Treatment Allocation and Survival in Patients Diagnosed with Nonmetastatic Muscle-invasive Bladder Cancer: An Analysis of a National Patient Cohort in England

TAR-200: Investigational intravesical drug delivery system for bladder cancer

Bladder cancer is second among the most common urothelial malignancy and one of the most expensive in terms of treatment. Localized bladder cancer is classified into non-muscle invasive bladder cancer (NMIBC) and muscle invasive bladder cancer (MIBC). First line approach for treatment of NMIBC is transurethral resection of bladder tumor (TURBT) followed by intravesical instillation of immuno/chemotherapeutic agents to prevent or delay recurrence or progression. Historically intravesical Bacillus Calmette Geurin (BCG) instillation has been a mainstay of therapy for NMIBC post-TURBT. Commonly followed drug delivery is intravesical instillation that maximizes exposure of the drug to the lesion and minimizes systemic side effects. Gemcitabine used in bladder cancer due to its pharmacological properties making it appropriate for intravesical instillation. Limitations of intravesical instillation is low bladder permeability leading to decreased drug concentration in bladder tissues and frequent urination causing drug wash out or dilution reducing the effect of treatment. Effective intravesical therapy depends on the penetration of the drug into the tumor. TAR200 is a novel drug delivery system that facilitates sustained release of continuous low dose gemcitabine over an indwelling period providing a uniform concentration of drug after each voiding cycle and exposure of drug to the bladder tumor. There are completed and ongoing clinical trials to evaluate the efficacy of TAR200 alone or in combination with other chemotherapeutic agents in NMIBC and MIBC. FDA has granted breakthrough therapy designation (BTD) for TAR-200 in December 2023. This review highlights the potential of TAR-200 and clinical trials that improve bladder cancer treatment outcome.

Multiparametric MRI and artificial intelligence in predicting and monitoring treatment response in bladder cancer

Bladder cancer is the 10th most common and 13th most deadly cancer worldwide, with urothelial carcinomas being the most common type. Distinguishing between non-muscle-invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC) is essential due to significant differences in management and prognosis. MRI may play an important diagnostic role in this setting. The Vesical Imaging Reporting and Data System (VI-RADS), a multiparametric MRI (mpMRI)-based consensus reporting platform, allows for standardized preoperative muscle invasion assessment in BCa with proven diagnostic accuracy. However, post-treatment assessment using VI-RADS is challenging because of anatomical changes, especially in the interpretation of the muscle layer. MRI techniques that provide tumor tissue physiological information, including diffusion-weighted (DW)- and dynamic contrast-enhanced (DCE)-MRI, combined with derived quantitative imaging biomarkers (QIBs), may potentially overcome the limitations of BCa evaluation when predominantly focusing on anatomic changes at MRI, particularly in the therapy response setting. Delta-radiomics, which encompasses the assessment of changes (Δ) in image features extracted from mpMRI data, has the potential to monitor treatment response. In comparison to the current Response Evaluation Criteria in Solid Tumors (RECIST), QIBs and mpMRI-based radiomics, in combination with artificial intelligence (AI)-based image analysis, may potentially allow for earlier identification of therapy-induced tumor changes. This review provides an update on the potential of QIBs and mpMRI-based radiomics and discusses the future applications of AI in BCa management, particularly in assessing treatment response. CRITICAL RELEVANCE STATEMENT: Incorporating mpMRI-based quantitative imaging biomarkers, radiomics, and artificial intelligence into bladder cancer management has the potential to enhance treatment response assessment and prognosis prediction. KEY POINTS: Quantitative imaging biomarkers (QIBs) from mpMRI and radiomics can outperform RECIST for bladder cancer treatments. AI improves mpMRI segmentation and enhances radiomics feature extraction effectively. Predictive models integrate imaging biomarkers and clinical data using AI tools. Multicenter studies with strict criteria validate radiomics and QIBs clinically. Consistent mpMRI and AI applications need reliable validation in clinical practice.

