The economics of bladder cancer: costs and considerations of caring for this disease

Glycan-based therapeutic approaches for bladder cancer: Overcoming clinical barriers

Bladder cancer (BLCA) remains a significant global health concern, being characterized by high incidence, recurrence, and mortality rates. Disease heterogeneity and rapid progression pose major challenges for effective management and identification of actionable biomarkers. Conventional therapies often fail to successfully achieve disease control, urging the development of novel, personalized approaches. In recent years, anti-tumour immunotherapy approaches in both pre-clinical and clinical settings have boomed. However, the efficacy of these strategies has been limited by the low mutational burden in some tumours, which hinders neoantigen presentation and the identification of BLCA-specific signatures. Cancer-associated aberrant glycosylation presents a unique opportunity for identifying BLCA-specific glycosignatures and developing innovative targeted therapeutics. This review provides a comprehensive overview of the clinical challenges in BLCA management and emerging novel therapies. Furthermore, it highlights the potential of glycosylation alterations as a unique opportunity for developing glycan-based therapies, potentially revolutionizing BLCA treatment strategies.

Incidence of Bladder Cancer, Healthcare Pathways, and Economic Burden: A Real-World Observational Study From the French National Healthcare System Database

PURPOSE

To assess the incidence (all lesions) of bladder cancer (BC) in France, describe patient characteristics and healthcare pathways during the first year after diagnosis, and estimate medical costs.

METHODS

All adult patients with an initial BC diagnosis (ICD-10 codes: C67, D09.0, D41.4) in 2017 were selected from the French National Healthcare System Database. Patients were classified according to the most invasive surgical procedure they underwent. Treatments included cystectomy, transurethral resection of bladder tumor (TURBT), intravesical therapy, chemotherapy, and radiotherapy. Healthcare pathways were analyzed as sequences and grouped using hierarchical clustering. Medical costs during the first year of the disease were estimated for each cluster.

RESULTS

Out of 24,737 incident BC patients selected, the median age at diagnosis was 72 years, and 80.2% were men. Nearly 20% had received treatment for a cancer other than BC in the previous year. The majority (n = 9501, 38.4%) underwent TURBT only with a mean medical cost of €4435 [95% CI: 4322; 4548]. A total of 3037 patients (12.3%) underwent cystectomy as their initial treatment. The estimated costs for the group receiving intravesical instillations following a single TURBT (€6129 [5994; 6264]) were lower than those for the group with repeated TURBT (€9357 [9086; 9628]). Costs for patients who received systemic treatment after cystectomy were the highest at €25,636 [24,519; 26,752].

CONCLUSION

Our study estimates the incidence of BC in France, describes healthcare pathways at the national level, and analyses the associated economic burden.

[Bimodal and multimodal endoscopy of the urinary bladder in diagnosis and treatment]

White light cystoscopy is a precise instrument for the detection and treatment of papillary bladder tumors. Various additional macroscopic detection methods have been established. Some of them, especially PDD or NBI, have been shown to have an additional benefit on the recurrence rate of bladder tumors, so they should be used as part of the diagnosis and treatment when available. Other microscopic classification techniques or multimodality techniques are currently under development. Widespread use of these techniques is still pending. Newer modalities such as multi-parametric imaging or AI-assisted endoscopy promise a significant leap in innovation in the future and could ensure that real-time urological endoscopy is significantly advanced.

Association of arsenic exposure with PDGF-BB in vitro and in a South Texas population exposed through drinking water

Exposure to arsenic (As) from drinking water is a global public health concern, as As is a recognized carcinogen. Groundwater in South Texas, particularly in areas with Gulf Coast aquifers, contains high levels of As. Private wells are neither regulated nor regularly monitored, leaving residents vulnerable to arsenic exposure. This study aimed to investigate potential biomarkers of health effects for long-term, low-level As exposure among private well users in South Texas and to cross-validate findings using an in vitro model. Among 74 private well users, the association between urinary As levels and urinary LDH and 16 cytokine levels was assessed. After adjusting for covariates, linear regression analysis showed weak but significant associations between urinary total inorganic As levels and LDH (β = 0.37, p < 0.01, R2 = 0.23) and PDGF-BB (β = 0.22, p = 0.02, R2 = 0.17). However, no significant associations were found with other cytokines. To compare findings from the population study, SV-HUC-1 uroepithelial cells were exposed to 0.1 or 0.5 μM NaAsO₂ subchronically for 5 weeks, corresponding to total arsenic levels of 7.5 and 37.5 μg/L in drinking water. As exposure was not cytotoxic at either dose, as indicated by lactate dehydrogenase (LDH) activity. However, platelet-derived growth factor (PDGF)-BB protein levels showed a statistically significant increase at a lower concentration of 0.1 μM. These findings suggest that PDGF-BB may serve as a potential biomarker for low-level As exposure, but further studies are required for confirmation.

Uncovering citron kinase as a key biomarker for predicting outcomes and therapy efficacy in non-muscle-invasive bladder cancer

Non-muscle-invasive bladder cancer (NMIBC) is highly heterogeneous, with frequent recurrence and progression. Identifying biomarkers can improve the prediction of therapeutic response and prognosis, guiding clinical decisions. In this study, public NMIBC databases were analyzed for differential expression, receiver operating characteristic (ROC), Cox regression, and Kaplan-Meier survival to identify and validate potential prognostic biomarkers of NMIBC. Functional enrichment analysis was conducted to reveal the potential molecular mechanisms of hub genes. Bioinformatics findings were validated through immunohistochemistry (IHC) and in vitro experiments. Immune cell infiltration and drug sensitivity analyses were performed to assess differences between low- and high-CIT expression groups. Citron kinase (CIT) was identified as a biomarker linked to aggressive tumors and poor prognosis in NMIBC patients. CIT overexpression predicts poor intravesical Bacillus Calmette-Guérin (BCG) efficacy in patients with NMIBC. Immunohistochemical staining demonstrated that the protein expression analysis of CIT was consistent with the mRNA analysis results. Functional enrichment analysis revealed that the function of CIT is associated with tumor development and progression. Furthermore, in vitro cell experiments demonstrated that CIT knockdown inhibited cell proliferation by inducing cell cycle arrest at the G2/M phase via downregulation of cyclin dependent kinase 1. Immune infiltration analysis revealed that high CIT expression contributed to BCG resistance by reducing CD8+ T cell infiltration in the NMIBC microenvironment. Additionally, drug sensitivity analysis further demonstrated that high CIT expression leads to resistance to common chemotherapy drugs, including epirubicin, gemcitabine, and cisplatin. This study identifies CIT as a promising biomarker, offering a foundation for prognostic evaluation and personalized therapeutic strategies for NMIBC patients.

The role of multiparametric MRI-based VI-RADS in predicting the need for a second TURB

PURPOSE

To prospectively evaluate the value of Vesical Imaging Reporting and Data System (VI‑RADS) prior to initial transurethral resection of the bladder (TURB) in predicting residual tumor at second TURB and subsequent prognosis of patients.

