but subsequently underwent TURBT and were considered ineligible because of extensive bladder disease, and 1 elected to undergo RC. CONCLUSIONS We identified many patients with MIBC over a period of 16 months. However, the number of patients eligible to receive chemotherapy and in whom cystectomy and radiation therapy were both valid options was not as high as previously reported in retrospective CMT series. Many patients were excluded after TURBT. Our preliminary data indicate that only a very small subset of patients with MIBC are ideal candidates for CMT. Further research is required to identify patients who are suitable for CMT.
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Williams SB, Shan Y, Jazzar U, Mehta HB, Baillargeon JG, Huo J, Senagore AJ, Orihuela E, Tyler DS, Swanson TA, Kamat AM. Comparing Survival Outcomes and Costs Associated With Radical Cystectomy and Trimodal Therapy for Older Adults With Muscle-Invasive Bladder Cancer. JAMA Surg 2019; 153:881-889. [PMID: 29955780 DOI: 10.1001/jamasurg.2018.1680] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance Radical cystectomy is the guidelines-recommended treatment of muscle-invasive bladder cancer, but a resurgence of trimodal therapy has occurred. Limited comparative data are available on outcomes and costs attributable to these 2 treatments. Objective To compare the survival outcomes and costs between trimodal therapy and radical cystectomy in older adults with muscle-invasive bladder cancer. Design, Setting, and Participants This population-based cohort study used data from the Surveillance, Epidemiology, and End Results-Medicare linked database. A total of 3200 older adults (aged ≥66 years) with clinical stage T2 to T4a bladder cancer diagnosed from January 1, 2002, to December 31, 2011, and with claims data available through December 31, 2013, were included in the analysis. Patients who received radical cystectomy underwent either only surgery or surgery in combination with radiotherapy or chemotherapy. Patients who received trimodal therapy underwent transurethral resection of the bladder followed by radiotherapy and chemotherapy. Propensity score matching by sociodemographic and clinical characteristics was used. Data analysis was performed from August 1, 2017, to March 11, 2018. Main Outcomes and Measures Overall survival and cancer-specific survival were evaluated using the Cox proportional hazards regression model and the Fine and Gray competing risk model. All Medicare health care costs for inpatient, outpatient, and physician services within 30, 90, and 180 days of treatment were compared. The total amount spent nationwide was estimated, using 180-day medical costs between treatments, by the total number of new cases of muscle-invasive bladder cancer in the United States in 2011. Results Of the 3200 patients who met the inclusion criteria, 2048 (64.0%) were men and 1152 (36.0%) were women, with a mean (SD) age of 75.8 (6.0) years. After propensity score matching, 687 patients (21.5%) underwent trimodal therapy and 687 patients (21.5%) underwent radical cystectomy. Patients who underwent trimodal therapy had significantly decreased overall survival (hazard ratio [HR], 1.49; 95% CI, 1.31-1.69) and cancer-specific survival (HR, 1.55; 95% CI, 1.32-1.83). No differences in costs at 30 days were observed between trimodal therapy ($15 233 in 2002 vs $18 743 in 2011) and radical cystectomy ($17 990 in 2002 vs $21 738 in 2011). However, median total costs were significantly higher with trimodal therapy than with radical cystectomy at 90 days ($80 174 vs $69 181; median difference, $8964; Hodges-Lehmann 95% CI, $3848-$14 079) and at 180 days ($179 891 vs $107 017; median difference, $63 771; Hodges-Lehmann 95% CI, $55 512-$72 029). Extrapolating these figures to the total US population revealed $335 million in excess spending for trimodal therapy compared with the less costly radical cystectomy ($492 million) for patients who received a muscle-invasive bladder cancer diagnosis in 2011. Conclusions and Relevance Trimodal therapy was associated with significantly decreased overall survival and cancer-specific survival as well as $335 million in excess spending in 2011. These findings have important health policy implications regarding the appropriate use of high value-based care among older adults with invasive bladder cancer who are candidates for either radical cystectomy or trimodal therapy.
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Affiliation(s)
- Stephen B Williams
- Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Yong Shan
- Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Usama Jazzar
- Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Hemalkumar B Mehta
- Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Jacques G Baillargeon
- Sealy Center on Aging, Division of Epidemiology, Department of Medicine, The University of Texas Medical Branch, Galveston
| | - Jinhai Huo
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville
| | - Anthony J Senagore
- Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Eduardo Orihuela
- Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas Medical Branch, Galveston
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston
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Williams SB, Shan Y, Ray-Zack MD, Hudgins HK, Jazzar U, Tyler DS, Freedland SJ, Swanson TA, Baillargeon JG, Hu JC, Kaul S, Kamat AM, Gore JL, Mehta HB. Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer. JAMA Surg 2019; 154:e191629. [PMID: 31166593 DOI: 10.1001/jamasurg.2019.1629] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. Objective To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs. Design, Setting, and Participants This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018. Main Outcomes and Measures Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias. Results Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83 754 vs $68 692; median difference, $11 805; 95% CI, $7745-$15 864), 180 days ($187 162 vs $109 078; median difference, $62 370; 95% CI, $55 581-$69 160), and 365 days ($289 142 vs $148 757; median difference, $109 027; 95% CI, $98 692-$119 363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136 935 (95% CI, $122 131-$152 115) higher mean costs compared with radical cystectomy 1 year after diagnosis. Conclusions and Relevance Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.