Fractionation versus Adaptation for Compensation of Target Volume Changes during Online Adaptive Radiotherapy for Bladder Cancer: Answers from a Prospective Registry

Online adaptive radiotherapy (ART) allows adaptation of the dose distribution to the anatomy captured by with pre-adaptation imaging. ART is time-consuming, and thus intra-fractional deformations can occur. This prospective registry study analyzed the effects of intra-fraction deformations of clinical target volume (CTV) on the equivalent uniform dose (EUDCTV) of focal bladder cancer radiotherapy. Using margins of 5-10 mm around CTV on pre-adaptation imaging, intra-fraction CTV-deformations found in a second imaging study reduced the 10th percentile of EUDCTV values per fraction from 101.1% to 63.2% of the prescribed dose. Dose accumulation across fractions of a series was determined with deformable-image registration and worst-case dose accumulation that maximizes the correlation of cold spots. A strong fractionation effect was demonstrated-the EUDCTV was above 95% and 92.5% as determined by the two abovementioned accumulation methods, respectively, for all series of dose fractions. A comparison of both methods showed that the fractionation effect caused the EUDCTV of a series to be insensitive to EUDCTV-declines per dose fraction, and this could be explained by the small size and spatial variations of cold spots. Therefore, ART for each dose fraction is unnecessary, and selective ART for fractions with large inter-fractional deformations alone is sufficient for maintaining a high EUDCTV for a radiotherapy series.

Nationwide analysis of survival after radical cystectomy for bladder cancer in Finland

BACKGROUND

Population-based survival results after radical cystectomy (RC) are limited. Our objective was to report short and long-term survival results after RC for bladder cancer from Finland in a population-based setting.

MATERIALS AND METHODS

The Finnish National Cystectomy Database containing retrospectively collected essential RC data covering the years 2005-2017 was combined with the survival data from the Finnish Cancer Registry. Kaplan-Meier plots were used to estimate survival and the survival graphs were illustrated according to the final pathological staging. Centers were divided according to operational volume, and the results were then compared using Pearsons's Chi-squared test.

RESULTS

A total of 2047 patients were included in the study. 30-, and 90-day mortality was 1.3%, and 3.8%, respectively. The OS of the entire RC population at 5- and 10 years was 66% and 55%, and CSS was 74% and 72%, respectively. Center volume did not significantly associate with surgical mortality or long-term survival. The 5- and 10-year OS according to pT-category was 87% and 74% for pT0, 85% and 69% for pTa-pTis-pT1, 70% and 58% for pT2, 50% and 42% for pT3 and 41% and 30% for pT4. The corresponding 5- and 10-year CSS rates were 96% and 93% for pT0, 91% and 90% for pTa-pTis-pT1, 78% and 75% for pT2, 56% and 55% for pT3 and 47% and 44% for pT4. The 5- and 10-year OS rates in patients with no lymph node metastases (pN-) were 74% and 62%, and CSS 82% and 80%, respectively. If lymph nodes were positive (pN+), the corresponding OS rates were 44% and 34% and CSS 49% and 48%, respectively.

CONCLUSION

RC survival results have improved in contemporary series and are associated with the pTNM-status. The nationwide results from Finland demonstrate outcome comparable to high volume single-center series.

Cohort profile: radiotherapy dataset (RTDS) in England

PURPOSE

The purpose of the Radiotherapy Dataset (RTDS) is to collect consistent and comparable data across all providers of National Health Service (NHS)-funded radiotherapy and to provide intelligence for service planning, commissioning, clinical practice and research.

PARTICIPANTS

The RTDS is a mandated dataset requiring providers to collect and submit data monthly for patients treated in England. Data is available from 01 April 2009 to 2 months behind the calendar month.The National Disease Registration Service (NDRS) started receiving data from 01 April 2016. Prior to this, the National Clinical Analysis and Specialised Applications Team (NATCANSAT) were responsible for the RTDS. NDRS holds a copy of the NATCANSAT data for English NHS providers.The RTDS contains clinical information on the primary disease being treated, modality and intent of treatment, dose fractionation and hospital appointment details. Due to constraints in RTDS coding, linkage to the English National Cancer Registration dataset is beneficial.

FINDINGS TO DATE

The RTDS has been linked to the English National Cancer Registration and Systemic Anti-Cancer Therapy (SACT) datasets and to Hospital Episode Statistics (HES) to provide a more complete picture of the patient cancer pathway. Findings include a study to compare outcomes for patients treated with radical radiotherapy, an investigation of factors influencing 30-day mortality, assessing sociodemographic variation in the use of treatment and a study to assess the service impact of the COVID-19 pandemic. A range of other studies have been completed or are ongoing currently.

FUTURE PLANS

The RTDS can be used for a variety of functions including cancer epidemiological studies to investigate inequalities in treatment access; provide service planning intelligence; monitor clinical practice; and support clinical trial design and recruitment. Collection is to continue indefinitely, with regular updates to the data specification to enable capture of more detailed information on radiotherapy planning and delivery.