METHODS

We enrolled suspected bladder cancer patients and scheduled multiparametric magnetic resonance imaging (mpMRI) of bladder for them before initial TURB. Second TURB were conducted based on initial resection reports, with comparisons made between patients with VI-RADS scores <3 and ≥3 regarding residual tumor rate, recurrence-free survival (RFS) and progression-free survival (PFS). Predictive efficacy of VI-RADS was assessed using Chi-square tests, logistic and Cox regression analyses, ROC curves, and Kaplan-Meier analyses.

RESULTS

A total of 108 patients were included, and residual tumors were detected in 25.0% (27/108) of them at second TURB, with a significant difference between patients with VI-RADS score <3 and ≥3 (8/81 vs. 19/27, p <0.001). VI-RADS ≥3 demonstrated a sensitivity of 70.4%, specificity of 90.1%, positive predictive value (PPV) of 70.4%, and negative predictive value (NPV) of 90.1%. Stratified analysis showed VI-RADS achieved a NPV of 95.2% for disease-free Ta patients, while 84.6% for T1 patients. After a median follow-up of 30 months for the 92 patients, 24 experienced tumor recurrence. VI-RADS ≥3 was found to be an independent predictor of tumor recurrence (HR = 4.297, p = 0.003).

CONCLUSIONS

VI-RADS ≥3 is associated with higher residual tumor rate at second TURB and higher recurrence risk. It might be an option for omitting second TURB when VI-RADS is <3, especially for Ta patients.

The Financial Burden of Localized and Metastatic Bladder Cancer

BACKGROUND AND OBJECTIVE

Bladder cancer (BCa) imposes a substantial economic burden on health care systems and patients. Understanding these financial implications is crucial for effective resource allocation and optimization of treatment cost effectiveness. Here, we aim to systematically review and analyze the financial burden of BCa from the health care and patient perspectives.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)-compliant systematic review was conducted, searching PubMed/Medline, Embase, and public sources for studies evaluating the financial impact of BCa, encompassing costs, cost effectiveness, and financial toxicity (FT).

KEY FINDINGS AND LIMITATIONS

Non-muscle-invasive BCa (NMIBC) incurs significant costs for surveillance and treatment, with costs exceeding $200 000 after 5 yr for high-risk NMIBC patients progressing after bacillus Calmette-Guerin (BCG) treatment (including inpatient, outpatient, and physician service expenses). Muscle-invasive BCa generates substantial costs from radical cystectomy (RC) and neoadjuvant chemotherapy, averaging $30 000-40 000 from surgical costs of RC, with additional expenses in case of complications. Trimodal therapy has higher costs (1-yr management cost >$200 000) than RC because of higher outpatient, radiology, and medication costs. Metastatic BCa incurs the highest financial burden, with systemic therapy costs ranging from $40 000 to over $100 000 per five-cycle course, increasing further with combination therapies (ie, enfortumab vedotin and pembrolizumab), treatment-related toxicity, and supportive care. FT is particularly prevalent among younger, less educated, and minority populations.

CONCLUSIONS AND CLINICAL IMPLICATIONS

BCa treatment, particularly in advanced stages, imposes a substantial economic burden. Innovations in care, while improving oncologic outcomes, necessitate detailed cost-effectiveness assessments. Addressing these economic challenges is essential for optimizing BCa management, targeting patients at a higher risk of FT, and improving patient quality of life.

Targeting COPA to Enhance Erdafitinib Sensitivity in FGFR-Altered Bladder Cancer

Fibroblast growth factor receptor (FGFR) family aberrations are common in urothelial cancer. The FGFR tyrosine kinase inhibitor erdafitinib has been approved for locally advanced or metastatic urothelial cancer with FGFR2/3 alterations. Despite the initial efficacy of erdafitinib, resistance cannot be avoided. The molecular mechanisms underlying erdafitinib resistance have not been well investigated. Here, genome-wide CRISPR screen is performed and coatomer protein complex subunit α (COPA) is identified as a key target to enhance erdafitinib sensitivity. Functionally, the deficiency of COPA reduces the proliferation of FGFR-altered bladder cancer cells upon erdafitinib treatment. Mechanistically, COPA knockout increases the degradation of leucine-rich pentatricopeptide repeat containing (LRPPRC) protein, leading to reduced inhibitor of DNA binding 3 (ID3) mRNA stability in an m6A-dependent manner. Collectively, these findings reveal a novel mechanism of erdafitinib resistance, providing a potential therapeutic target for FGFR-altered bladder cancer.

Randomized Comparison of Magnetic Resonance Imaging Versus Transurethral Resection for Staging New Bladder Cancers: Results From the Prospective BladderPath Trial

PURPOSE

Transurethral resection of bladder tumor (TURBT) is the initial staging procedure for new bladder cancers (BCs). For muscle-invasive bladder cancers (MIBCs), TURBT may delay definitive treatment. We investigated whether definitive treatment can be expedited for MIBC using flexible cystoscopic biopsy and multiparametric magnetic resonance imaging (mpMRI) for initial staging.

PATIENTS AND METHODS

We conducted a prospective open-label, randomized study conducted within 17 UK hospitals (registered as ISRCTN 35296862). Participants with suspected new BC were randomly assigned 1:1 to TURBT-staged or mpMRI-staged care, with minimization factors of sex, age, and clinician visual assessment of stage. Blinding was not possible. Patients unable/unwilling to undergo mpMRI or with previous BC were ineligible. The study had two stages with separate primary outcomes of feasibility and time to correct treatment (TTCT) for MIBC, respectively.

RESULTS

Between May 31, 2018, and December 31, 2021, 638 patients were screened, and 143 participants randomly assigned to TURBT (n = 72; 55 males, 15 MIBCs) or initial mpMRI (n = 71; 53 males, 14 MIBCs). For feasibility, 36 of 39 (92% [95% CI, 79 to 98]) participants with suspected MIBC underwent mpMRI. The median TTCT for participants with MIBC was significantly shorter with initial mpMRI (n = 12, 53 days [95% CI, 20 to 89] v n = 14, 98 days [95% CI, 72 to 125] for TURBT, log-rank P .02). There was no detriment for participants with non-MIBC (median TTCT: n = 30, 17 days [95% CI, 8 to 25] for mpMRI v n = 28, 14 days [95% CI, 10 to 29] for TURBT, log-rank P = .67). No serious adverse events were reported.

CONCLUSION

The mpMRI-directed pathway led to a 45-day reduction in TTCT for MIBC. Incorporating mpMRI ahead of TURBT into the standard pathway was beneficial for all patients with suspected MIBC.

METTL3 promotes an immunosuppressive microenvironment in bladder cancer via m6A-dependent CXCL5/CCL5 regulation

BACKGROUND

Bladder cancer (BLCA) is a challenging malignancy with a poor prognosis, particularly in muscle-invasive cases. Despite recent advancements in immunotherapy, response rates remain suboptimal. This study investigates the role of METTL3, an m6A RNA methylation "writer," in regulating the immune microenvironment of BLCA.