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Affiliation(s)
- Stephen B Williams
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | - Yong Shan
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | - Mohamed D Ray-Zack
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | - Hogan K Hudgins
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | - Usama Jazzar
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | | | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas Medical Branch at Galveston, Galveston
| | - Jacques G Baillargeon
- Sealy Center on Aging, Division of Epidemiology, Department of Medicine, The University of Texas Medical Branch at Galveston, Galveston
| | - Jim C Hu
- Department of Urology, Weill Cornell Medicine, New York, New York
| | - Sapna Kaul
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch at Galveston, Galveston
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston
| | - John L Gore
- Department of Urology, University of Washington, Seattle
| | - Hemalkumar B Mehta
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
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Kaushik D, Wang H, Michalek J, Liss MA, Liu Q, Jha RP, Svatek RS, Mansour AM. Chemoradiation Vs Radical Cystectomy for Muscle-invasive Bladder Cancer: A Propensity Score-weighted Comparative Analysis Using the National Cancer Database. Urology 2019; 133:164-174. [PMID: 31401220 DOI: 10.1016/j.urology.2019.05.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/19/2019] [Accepted: 05/16/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To address the overarching question whether chemoradiation therapy (CMT) offers overall survival (OS) similar to that of radical cystectomy (RC) in muscle-invasive bladder cancer (MIBC), we performed analyses using the National Cancer Database. MATERIALS AND METHODS Patients diagnosed with MIBC in 2004-2014 who underwent RC or received primary CMT were identified in the National Cancer Database. Survival was estimated using the weighted Kaplan-Meier method, and propensity score-weighted Cox proportional hazards model were used to evaluate association of clinicopathologic features with outcome. RESULTS Of 484,367 patients with a diagnosis of bladder cancer, 35,856 underwent RC and 4050 received CMT. After applying the exclusion/inclusion criteria, data for 15,854 patients who underwent RC and 2083 who received CMT were available for analysis. Five-year OS was 40.4% in the RC group and 29.4% in the CMT group (P <.001). OS was significantly shorter in the CMT group than in the RC group in both multivariate analysis (hazards ratio [HR] 1.15, 95% CI 1.08-1.22; P <.001) and propensity score-weighted analysis (HR 1.18, 95% CI 1.07-1.30; P <.001). Interaction terms indicated better survival after RC in patients younger than 70 years (HR 1.61, 95% CI 1.34-1.93; P <.001); subgroup analyses identified a survival benefit in patients with N0/N1 disease who underwent RC (HR 1.21, 95% CI 1.09-1.33; P <.001). CONCLUSION AND RELEVANCE OS after 1 year of treatment was increased in RC group compared to CMT group in patient with MIBC. Further studies are required to identify optimal treatment for specific patients.
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Affiliation(s)
- Dharam Kaushik
- Department of Urology, University of Texas Health, San Antonio, TX.
| | - Hanzhang Wang
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Joel Michalek
- Department of Epidemiology and Biostatistics, University of Texas Health, San Antonio, TX
| | - Michael A Liss
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Qianqian Liu
- Department of Epidemiology and Biostatistics, University of Texas Health, San Antonio, TX
| | - Richa Priya Jha
- Department of Epidemiology and Biostatistics, University of Texas Health, San Antonio, TX
| | - Robert S Svatek
- Department of Urology, University of Texas Health, San Antonio, TX
| | - Ahmed M Mansour
- Department of Urology, University of Texas Health, San Antonio, TX
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Merten R, Ott O, Haderlein M, Bertz S, Hartmann A, Wullich B, Keck B, Kühn R, Rödel CM, Weiss C, Gall C, Uter W, Fietkau R. Long-Term Experience of Chemoradiotherapy Combined with Deep Regional Hyperthermia for Organ Preservation in High-Risk Bladder Cancer (Ta, Tis, T1, T2). Oncologist 2019; 24:e1341-e1350. [PMID: 31292267 PMCID: PMC6975936 DOI: 10.1634/theoncologist.2018-0280] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 02/11/2019] [Indexed: 01/19/2023] Open
Abstract
This article reports on the different treatments for bladder cancer and related effects on frequency of bladder preservation, disease‐free survival, and overall survival, with a focus on the efficacy and safety of chemoradiotherapy combined with regional deep hyperthermia of high‐risk bladder cancer after transurethral resection of bladder tumor. Background. The aim of this study was to evaluate the efficacy and safety of chemoradiotherapy (RCT) combined with regional deep hyperthermia (RHT) of high‐risk bladder cancer after transurethral resection of bladder tumor (TUR‐BT). Materials and methods. Between 1982 and 2016, 369 patients with pTa, pTis, pT1, and pT2 cN0–1 cM0 bladder cancer were treated with a multimodal treatment after TUR‐BT. All patients received radiotherapy (RT) of the bladder and regional lymph nodes. RCT was administered to 215 patients, RCT + RHT was administered to 79 patients, and RT was used in 75 patients. Treatment response was evaluated 4–6 weeks after treatment with TUR‐BT. Results. Complete response (CR) overall was 83% (290/351), and in treatment groups was RT 68% (45/66), RCT 86% (178/208), and RCT + RHT 87% (67/77). CR was significantly