Diagnosis, treatment and survival from bladder, upper urinary tract, and urethral cancers: real-world findings from NHS England between 2013 and 2019

OBJECTIVE

We report NHS England data for patients with bladder cancer (BC), upper tract urothelial cancer (UTUC: renal pelvic and ureteric), and urethral cancers from 2013 to 2019.

MATERIALS AND METHODS

Hospital episode statistics, waiting times, and cancer registrations were extracted from NHS Digital.

RESULTS

Registrations included 128 823 individuals with BC, 16 018 with UTUC, and 2533 with urethral cancer. In 2019, 150 816 persons were living with a diagnosis of BC, of whom 113 067 (75.0%) were men, 85 117 (56.5%) were aged >75 years, and 95 553 (91.7%) were Caucasian. Incidence rates were stable (32.7-34.3 for BC, 3.9-4.2 for UTUC and 0.6-0.7 for urethral cancer per 100 000 population). Most patients 52 097 (mean [range] 41.3% [40.7-42.0%]) were referred outside the 2-week-wait pathway and 15 340 (mean [range] 12.2% [11.7-12.6%]) presented as emergencies. Surgery, radiotherapy, chemotherapy, or multimodal treatment use varied with disease stage, patient factors and Cancer Alliance. Between 27% and 29% (n = 6616) of muscle-invasive BCs did not receive radical treatment. Survival rates reflected stage, grade, location, and tumour histology. Overall survival rates did not improve over time (relative change: 0.97, 95% confidence interval 0.97-0.97) at 2 years in contrast to other cancers.

CONCLUSION

The diagnostic pathway for BC needs improvement. Increases in survival might be delivered through greater use of radical treatment. NHS Digital data offers a population-wide picture of this disease but does not allow individual outcomes to be matched with disease or patient features and key parameters can be missing or incomplete.

The impact of cardiopulmonary exercise testing (CPET) and Charlson comorbidity index (CCI) in a large contemporary cohort of patients undergoing robot-assisted radical cystectomy and intracorporeal urinary diversion (RARC-ICUD)

Objective

The aim of this study was to investigate whether pre-operative comorbidity status measured by the Charlson comorbidity index (CCI) or cardiopulmonary exercise testing (CPET) is associated with postoperative complications and length of stay (LOS) in patients undergoing robot-assisted radical cystectomy and intracorporeal urinary diversion (RARC-ICUD).

Patients and methods

We conducted a retrospective study of a prospectively maintained database of 428 consecutive patients who underwent RARC-ICUD at a tertiary referral centre between 2011 and 2019. CCI was correlated with peri-operative outcomes including postoperative LOS, Clavien-Dindo (CD) complications and survival. A planned subgroup analysis was performed to evaluate the relationship between pre-operative CPET, and the same outcomes utilising the threshold of anaerobic threshold (AT) ≥ 11/ <11 ml/kg/min were analysed.

Results

Of the total cohort, 350 patients undergoing RARC-ICUD with complete data were included in the final analysis. A CCI score ≥5 was associated with a higher rate of CD III-V complications at 30-day incidence rate ratio (IRR) = 3.033, (p = 0.02) and at 90-day IRR 2.495, (p = 0.04) postsurgery. LOS was not associated with CCI; the strongest association with LOS was a CD complication of any grading. CCI did not predict readmission or mortality rates after surgery. Subanalyses of patients who underwent pre-operative CPET found that CPET <11 ml/kg/min did not predict for LOS, CD complications or death within 1 year of surgery.

Conclusions

CCI score is a simple, reliable and cost-effective way of identifying patients at increased risk of complication after RARC-ICUD. Surgeons performing radical cystectomy should consider utilising CCI to augment pre-operative patient counselling prior to RARC-ICUD.