METHODS

Through bioinformatics analysis, we identified METTL3 as being associated with the formation of an immunosuppressive microenvironment in BLCA and poor response to immunotherapy. Subsequently, we silenced METTL3 expression in BLCA cells using short hairpin RNA (shRNA) or inhibited its function with STM2457. The effectiveness of these interventions in remodeling the BLCA tumor microenvironment (TME) was confirmed through animal experiments and flow cytometry. Mechanistically, RNA sequencing and methylated RNA immunoprecipitation (MeRIP) sequencing revealed the molecular pathways by which METTL3 regulates the TME. This was further validated using in vitro cell co-culture, immunoprecipitation, ELISA, and RNA degradation assays. The synergistic effect of METTL3 with anti-Programmed Cell Death Protein 1 (PD-1) treatment in BLCA was confirmed in both orthotopic and ectopic BLCA animal models.

RESULTS

METTL3 was found to increase CXCL5 levels and suppress CCL5 expression in an m6A-dependent manner, leading to increased recruitment of myeloid-derived suppressor cells (MDSCs) and reduced infiltration of CD8+T cells. Silencing METTL3 or inhibiting its function restored immune cell balance and significantly enhanced the efficacy of anti-PD-1 therapy. Clinically, METTL3 overexpression correlated with poor complete response rate to immune checkpoint inhibitors (ICIs) therapy, associated with an immunosuppressive microenvironment characterized by elevated MDSC levels and reduced CD8+T cell infiltration.

CONCLUSIONS

These findings highlight METTL3 as a key regulator of the immune microenvironment in BLCA and a promising therapeutic target to improve immunotherapy outcomes. Targeting METTL3 could potentially enhance the efficacy of ICIs in patients with BLCA.

Validation of a microRNA profile in urine liquid biopsy with diagnostic and stratification value for bladder cancer classification, available through the open app BladdermiRaCan

We aimed to identify a profile of urine microRNAs (miRNAs) with diagnostic and stratification potential in the whole range of bladder cancer (BC) categories, to avoid current invasive, harmful and expensive procedures. We collected a first morning urine sample from the screening (35 BC patients and 15 age- and gender-matched controls) and validation cohorts (172 BC and 94 controls). In the screening stage we analyzed the expression level of 179 miRNAs by real-time reverse transcription quantitative PCR in urine supernatants. miRNA levels in each sample were normalized by the levels of the previously identified and stably expressed miR-29c-3p. We performed an ordinal regression for each miRNA with False Discovery Rate (FDR) adjustment to identify dysregulated miRNAs, and an ordinal elastic net logistic regression model to identify a miRNA profile for BC diagnosis and stratification with the software R (v3.5.1). Next, we validated the most dysregulated miRNAs, and empirically identified the real miRNA targets in BC cells by miR-eCLIP immunoprecipitation and sequencing. We identified 70 dysregulated miRNAs in BC patients (p < 0.05 FDR-adjusted). With the expression level of 7 miRNAs in urine (miR-221-3p, miR-93-5p, miR-362-3p, miR-191-5p, miR-200c-3p, miR-192-5p, miR-21-5p) we could stratify BC patients and control subjects. To enable the global use of our model, we developed the free BladdermiRaCan online tool. Furthermore, we identified miR-21-5p, miR-425-5p and miR-99a-5p as follow-up markers for BC relapse, and miR-21-5p and miR-221-3p as markers for metastasis. These miRNAs were also dysregulated in BC tissue sections from a subgroup of patients from which urine samples were studied. In conclusion, we have validated and patented a 7-miRNAs urine profile able to diagnose and stratify BC patients; BladdermiRaCan will enable the global use of our model. The experimentally verified target proteins identified for these miRNAs may unravel novel therapeutic targets.

Perspective on the use of optics in bladder cancer detection and diagnosis

Significance

Bladder cancer (BC) diagnosis, management, and outcomes depend on the accurate detection of tumors via optical technologies. Accordingly, understanding the benefits and limitations of these technologies permits improvements in patient care and identifies areas for future research.

Aim

We outline the current process of BC detection and diagnosis, explore the current role of optical technologies, and discuss the opportunities and challenges they present in this field.

Approach

The current diagnostic pathway of BC, the use of optical technologies, and their shortcomings in this process are reviewed. From there, opportunities and challenges of optics in BC detection and diagnosis are discussed.

Results

BC management is expensive due to the limitations of white light cystoscopy, the requirement for histopathological confirmation, and the need for long-term surveillance. Alternative non-optical methods lack accuracy, and available optical techniques focus only on cancer detection. Alternatives to histopathology need to provide accurate real-time results to be effective. Optical advancements offer potential benefits; however, challenges include cost-effectiveness, device complexity, required training, and tumor heterogeneity.

Conclusions

Optical techniques could accelerate BC diagnosis, reduce costs, and enable alternative treatments. However, overcoming technical and practical challenges is essential for their successful integration.

Comparing direct medical care costs of patients with bladder cancer who received an ileal conduit vs. neobladder in the year following cystectomy

PURPOSE

Bladder cancer is 1 of the most costly cancers, however there is limited research on medical care costs by type of urinary diversion. The objective of our study was to compare medical care costs of the 2 most common urinary diversions in the year following radical cystectomy.

METHODS

The Bladder Cancer Quality of Life Study included patients diagnosed with bladder cancer who underwent radical cystectomy and received an ileal conduit (IC, n = 821) or neobladder (NB, n = 181) in 3 integrated health systems. Medical care costs per patient per quarter were estimated for the year following cystectomy. Multivariable generalized linear models with a gamma distribution and log link were used to estimate mean monthly medical care costs (2022 USD$), adjusted for patient demographic and clinical characteristics.

RESULTS

In multivariable analysis, mean monthly costs per quarter were not significantly different between IC and NB patients in the 12 months following cystectomy. Overall, mean monthly costs in IC and NB patients were highest during the first quarter and decreased thereafter. Factors associated with higher mean costs across all quarters included presence of any complications and advanced tumor stage at cystectomy (all P < 0.001).

CONCLUSION

Our study addresses an important knowledge gap by quantifying the medical costs of bladder cancer patients by urinary diversion type and comparing costs of different treatment approaches. Studies that assess patient-reported outcomes and out-of-pocket costs, by urinary diversion type, are warranted to inform treatment decision-making and cost conversations.