improved by concurrent RCT compared with RT (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.05–5.12; p = .037), less influenced by hyperthermia (OR, 2.56; 95% CI, 0.88–8.00; p = .092). Overall survival (OS) after RCT was superior to RT (hazard ratio [HR], 0.7; 95% CI, 0.50–0.99; p = .045). Five‐year OS from unadjusted Kaplan‐Meier estimates was RCT 64% versus RT 45%. Additional RHT increased 5‐year OS to 87% (HR, 0.32; 95% CI, 0.18–0.58; p = .0001). RCT + RHT compared with RCT showed a significantly better bladder‐preservation rate (HR, 0.13; 95% CI, 0.03–0.56; p = .006). Median follow‐up was 71 months. The median number of RHT sessions was five. Conclusion. The multimodal treatment consisted of a maximal TUR‐BT followed by RT; concomitant platinum‐based chemotherapy combined with RHT in patients with high‐grade bladder cancer improves local control, bladder‐preservation rate, and OS. It offers a promising alternative to surgical therapies like radical cystectomy. Implications for Practice. Radical cystectomy with appropriate lymph node dissection has long represented the standard of care for muscle‐invasive bladder cancer in medically fit patients, despite many centers reporting excellent long‐term results for bladder preserving strategies. This retrospective analysis compares different therapeutic modalities in bladder‐preservation therapy. The results of this study show that multimodal treatment consisting of maximal transurethral resection of bladder tumor followed by radiotherapy, concomitant platinum‐based chemotherapy combined with regional deep hyperthermia in patients with Ta, Tis, T1–2 bladder carcinomas improves local control, bladder‐preservation rate, and survival. More importantly, these findings offer a promising alternative to surgical therapies like radical cystectomy. The authors hope that, in the future, closer collaboration between urologists and radiotherapists will further improve treatments and therapies for the benefit of patients.
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Affiliation(s)
- Ricarda Merten
- Department of Radiation Oncology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Oliver Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Marlen Haderlein
- Department of Radiation Oncology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Simone Bertz
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Arndt Hartmann
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Bernd Wullich
- Department of Urology and Pediatric Urology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Bastian Keck
- Department of Urology and Pediatric Urology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Reinhard Kühn
- Department of Urology, Martha Maria Medical Center, Nuremberg, Germany
| | - Claus Michael Rödel
- Department of Radiotherapy and Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Christian Weiss
- Department of Radiation Oncology, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Wolfgang Uter
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
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Tumor Location May Predict Adverse Pathology and Survival Following Definitive Treatment for Bladder Cancer: A National Cohort Study. Eur Urol Oncol 2019; 2:304-310. [DOI: 10.1016/j.euo.2018.08.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/06/2018] [Accepted: 08/21/2018] [Indexed: 12/29/2022]
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50
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Systematic review and meta-analysis on trimodal therapy versus radical cystectomy for muscle-invasive bladder cancer: Does the current quality of evidence justify definitive conclusions? PLoS One 2019; 14:e0216255. [PMID: 31034504 PMCID: PMC6488073 DOI: 10.1371/journal.pone.0216255] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 04/16/2019] [Indexed: 12/25/2022] Open
Abstract
Objectives To systematically review and meta-analyze the current literature in a methodologically rigorous and transparent manner for quantitative evidence on survival outcomes among patients diagnosed with muscle-invasive bladder cancer that were treated by either trimodal therapy or radical cystectomy. Materials and methods MEDLINE, EMBASE, CENTRAL were systematically searched for comparative observational studies reporting disease-specific survival and/or overall survival on adult patients diagnosed with localized muscle-invasive bladder cancer that were exposed to either trimodal therapy or radical cystectomy. Studies qualified for meta-analysis (random effects model) if they were not at critical risk of bias (RoB). Results The literature search identified 12 eligible studies. Three (all rated as “moderate RoB”) out of 6 studies reporting on disease-specific survival qualified for quantitative analysis and yielded a pooled hazard ratio (trimodal therapy versus radical cystectomy) of 1.39 (95% confidence interval: 1.03–1.88). Four (mainly rated as “serious RoB”) out of 12 studies were included in the meta-analysis of overall survival and estimated a hazard ratio of 1.39 (1.20–1.59). Conclusion Pooled results were significant in favor of radical cystectomy. The conclusion is mainly driven by large population-based studies that are at high RoB. Hence, the certainty of these treatment estimates can be considered very low and further research will likely have an important impact on these estimates. At present, the ultimate decision between trimodal therapy and radical cystectomy should be left to the patient based on individual preferences and on the recommendation of a multidisciplinary provider team experienced with both approaches.
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