Combined Modality Bladder-Sparing Therapy for Muscle-Invasive Bladder Cancer: How (Should) We Do It? A Narrative Review

Organ-sparing combined-modality treatment for muscle-invasive bladder cancer remains underutilized despite high-quality evidence regarding its efficacy, safety, and preservation of quality of life. It may be offered to patients unwilling to undergo radical cystectomy, as well as those unfit for neoadjuvant chemotherapy and surgery. The treatment plan should be tailored to each patient's characteristics, with more intensive protocols offered to patients who are fit for surgery but opt for organ-sparing. After a thorough, debulking transurethral resection of the tumor and neoadjuvant chemotherapy, the response evaluation should trigger further management with either chemoradiation or early cystectomy in non-responders. A hypofractionated, continuous radiotherapy regimen of 55 Gy in 20 fractions with concurrent radiosensitizing chemotherapy with gemcitabine, cisplatin, or 5-fluorouracil and mitomycin C is currently preferred based on clinical trials. The response should be evaluated with repeated transurethral resections of the tumor bed and abdominopelvic-computed tomography after chemoradiation, with quarterly assessments during the first year. Salvage cystectomy should be offered to patients fit for surgery who failed to respond to treatment or developed a muscle-invasive recurrence. Non-muscle-invasive bladder recurrences and upper tract tumors should be treated in line with guidelines for respective primary tumors. Multiparametric magnetic resonance can be used for tumor staging and response monitoring, as it may distinguish disease recurrence from treatment-induced inflammation and fibrosis.

Prevalence, Predictors, and Oncologic Outcomes of Pelvic Organ Involvement in Women Undergoing Radical Cystectomy

CONTEXT.—

In women, radical cystectomy includes removal of the bladder, uterus, fallopian tubes, ovaries, and anterior vaginal wall, yet contiguous extension of urothelial carcinoma to all pelvic organs is rare and routine removal may be unnecessary.

OBJECTIVE.—

To study pelvic organ involvement in women at radical cystectomy and investigate oncologic outcomes.

DESIGN.—

Women with bladder cancer who underwent radical cystectomy at the Mayo Clinic and University of Toronto (1980-2018) were evaluated. Cancer-specific survival (CSS) was estimated with the Kaplan-Meier method; comparisons were made with the log-rank test. Associations with CSS were evaluated with Cox proportional hazard modeling.

RESULTS.—

A total of 70 women with pT4a and 83 with pT3b cancer were studied. Organs involved were vagina (n = 41 of 70; 58.6%), uterus (n = 26 of 54; 48.1%), cervix (n = 15 of 54; 27.8%), fallopian tubes (n = 10 of 58; 17.2%), and ovaries (n = 7 of 58; 12.1%); 22 of 58 patients (37.9%) had >1 organ involved. Of 70 with pT4a cancer, 64 were available for survival analysis by 3 pelvic organ groups: vaginal only, vaginal and/or cervical/uterine, and vaginal and/or cervical/uterine and/or fallopian tubes/ovarian involvement. Three-year CSS for vaginal involvement only was 39%; it was 14% if cervical/uterine involvement, and <1% if fallopian tube/ovarian involvement was included (P = .02). Among 20 women with pT4aN0/Nx and vaginal involvement only, 3-year CSS for vaginal involvement was 50%, whereas among 48 women with pT3bN0/Nx cancer, 3-year CSS was 58%, P = .70.

CONCLUSIONS.—

Isolated vaginal involvement should be separated from uterine and/or adnexal extension of urothelial carcinoma at pathologic staging. Direct ovarian extension is rare and routine removal may be unnecessary.

Bladder Preservation for Muscle-Invasive Bladder Cancer With Variant Histology

A growing body of evidence has shown bladder-preservation with chemo-radiotherapy achieves comparable survival to Radical Cystectomy (5-year OS 50%-70%) and superior quality of life outcomes for patients with muscle-invasive urothelial carcinoma of the bladder (UC). However, up to 55% of patients harbor variant histology and in this review we aim to clarify the role of bladder-preservation for this group. We first draw the distinction between urothelial carcinoma with divergent differentiation (UCDD) and non-urothelial carcinoma (NUC). UCDD is common, increasing in prevalence, and whilst each subtype may have its own characteristics current evidence suggests comparable outcomes with radical cystectomy and bladder-preservation. Non-urothelial carcinoma is a collection of distinct pathologies each deserving of its own management strategy. However, these tumors are rare, and evidence is generated from retrospective studies with significant inherent bias. Small cell carcinoma of the bladder has good evidence for bladder-preservation; however, other pathologies such as Squamous Cell Carcinoma and Adenocarcinoma are not well supported. We recommend careful multidisciplinary appraisal of the evidence for each subtype and honest patient discussion about the limited evidence before reaching management decisions. As we look to the future molecular-profiling may help better characterize these tumors and aid in treatment selection.