Chaetoglobosin A induces apoptosis in T-24 human bladder cancer cells through oxidative stress and MAPK/PI3K-AKT-mTOR pathway

Chaetoglobosin A (ChA) is an antitumor compound produced by Chaetomium globosum. However, the mechanism of its antitumor effect has been rarely reported. In this study, we evaluated the anti-proliferative effect of ChA on T-24 human bladder cancer cells and explored its mechanism of action. ChA was found to have a good inhibitory effect on T-24 cells by MTT assay with an IC50 value of 48.14 ± 10.25 μΜ. Moreover, it was found to have a migration inhibitory ability and a sustained proliferation inhibitory effect on tumor cells by cell aggregation assay and cell migration assay. The cells morphological changes were determined by Hoechst33342 assay. While Annexin V-FITC/PI double-staining assay also demonstrated that the number of apoptotic cells increased with the increase of drug concentration. Flow cytometry results showed that ChA treatment increased reactive oxygen species (ROS) and decreased mitochondrial membrane potential (MMP) in T-24 cells and inhibited cell mitosis, resulting in an increase in the number of sub-G1 phase cells. Further western blot experiments demonstrated that MAPK and PI3K-AKT-mTOR pathways were activated after drug treatment in addition to endogenous and exogenous apoptotic pathways. The addition of the ROS inhibitor N-acetylcysteine (NAC) upregulated the expression level of Bcl-2 protein, decreased p38 phosphorylation, increased ERK phosphorylation and restored the levels of PI3K and p-mTOR after ChA treatment. These suggest that ChA induces apoptosis by regulating oxidative stress, MAPK, and PI3K-AKT-mTOR signaling pathways in T-24 cells.

Association of energy source with outcomes in en bloc TURB: secondary analysis of a randomized trial

PURPOSE

To comprehensively evaluate the efficacy of different energy sources used for en-bloc transurethral resection of bladder tumors (ERBT) on perioperative outcomes.

METHODS

This sub-analysis derived from a prospective randomized study that enrolled patients undergoing ERBT vs conventional transurethral resection of the bladder (cTURB) from January 2019 to January 2022 (NCT03718754). Endpoints were pathological specimen quality and perioperative outcomes after either monopolar (m-ERBT) or bipolar (b-ERBT) or laser (l-ERBT) ERBT.

RESULTS

237 bladder tumors resected in 188 patients included in the analyses: 29 (12.2%) m-ERBT, 136 (57.4%) b-ERBT and 72 (30.4%) l-ERBT. Detrusor muscle (DM) was detected in 191 (80.6%) specimens. Per-tumor analysis revealed comparable rate of DM in the specimens obtained via different energy modalities (p = 0.7). Operative time was longer in the l-ERBT cohort compared to m-ERBT and b-ERBT (p = 0.02) and no obturator nerve reflex (ONR) onset was reported. On logistic regression analysis, b-ERBT was associated with negative lateral resection margins (OR 2.81; 95% CI 1.02-7.70; p = 0.04). There was no significant association of the resection technique with perforation and conversion rates (all p > 0.05). Within a median follow up of 22mo (IQR 11-29), a total of 35 (18.6%) patients had a local recurrence. On Cox regression analysis, patients resected with b-ERBT were less likely to have a recurrence (HR 0.34; 95% CI 0.15-0.78; p = 0.01); When adjusting for established confounders, this association was confirmed (HR 0.24; 95% CI 0.10-0.60; p = 0.002).

CONCLUSIONS

Different energy sources might achieve comparable perioperative outcomes. Further perspectives involve the assessment of long-term differential oncological outcomes associated with various energy modalities.

Bladder cancer biomarkers

Bladder cancer (BCa) is among the most frequently diagnosed urinary tract cancers, characterized by a high recurrence rate and significant clinical heterogeneity. Effective diagnosis and treatment of BCa demand continuous advancements in medical technologies, particularly given the limitations of classical methods such as cystoscopy and urine cytology. A comprehensive search of PubMed and Web of Science was conducted using relevant keywords to structure this narrative review. Additionally, specialist journals were reviewed. Only articles in English were included, with selection based on titles, abstracts, and availability of full texts. In recent years, biomarkers have emerged as crucial tools complementing traditional techniques, providing more precise, sensitive, and non-invasive methods for early detection, prognosis, and monitoring treatment response in BCa. Molecular, genetic, and protein biomarkers enable a deeper understanding of BCa biology, creating opportunities for personalized therapy tailored to individual patient needs. However, despite their potential, certain challenges remain, including standardization, validation, and integration into routine clinical practice. This review highlights recent advancements in BCa biomarkers and their transformative potential in oncological care. It underscores the importance of incorporating these innovations to refine diagnostic and therapeutic approaches, ultimately improving patient outcomes. Modern diagnostic and prognostic tools for BCa can enhance treatment outcomes by enabling early disease detection and reducing recurrence risks. This progress promises to improve patients' quality of life by minimizing disease burden and fostering effective, tailored care strategies.

Real-World Economic Burden and Healthcare Resource Utilization of Radical Cystectomy and Trimodal Therapy for Bladder Cancer in the United States

OBJECTIVE

To leverage contemporary real-world data to offer a comprehensive and longitudinal assessment of cost and healthcare resource utilization in patients with bladder cancer who underwent radical cystectomy (RC) or trimodal therapy (TMT).

METHODS

Claims data between October 01, 2015, and April 24, 2023, were assessed to determine patient characteristics, costs, and healthcare resource utilization. Patients were followed from 90-days up to 5-years of follow-up. Costs and healthcare utilization were further broken down by place of service and specific cost drivers, and subgroups were assessed to explore aspects of treatment recommended guidelines.

RESULTS

Of 1323 patients, 839 underwent RC (median age 71 years; 26.2% female), and 484 received trimodal therapy (median age 75; 26.2% female). Median [IQR] per-patient costs were $70,671 [$55,878-$106,812] for the RC cohort at 90-days follow-up and rose to $211,671 [$138,597-$346,389] by 5-years post-index. For trimodal therapy, total costs were $34,612 [$16,705-$64,263] at 90-days and increased to $274,462 [$186,337-$421,534] by 5-years. At 90-days, median overall visits (inpatient, outpatient, emergency room, or other) were 26 [16-39] for RC and 19 [12-33] for trimodal therapy; overall visits were 163 [119-218] and 186 [144-238] by 5-years, respectively.

CONCLUSION

This analysis reveals that RC costs were primarily driven by inpatient services, particularly inpatient facility costs. For trimodal therapy, outpatient costs predominated, driven by drugs administered and outpatient radiology facilities. The considerable costs and utilization associated with these treatments underscore the need for value-based therapeutic approaches aimed at enhancing patient outcomes.