Non-metastatic muscle-invasive bladder cancer: the role of age in receiving treatment with curative intent

OBJECTIVES

To evaluate which patient and tumour characteristics are associated with remaining untreated in patients with potentially curable, non-metastatic muscle-invasive bladder cancer (MIBC), and to compare survival of untreated vs treated patients with similar characteristics.

PATIENTS AND METHODS

For this cohort study, 15 047 patients diagnosed with cT2-T4aN0/xM0/x urothelial MIBC between 2005 and 2019 were identified in the Netherlands Cancer Registry. Factors associated with remaining untreated were identified using logistic regression analyses. Interhospital variation was assessed using multilevel analysis. Using a propensity score, the median overall survival (mOS) of untreated and treated patients was evaluated. Analyses were stratified by age (&lt;75 vs ≥75 years).

RESULTS

One-third of patients aged ≥75 years remained untreated; increasing age, worse performance status, worse renal function, cT4a stage and previous radiotherapy in the abdomen/pelvic area increased the odds of remaining untreated. One in 10 patients aged &lt;75 years remained untreated; significant associations were only found for performance status, renal function and cT4a stage. Interhospital variation for remaining untreated was largest for patients aged ≥75 years, ranging from 37% to 69% (case-mix-adjusted). Irrespective of age, mOS was significantly worse for untreated patients: 6.4 months (95% confidence interval [CI] 5.1-7.3) vs 16.0 months (95% CI 13.5-19.1) for treated patients.

CONCLUSION

On average, one in five patients with non-metastatic MIBC remained untreated. Untreated patients were generally older and had a more unfavourable prognostic profile. Untreated patients had significantly worse overall survival, regardless of age. Age alone should therefore not affect treatment decision-making. Considering the large interhospital variation, a proportion of untreated patients might be wrongfully denied life-prolonging treatment.

Disease Management of Clinical Complete Responders to Neoadjuvant Chemotherapy of Muscle-Invasive Bladder Cancer: A Review of Literature

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.

Increased One-Year Mortality Among Elderly Patients After Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Retrospective, Observational Comparative Study

Introduction

Muscle invasive bladder cancer (MIBC) is a common malignancy amongst elderly. Increasing life expectancy, prevalence of smoking, lifelong exposure to environmental pollutants and immunosenescence contribute to growing number of cases. Traditionally, radical cystectomy (RC) with pelvic lymph node dissection (PLND) constituted the mainstay of treatment for MIBC, but despite proven feasibility in elderly population, it has been associated with significant burden of morbidity, mortality, and complications.

Study Objective

We aimed to re-evaluate the safety and efficacy of RC amongst the elderly patients with MIBC.

Material and Methods

This single-center, retrospective, observational comparative study was conducted among 568 patients who underwent RC due to MIBC between 2003 and 2021. We evaluated the influence of chronological age (<70 vs ≥70 years) on clinical, demographic, and pathological variables related to MIBC and RC.

Results

Elderly patients had similar clinical and pathological features of disease compared to their younger counterparts; nonetheless, they more often received simplified urinary diversion, ie ureterostomy (60.25% vs 39.33%, p<0.001) and had no PLND (15.76% vs 8.5%, p=0.01) during RC. Furthermore, more elderly patients were treated for secondary MIBCs and fewer had history of smoking. Severe complication and 90-day mortality rates were comparable between groups; however, the elderly had significantly higher all-cause mortality at one year post RC (46.67% vs 33.25%, p=0.003). On multivariate analysis, one-year mortality risk was independently associated with elderly age (HR=2.119, 95% CI: 1.227–3.660, p=0.007), rural residency (HR=1.760, 95% CI: 1.043–2.968, p=0.034), extravesical extension of tumor (HR=2.109, 95% CI: 1.155–3.850, p=0.015), lymph node metastasis (HR=2.268, 95% CI: 1.290–3.987, p=0.004) and omission of PLND (HR=6.064, 95% CI: 2.926–12.568, p<0.001).

Conclusion

Radical cystectomy in elderly patients is associated with significant one-year mortality. Our study emphasizes the unmet need for considerate planning of treatment for MIBC in potentially vulnerable groups of elderly patients. Efforts are needed to reliably identify those unlikely to benefit from surgery and facilitate patient-centered choice of alternative therapies.

Effective prediction model for preventing postoperative deep vein thrombosis during bladder cancer treatment

Objective

To begin to understand how to prevent deep vein thrombosis (DVT) after an innovative operation termed intracorporeal laparoscopic reconstruction of detenial sigmoid neobladder, we explored the factors that influence DVT following surgery, with the aim of constructing a model for predicting DVT occurrence.

Methods

This retrospective study included 151 bladder cancer patients who underwent intracorporeal laparoscopic reconstruction of detenial sigmoid neobladder. Data describing general clinical characteristics and other common parameters were collected and analyzed. Thereafter, we generated model evaluation curves and finally cross-validated their extrapolations.

Results

Age and body mass index were risk factors for DVT, whereas postoperative use of hemostatic agents and postoperative passive muscle massage were significant protective factors. Model evaluation curves showed that the model had high accuracy and little bias. Cross-validation affirmed the accuracy of our model.

Conclusion

The prediction model constructed herein was highly accurate and had little bias; thus, it can be used to predict the likelihood of developing DVT after surgery.

Setting standards for cystectomy using the British Association of Urological Surgeons Complex Operations Reports, 2016–2018

Objective:

To produce comprehensive standards for cystectomy using contemporary data collected across a nation.

Patients and methods:

Surgical departments upload cystectomy data to the British Association of Urological Surgeons (BAUS) Complex Operations Database. Analysis of 2016–2018 data was performed for all recorded 5288 patients undergoing cystectomy in England. Logistic regression with general linear models was used to assess differences in patient selection between operative modalities. Analysis involved assessment of case selection, operative decisions and outcomes, case volume and pathological outcomes.

Results:

Using national Hospital Episode Statistics, the BAUS cystectomy dataset was estimated 93% complete. Median age was 70 years (interquartile range 63–75) and 75% were male. Charlson comorbidity index ⩽2 was reported in 87%. Primary treatment of muscle-invasive bladder cancer accounted for 46% of cases. Commonest preoperative disease stages were T2N0 and T1N0 (35% and 25% respectively). Robotic-assisted (RAC), laparoscopic (LC) and open cystectomy (OC) were performed in 41%, 5.5% and 54% of cases respectively. T-stage distribution differed by operative modality. Transfusion rates were 3.7% for RAC, 6.0% for LC and 18% for OC. Increasing positive surgical margin rates were observed with increasing T-stage, up to T3. The conversion-to-open rate for minimally-invasive surgery was 1.7%. Median annual centre and surgeon case volumes were highest for RAC. Median length of stay was 7, 10 and 10 days for RAC, LC and OC respectively. Postoperative histological upstaging was common (33% of cT1, 50% of cT2 cases). Lymph node positive rates were 28% for muscle-invasive bladder cancer.

Conclusion:

Analysis of this data provides understanding of ‘real-world’ cystectomy practice. Presentation of data specific to operative modality allows surgeons and centres to benchmark their respective practices. These findings offer to enhance patient and public understanding beyond that currently facilitated by publicly-facing information sources. They carry relevance by describing a near-complete and large volume of modern practice in a publicly funded healthcare system.

Level of evidence:

2b

Clinical Outcomes of a Randomized Trial of Adaptive Plan-of-the-Day Treatment in Patients Receiving Ultra-hypofractionated Weekly Radiation Therapy for Bladder Cancer

PURPOSE

Hypofractionated radiation therapy can be used to treat patients with muscle-invasive bladder cancer unable to have radical therapy. Toxicity is a key concern, but adaptive plan-of the day (POD) image-guided radiation therapy delivery could improve outcomes by minimizing the volume of normal tissue irradiated. The HYBRID trial assessed the multicenter implementation, safety, and efficacy of this strategy.

METHODS

HYBRID is a Phase II randomized trial that was conducted at 14 UK hospitals. Patients with T2-T4aN0M0 muscle-invasive bladder cancer unsuitable for radical therapy received 36 Gy in 6 weekly fractions, randomized (1:1) to standard planning (SP) or adaptive planning (AP) using a minimization algorithm. For AP, a pretreatment cone beam computed tomography (CT) was used to select the POD from 3 plans (small, medium, and large). Follow-up included standard cystoscopic, radiologic, and clinical assessments. The primary endpoint was nongenitourinary Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 3 (≥G3) toxicity within 3 months of radiation therapy. A noncomparative single stage design aimed to exclude ≥30% toxicity rate in each planning group in patients who received ≥1 fraction of radiation therapy. Local control at 3-months (both groups combined) was a key secondary endpoint.