RBPMS inhibits bladder cancer metastasis by downregulating MYC pathway through alternative splicing of ANKRD10

RNA-binding proteins (RBPs) are pivotal mediators of the alternative splicing (AS) machinery of pre-mRNA. Research has demonstrated that the AS process is significantly dysregulated and plays a crucial role in bladder cancer (BLCA). We conducted comprehensive screening and analysis of the TCGA-BLCA cohort, specifically focusing on genes with significant differences in expression levels between carcinoma and adjacent non-cancerous tissues. Among the 500 differentially expressed genes, 5 RNA-binding proteins were identified. Only the RNA-binding protein with multiple splicing (RBPMS) demonstrated a consistent downregulation in BLCA and was correlated with an unfavorable prognosis for affected patients. Subsequent experiments revealed that RBPMS exerted inhibitory effects on the epithelial-mesenchymal transition (EMT) pathway and the migratory potential of BLCA cells. RNA-Seq analysis identified ANKRD10 as a key target mRNA regulated by RBPMS in BLCA. RBPMS depletion in BLCA cells resulted in AS of ANKRD10 and increased ANKRD10-2 expression. ANKRD10-2 functioned as a transcriptional co-activator of MYC proteins, thereby augmenting their transcriptional activity. Furthermore, ANKRD10-2 knockdown significantly rescued the migration enhancement induced by RBPMS depletion in BLCA cells. Taken together, this study revealed a mechanism whereby RBPMS suppresses the migration and invasion of BLCA cells by attenuating MYC pathway activity via the AS of ANKRD10.

Development of a Technique for Diagnosis and Screening of Superficial Bladder Cancer by Cell-Pellet DNA From Urine Sample

Bladder cancer (BCa) is the most common malignancy of the urinary system with high incidence and recurrence rates. There are several ways to detect BCa. However, different approaches have different accuracy, which essentially depends on the sensitivity and specificity of the technique. Alternative noninvasive diagnostic tools for BCa are needed. We isolated and compared urinary cell-pellet DNA (cpDNA), cell-free DNA, and exosomal DNA from patients with localized BCa. Consequently, we analyzed 12 tissues and cpDNA samples by next-generation sequencing and then used bioinformatic tools to analyze genomic and transcriptomic alterations in coding and noncoding sequences. Then, cpDNA and tissue DNA from 12 patients were analyzed using next-generation sequencing to verify that the genomic characteristics of cpDNA are concordant with those of tissue. We also detected somatic mutation patterns between tissues and their corresponding cpDNA samples. An overlapping variant analysis was performed based on somatic mutation data and a high similarity was observed. Moreover, we identified frequently mutated signaling pathways. In these results, several point mutations were analyzed in FGFR3, TTN, and LEPROTL1 from the cpDNA of patients with BCa. Tumor mutational burden analysis showed that cpDNA had no significant difference in tumor mutational burden compared with tumor tissue. These results provide that cpDNA is a potential diagnostic source for detecting and managing BCa using alternative noninvasive methods from patient urine. Our findings may serve as a clinical tool for early detection or recurrence screening of nonmuscle invasive BCa using urinary cpDNA.

TE-RPA: One-tube telomerase extension recombinase polymerase amplification-based electrochemical biosensor for precise diagnosis of urothelial carcinoma

Telomerase demonstrates potential as a non-invasive urinary biomarker for urothelial carcinoma (UC); however, current detection methods are either labor-intensive or exhibit suboptimal performance. There is a need for alternative approaches to enable rapid and early diagnosis of UC. In this study, we propose TE-RPA, which combines telomerase extension (TE) with recombinase polymerase amplification (RPA) for one-tube isothermal amplification. The GC content and length of the telomerase substrate were first considered during the screening process. TE-RPA exponential amplification was initiated by the addition of MgOAc along with a forward primer derived from the products of telomerase-mediated extension and a corresponding reverse primer. The amplification product from TE-RPA was subsequently detected using CRISPR-Cas12a system for trans-cleavage of signal probes on the surface of screen-printed electrode in an electrochemical biosensor, resulting in a current change that reflects the corresponding concentration of telomerase. The TE-RPA/CRISPR-Cas12a/electrochemical sensing platform achieves a limit of detection (LOD) for telomerase activity as low as a single-cell level. In addition, the platform attained an area under the curve (AUC) value of 0.9589 in a clinical evaluation involving urine samples from 43 suspected UC patients. Overall, our proposed platform not only offers an efficient method for telomerase isothermal amplification but also provides a portable and precise diagnostic tool for UC.

Cost-Utility Analysis of Dose-Dense Methotrexate, Vinblastine, Doxorubicin, and Cisplatin Chemotherapy Regimen in Comparison With Gemcitabine and Cisplatin Chemotherapy Regimen in the Treatment of Patients With Muscle Invasive Bladder Cancer in Iran

OBJECTIVES

Bladder cancer incurs the highest lifetime treatment cost per patient among various cancers. Current guidelines endorse several cisplatin-based regimens as neoadjuvant chemotherapy. This cost-utility analysis aimed to compare 2 primary neoadjuvant chemotherapy regimens-dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (dd-MVAC) and gemcitabine and cisplatin (GC)-for patients with muscle-invasive bladder cancer, providing economic evidence to inform treatment guidelines in Iran.

METHODS

A Markov decision model was constructed, incorporating 4 states: after radical cystectomy without recurrence, no radical cystectomy, recurrence, and death over a lifetime horizon. Clinical outcomes were derived from the VESPER (French Genito-Urinary Tumor Group and French Association of Urology V05) phase 3 randomized controlled trial, whereas costs were obtained from local Iranian data. The main result involved determining an incremental cost-effectiveness ratio within the simulated population, with a willingness-to-pay threshold of 1656 USD (equivalent to Iran's gross domestic product per capita in 2023). Costs and benefits were discounted at 5.8% per annum, and probabilistic and univariate deterministic sensitivity analyses were conducted.

RESULTS

From the perspective of the Iranian healthcare payer, 6 cycles of dd-MVAC yielded 0.02 greater quality-adjusted life-years compared with 4 cycles of GC, resulting in a cost saving of 1 173 491 USD and an incremental cost-effectiveness ratio of -78 708 870. Consequently, dd-MVAC emerged as the dominant option over a lifetime horizon (23 years). The model proved most sensitive to variations in recurrence and toxicity probabilities during treatment.

CONCLUSIONS

Based on this study's results, dd-MVAC represents a cost-saving treatment regimen per patient in the Iranian health system compared with GC, with superior utility.

Evaluation of six novel biomarkers for predicting recurrence of non-muscle invasive bladder cancer after endoscopic resection- a prospective observational study

PURPOSE

To prospectively evaluate prognostic capabilities of non-muscle invasive bladder cancer (NMIBC) biomarkers for predicting disease recurrence or progression after radical TURB (transurethral resection of bladder tumor).

METHODS

Evaluated biomarkers included blood: plasminogen activator inhibitor 1 (PAI-1), soluble urokinase plasminogen activator receptor (suPAR), interleukin 8 (IL-8) and urine: IL-8, vascular endothelial growth factor (VEGF) and apolipoprotein E (APOE). Blood and urine samples acquired before TURB for NMIBC from 223 subjects were analysed. The primary outcome was tumor recurrence or progression.

RESULTS

After 3 months follow-up with cystoscopy or TURB- 92 patients were tumor free (Group 1). In 131 subjects (Group 2) a recurrence of NMIBC (n = 120) or progression to muscle invasive bladder cancer (MIBC) (n = 11) has been observed. No major clinical differences between these two groups were spotted. The group 2 has presented with significantly higher concentrations of blood IL-8 and suPAR as well as urine VEGF and APOE. The serum IL-8 and urinary VEGF showed the highest prognostic abilities with AUROC of 0.611 (95% CI: 0.534-0.687, p = 0.0044) and 0.632 (95% CI: 0.557-0.707, p = 0.0006), respectively. Multivariable machine learning models which included all investigated biomarkers and European Organisation for Research and Treatment of Cancer (EORTC) risk scores have allowed to discriminate the two patient entities with AUROC of 0.84 (95% CI: 0.73-0.95, p < 0.0001).

CONCLUSIONS

The assessed biomarkers alone have shown unsatisfactory prognostic capabilities to be used for prognostication of outcomes after TURB. More complex multivariable prediction models may improve their prognostic performance.

TRIAL REGISTRATION

The study was retrospectively registered at clinicaltrails.gov with National Clinical Trial number (NCT): NCT06235853.

VI-RADS followed by Photodynamic Transurethral Resection of Non-Muscle-Invasive Bladder Cancer vs White-Light Conventional and Second-resection: the 'CUT-less' Randomised Trial Protocol

BACKGROUND

A second transurethral resection of bladder tumour (Re-TURBT) is recommended by European Association of Urology (EAU) Guidelines on non-muscle-invasive bladder cancers (NMIBCs) due to the risk of understaging and/or persistent disease following the primary resection. However, in many cases this may be unnecessary, potentially harmful, and significantly expensive constituting overtreatment. The CUT-less trial aims to combine the preoperative staging accuracy of Vesical Imaging-Reporting and Data System (VI-RADS) and the intraoperative enhanced ability of photodynamic diagnosis (PDD) to overcome the primary TURBT pitfalls thus potentially re-defining criteria for Re-TURBT indications.

STUDY DESIGN

Single-centre, non-inferiority, phase IV, open-label, randomised controlled trial with 1:1 ratio.

ENDPOINTS

The primary endpoint is short-term BC recurrence between the study arms to assess whether patients preoperatively categorised as VI-RADS Score 1 and/or Score 2 (i.e., very-low and low likelihood of MIBC) could safely avoid Re-TURBT by undergoing primary PDD-TURBT. Secondary endpoints include mid- and long-term BC recurrences and progression (i-ii). Also, health-related quality of life (HRQoL) outcomes (iii) and health-economic cost-benefit analysis (iv) will be performed.

PATIENTS AND METHODS

All patients will undergo preoperative Multiparametric Magnetic Resonance Imaging of the bladder with VI-RADS score determination. A total of 327 patients with intermediate-/high-risk NMIBCs, candidate for Re-TURBT according to EAU Guidelines, will be enrolled over a 3-year period. Participants will be randomised (1:1 ratio) to either standard of care (SoC), comprising primary white-light (WL) TURBT followed by second WL Re-TURBT; or the Experimental arm, comprising primary PDD-TURBT and omitting Re-TURBT. Both groups will receive adjuvant intravesical therapy and surveillance according to risk-adjusted schedules. Measure of the primary outcome will be the relative proportion of BC recurrences between the SoC and Experimental arms within 4.5 months (i.e., any 'early' recurrence detected at first follow-up cystoscopy). Secondary outcomes measures will be the relative proportion of late BC recurrences and/or BC progression detected after 4.5 months follow-up. Additionally, we will compute the HRQoL variation from NMIBC questionnaires modelled over a patient lifetime horizon and the health-economic analyses including a short-term cost-benefit assessment of incremental costs per Re-TURBT avoided and a longer-term cost-utility per quality-adjusted life year gained using 2-year clinical outcomes to drive a lifetime model across the two arms of treatment.

TRIAL REGISTRATION

ClinicalTrial.gov identifier (ID): NCT05962541; European Union Drug Regulating Authorities Clinical Trials Database (EudraCT) ID: 2023-507307-64-00.

Predictive value of Bladder EpiCheck® in detecting residual tumor before second TUR for non-muscle-invasive bladder cancer

PURPOSE

As Bladder EpiCheck® (BE) is a promising urinary biomarker for diagnosis and follow up of non-muscle-invasive bladder cancer (NMIBC), there are no studies evaluated this tool for second transurethral resection (TUR) indication. We aim to evaluate the performance of BE in predicting residual tumor before second TUR in NMIBC and its effects on clinical decision making.

METHODS

A total of 50 patients who were diagnosed with NMIBC and indicated for a second TUR were included in the study prospectively. The urine sample taken one day before the second TUR operation was evaluated with BE and the results were compared with second TUR pathologies.

RESULTS

The mean age was 65.3 and 45 of the patients were male. Specificity and negative predictive value of BE in primary tumor stage Ta were 100% and 87.5% while in primary tumor stage T1 were 71.4% and 68.2%, respectively. The specificity and negative predictive value of BE were 77.8% and 75%, respectively, in patients with high grade primary tumor. When all NMIBC were evaluated, the specificity and negative predictive value of BE were found to be 78.6% and 73.3% for second TUR, respectively. As an independent predictor of residual tumor in this group, positivity rates of BE were higher in T1 (p < 0.037) and high grade (p < 0.002) tumors.

CONCLUSIONS

BE may be useful in detecting residual tumor before second TUR and benefit in clinical decision making with high specificity and negative predictive value. These results encourage the use of BE to reduce number of unnecessary second TUR procedures. It may improve cost effectivity and quality of life as high numbered studies are needed to support these views and to incorporate BE into clinical practice.

Varying the intensity of cystoscopic surveillance for high-risk non-muscle-invasive bladder cancer

OBJECTIVES

To compare the clinical, economic, and health utility outcomes associated with alternative cystoscopic surveillance regimens for high-risk non-muscle-invasive bladder cancer (HRNMIBC).

PATIENTS AND METHODS

We performed real-world clinical data-driven microsimulations of a hypothetical cohort of 100 000 patients diagnosed with HRNMIBC at age 70 years. The cohort was simulated to undergo alternative surveillance regimens recommended by five guidelines, and two hypothetical regimens-surveillance intensity escalation and de-escalation-which had a surveillance intensity moderately higher and lower, respectively, than the guideline-recommended regimens. We evaluated the 10-year cumulative incidence of muscle-invasive bladder cancer (MIBC), cancer-specific survival (CSS), overall survival (OS), and cost-effectiveness from a United States healthcare payer perspective.