RESULTS

Between April 15, 2014, and August 10, 2016, 65 patients were enrolled (SP, n = 32; AP, n = 33). The median follow-up time was 38.8 months (interquartile range [IQR], 36.8-51.3). The median age was 85 years (IQR, 81-89); 68% of participants (44 of 65) were male; and 98% of participants had grade 3 urothelial cancer. In 63 evaluable participants, CTCAE ≥G3 nongenitourinary toxicity rates were 6% (2 of 33; 95% confidence interval [CI], 0.7%-20.2%) for the AP group and 13% (4 of 30; 95% CI, 3.8%-30.7%) for the SP group. Disease was present in 9/48 participants assessed at 3 months, giving a local control rate of 81.3% (95% CI, 67.4%-91.1%).

CONCLUSIONS

POD adaptive radiation therapy was successfully implemented across multiple centers. Weekly ultrahypofractionated 36 Gy/6 fraction radiation therapy is safe and provides good local control rates in this older patient population.

Overcoming the Chasm Between Evidence and Routine Practice for Bladder Cancer; Just a Quixotic Notion?

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.

The role of palliative radiotherapy in the management of elderly and frail patients with advanced bladder cancer: A survey by the AIRO uro-group

Radiotherapy (RT) is rarely used in the palliative management of muscle-invasive bladder cancer (MIBC). This survey aims to explore current care patterns within the Italian Radiation Oncologist community on this topic. In 2020, the uro-oncological study group of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) conducted a survey evaluating the RT role in advanced MIBC. An electronic questionnaire was administered online to the society members asking for: general considerations, patients' selection, and aim of the treatment, RT schedule and practical consideration, past and future perspective. Sixty-one questionnaires were returned (33% response rate). Most responders (62.30%) declared to work in a Center with a multidisciplinary uro-oncological team, and 8.20% to evaluate more than 20 patients with MIBC/year for palliative RT. Elderly patients were the most frequently evaluated (46.7%) and life expectancy was the most common selection criteria (44.60%). Thirty Gy in 10 fractions (58.9%), whole bladder as GTV (62.5%), PTV isotropic margins of 1.5-2 cm (44.6%) and IMRT/VMAT technique (58.14%) were the most common treatment choices. Patients amenable for bladder palliative RT were most commonly referred by the urologist (43.86%) or the multidisciplinary team (38%). The reported main reasons for the low involvement of radiation oncologist in the management of MIBC patients were low attention to the palliative setting in bladder cancer (37.5%); radiation oncologist not involved in the management of these patients (32.1%); cases not discussed in the multidisciplinary board (26.8%). This survey illustrated the current use of palliative RT for patients with advanced MIBC in Italy and suggested the need for a greater involvement of radiation oncologists in their management.

Electronic Rapid Fitness Assessment Identifies Factors Associated with Adverse Early Postoperative Outcomes following Radical Cystectomy

PURPOSE

Frailty is associated with adverse outcomes following radical cystectomy. Prospective tools to identify factors affecting outcomes are needed. We describe a novel electronic rapid fitness assessment to evaluate geriatric patients undergoing radical cystectomy.

MATERIALS AND METHODS

Before undergoing radical cystectomy between February 2015 and February 2018, 80 patients older than age 75 years completed the electronic rapid fitness assessment and were perioperatively comanaged by the Geriatrics Service. Physical function and cognitive function over 12 domains were evaluated and an accumulated geriatric deficit score was compiled. Hospital length of stay, discharge disposition, unplanned intensive care unit admissions, urgent care visits, readmissions, complications and deaths were assessed.

RESULTS

A total of 65 patients who underwent radical cystectomy for bladder cancer without concomitant procedures completed the assessment. Median age was 80 (77, 84) years and 52 (80%) were male. A higher proportion of patients with intensive care unit admission, urgent care visit and major complications had impairments identified within electronic rapid fitness assessment domains, including Timed Up and Go. Readmission rates were similar between patients with or without deficits identified. Higher accumulated geriatric deficit score was significantly associated with intensive care unit admission (p=0.035), death within 90 days (p=0.037) and discharge to other than home (p=0.0002).

CONCLUSIONS

We demonstrated the feasibility of assessing fitness in patients older than 75 years undergoing radical cystectomy using a novel electronic fitness tool. Physical limitations and overall impairment corresponded to higher intensive care unit admission rates and adverse postoperative outcomes. Larger studies in less resourced environments are required to validate these findings.