RESULTS

The guideline-recommended surveillance regimens led to an estimated 10-year cumulative incidence of MIBC ranging from 11.0% to 11.6%, CSS 95.0% to 95.2%, and OS 69.7% to 69.8%. Surveillance intensity escalation resulted in a 10-year cumulative incidence of MIBC of 10.5% (95% confidence interval [CI] 10.3-10.7%), CSS of 95.4% (95% CI 95.2-95.5%), and OS of 69.9% (95% CI 69.6-70.1%), vs 11.9% (95% CI 11.7-12.1%), 94.9% (95% CI 94.8-95.1%), and 69.6% (95% CI 69.3-69.9%), respectively, from surveillance intensity de-escalation. By increasing surveillance intensity, the number-needed-to-treat to prevent one additional MIBC progression over 10 years was ≥80, and ≥257 to avoid one additional cancer-related mortality. Compared to surveillance intensity de-escalation, higher-intensity regimens incurred an incremental cost of ≥$336 000 per incremental quality-adjusted life year gained, which well exceeded conventional willingness-to-pay thresholds, ≥$686 000 per additional MIBC progression prevented, and ≥$2.2 million per additional cancer-related mortality avoided.

CONCLUSION

In microsimulations testing a wide range of cystoscopic surveillance intensity for patients newly diagnosed with HRNMIBC, moderate surveillance de-escalation appears associated with an insignificant change in 10-year OS and furthermore is cost-effective vs higher-intensity surveillance regimens. These results suggest that moderate surveillance de-escalation can reduce costs of care without compromising life expectancy for many patients.

The impact of preoperative venous thromboembolism on patients undergoing TURBT: Perioperative outcomes and healthcare costs from US insurance claims data

Objectives

To assess the impact of a positive history of venous thromboembolism (VTE) on perioperative outcomes, including length of in-hospital stay, readmission rates, 90-day postoperative complications, and healthcare costs in bladder cancer (BCa) patients undergoing transurethral resection of bladder tumour (TURBT) in the United States.

Patients and Methods

Patients aged ≥18 years with a BCa diagnosis undergoing TURBT were identified in the Merative® Marketscan® Research de-identified databases between 2007 and 2021. Multivariable logistic regression adjusted by relevant perioperative confounders was used to investigate the association between diagnosis of VTE before TURBT and 90-day complication rates, new postoperative VTE events, re-hospitalization, and total hospital expenditures (2021 US dollars). Sensitivity analyses on VTE severity (pulmonary embolism [PE], deep venous thrombosis [DVT] or superficial thrombophlebitis/phlebitis [SVT]), as well as TURBT extent (minor vs. major) were additionally examined.

Results

In total, 139 800 patients were identified, with 5.3% having preoperative VTE, including DVT (n = 3112, 42.20%), PE (n = 2046, 27.74%) and SVT (n = 2217, 30.06%). A history of preoperative VTE predicted higher rates of any complication (adjusted odds ratio [aOR] 1.28, 95% CI 1.14-1.43) and also higher rates of infectious and haemorrhagic complications. Additionally, preoperative VTE increased the risk of novel VTE events following TURBT (aOR 17.30, 95% CI 16.05-18.65), hospital length of stay (aOR 2.23, 95% CI 1.90-2.62), readmissions (aOR 1.47, 95% CI 1.39-1.56), and hospital associated costs (aOR 1.17, 95% CI 1.12-1.23). DVT and non-minor TURBT procedures did not increase the risk of any, infectious, or haemorrhagic complications, but other associations were maintained regardless of the severity of VTE (PE, DVT, SVT) or TURBT extent (minor/major).

Conclusions

A history of VTE before undergoing transurethral procedures for BCa is associated with significantly worse perioperative outcomes and higher healthcare costs. These findings may help us to counsel on the risks of the intervention and hopefully improve our ability to mitigate such risks.

Prospective Analysis of Confocal Laser Endomicroscopy for Assessment of the Resection Bed for Bladder Tumor

Background and objective

Urothelial bladder cancer (UCB) care requires frequent follow-up cystoscopy and surgery. Confocal laser endomicroscopy (CLE), a probe-based optical technique for real-time microscopic evaluation, has shown promising accuracy for grading of UCB. We investigated the diagnostic accuracy of CLE-based assessment of the surgical radicality of the bladder resection bed (RB).

Methods

We prospectively included 40 participants scheduled for transurethral resection of bladder tumors (TURBT) in two academic hospitals. Exclusion criteria were flat lesions, fluorescein allergy, and pregnancy. We performed CLE of the RB during TURBT. Histopathology of an RB biopsy was the reference test. Results at first cystoscopy 3 mo after TURBT are reported. A panel of two blinded observers evaluated the CLE images. The diagnostic accuracy of CLE for detection of detrusor muscle (DM) and residual tumor (rT) was calculated using 2 × 2 tables.

Key findings and limitations

Histopathology for 22 CLE-matched RB biopsies revealed rT in four cases (18%) and DM in 13 (59%). The quality of CLE imaging was low in four (18%), moderate in 16 (73%), and good in two (9%) cases. CLE was able to correctly predict rT in two of the four cases (50%) identified on histopathology. The sensitivity, specificity, positive predictive value, and negative predictive value were 0.5 (95% confidence interval [CI] 0.07-0.93), 0.83 (95% CI 0.59-0.96), 0.4 (95% CI 0.05-0.85), and 0.88 (95% CI 0.64-0.99) for CLE prediction of rT, and 0.69 (95% CI 0.39-0.91), 0.33 (95% CI 0.07-0.7), 0.6 (95% CI 0.32-0.84), and 0.43 (95% CI 0.1-0.82) for prediction of DM, respectively. Five patients (23%) had rT at 3-mo follow-up; CLE had predicted rT in three, and histopathology had revealed rT in two cases at TURBT.

Conclusions and clinical implications

CLE does not appear to be a reliable tool for detecting rT or DM in the RB after TURBT.

Patient summary

We investigated a special imaging technique called confocal laser endomicroscopy (CLE) for checking the bladder after surgery for bladder cancer in a group of 40 patients. CLE results were compared to traditional biopsy results and the patients were checked after 3 months. CLE was not very reliable in detecting any remaining cancer (only 50% accurate) or important muscle tissue in the surgical area, and the quality of the images varied. While CLE shows some promise, it is not currently a dependable method for evaluating the bladder after bladder cancer surgery.

Cascade-Activatable Nanoprodrug System Augments Sonochemotherapy of Bladder Cancer

Sonochemotherapy (SCT) has emerged as a powerful modality for cancer treatment by triggering excessive production of reactive oxygen species (ROS) and controlled release of chemotherapeutic agents under ultrasound. However, achieving spatiotemporally controlled release of chemotherapeutic agents during ROS generation is still an enormous challenge. In this work, we developed a cascade-activated nanoprodrug (CAN) system that utilizes a reversible covalent Schiff base mixed with a hypoxia-activatable camptothecin (CPT) prodrug. Briefly, the designed fluorinated CAN system is self-assembled into nanoparticles under aqueous conditions, which could penetrate deep tumors to offer sufficient oxygen for ultrasound-triggered ROS production. Consequently, the nanoparticles substantially exacerbated the hypoxia of the tumor microenvironment (TME) by elevating oxygen consumption. The aggravated hypoxia in turn served as a positive amplifier to boost the tumor-specific CPT release of Azo-CPT prodrug, which made up for the insufficient treatment efficacy of sonodynamic therapy (SDT). On this basis, we observed a substantial reduction, approximately 3.5-fold, in the half-maximal inhibitory concentration (IC50) of the CAN system compared to that of free CPT in bladder cancer cell lines (T24). Furthermore, the CAN system demonstrated potent antitumor efficacy with reduced side effects, resulting in regression and eradication of T24 tumors in various mouse models. In summary, the CAN system can be easily extended by incorporating different chemotherapeutic agents, showing great potential to revolutionize the clinical management paradigm of bladder cancer.

Is There a Role for Surgery in the Treatment of Metastatic Urothelial Carcinoma?

Purpose: Bladder cancer is one of the most common malignancies worldwide with over 614,000 new cases and 220,000 deaths annually. Five percent of newly diagnosed patients have metastatic disease. Metastatic urothelial carcinoma (mUC) is primarily treated with cisplatin-based chemotherapy, immunotherapy, targeted therapy, or combinations. Cure from disease is rarely achieved, with the overall survival being between 12 and 15 months, and the 5-year survival in the range of 5-15%. Historically, mUC has been deemed surgically incurable. There are limited data available to assess survival benefit with surgical extirpation of the primary site or metastases. In this review, we summarize findings from previous studies regarding the role of surgery in patients with clinically node-positive bladder cancer or metastatic urothelial carcinoma, focusing on cytoreductive radical cystectomy (RC) and distant metastasectomy. Materials and Methods: A literature search was conducted on The Medical Literature Analysis and Retrieval System Online (Medline), Excerpta Medica dataBASE (Embase), preprints, and ClinicalTrials.gov for studies that discussed the role of surgery in patients with clinically node-positive bladder cancer or mUC, focusing on cytoreductive radical cystectomy (RC) and distant metastasectomy. The keywords used included transitional cell carcinoma, urothelial carcinoma, bladder cancer, bladder carcinoma, bladder metastasis, bladder tumor, lymph node metastasis, metastasis, and muscle-invasive bladder cancer. Results: The final analysis included 21 studies, including 17 retrospective reviews, 2 prospective phase II trials, and 2 meta-analyses. Of the studies that assessed patients with urothelial carcinoma (UC) with nodal involvement, 15 of 17 showed improved survival with chemotherapy followed by radical cystectomy (RC). To our knowledge, few studies have solely assessed surgery in patients with distant metastases. Most studies include patients with both UC with local LN involvement and patients with distant sites of metastasis. Of these studies, 12 of 13 indicated improved survival with metastasectomy. Conclusions: While it remains to be seen whether metastasectomy will have a role in patients with mUC, patient selection is an important factor when assessing the survival benefits. Patient characteristics correlated with improved survival include good performance status, good response to chemotherapy, and single site of metastasis. Further studies of mUC patients are required to clearly assess the survival impact of cytoreductive surgery.

Loss of NUMB drives aggressive bladder cancer via a RHOA/ROCK/YAP signaling axis

Advances in bladder cancer (BCa) treatment have been hampered by the lack of predictive biomarkers and targeted therapies. Here, we demonstrate that loss of the tumor suppressor NUMB promotes aggressive bladder tumorigenesis and worsens disease outcomes. Retrospective cohort studies show that NUMB-loss correlates with poor prognosis in post-cystectomy muscle-invasive BCa patients and increased risk of muscle invasion progression in non-muscle invasive BCa patients. In mouse models, targeted Numb ablation induces spontaneous tumorigenesis and sensitizes the urothelium to carcinogenic insults, accelerating tumor onset and progression. Integrative transcriptomic and functional analyses in mouse and human BCa models reveal that upregulation of YAP transcriptional activity via a RHOA/ROCK-dependent pathway is a hallmark of NUMB-deficient BCa. Pharmacological or genetic inhibition of this molecular pathway selectively inhibits proliferation and invasion of NUMB-deficient BCa cells in 3D-Matrigel organoids. Thus, NUMB-loss could serve as a biomarker for identifying high-risk patients who may benefit from targeted anti-RHOA/ROCK/YAP therapies.

Impact of Endocrine Disruptors on the Genitourinary Tract

Over the last decades, the human species has seen an increase in the incidence of pathologies linked to the genitourinary tract. Observations in animals have allowed us to link these increases, at least in part, to changes in the environment and, in particular, to an increasing presence of endocrine disruptors. These can be physical agents, such as light or heat; natural products, such as phytoestrogens; or chemicals produced by humans. Endocrine disruptors may interfere with the signaling pathways mediated by the endocrine system, particularly those linked to sex hormones. These factors and their general effects are presented before focusing on the male and female genitourinary tracts by describing their anatomy, development, and pathologies, including bladder and prostate cancer.

Bladder cancer detection in urine by novel methylation markers

Although cystoscopy is a reliable tool for detecting bladder cancer (BC) in patients with hematuria, it is invasive, costly and often unnecessary since most patients with hematuria do not have BC. Consequently, developing urinary biomarkers for non-invasive BC detection is a major clinical need. While DNA methylation markers hold promise, diagnostic performance can still be improved. We assessed 11 candidate methylation markers for urinary BC detection. Urine samples from 77 primary BC patients and 69 controls were used for marker selection and training, with independent validation conducted on samples from 63 primary BC patients and 71 controls. Samples were self-collected at home, mailed to the hospital and analyzed via quantitative methylation-specific polymerase chain reaction. Marker performance was evaluated through univariable and multivariable logistic regression analyses. Decision curve analysis (DCA) gauged clinical utility by potential cystoscopy reduction. Evaluation identified three most promising markers: NRN1, GALR1, and HAND2. These markers exhibited significantly elevated methylation levels in BC compared to controls in both cohorts (P < 0.001). The combined marker set demonstrated an area under the curve (AUC) of 0.94 at 84% (95% CI: 76-92%) sensitivity and 96% (95% CI: 91-100%) specificity. Validation yielded nearly equivalent accuracy (AUC 0.89, sensitivity 76% (95% CI: 65-86%), specificity 93% (95% CI: 86-99%)). DCA indicated a potential of 20 to 35% reduction in cystoscopies depending on the clinical scenario. The excellent diagnostic potential of our methylation markers for non-invasive BC detection, emphasizes their significance for future diagnostic strategies.

Mevalonate pathway inhibition reduces bladder cancer metastasis by modulating RhoB protein stability and integrin β1 localization

The progression and outcome of bladder cancer (BLCA) are critically affected by the propensity of tumor metastasis. Our previous study revealed that activation of the mevalonate (MVA) pathway promoted migration of BLCA cells; however, the exact mechanism is unclear. Here we show that elevated expression of MVA pathway enzymes in BLCA cells, correlating with poorer patient prognosis by analyzing single-cell and bulk-transcriptomic datasets. Inhibition of the MVA pathway, either through knockdown of farnesyl diphosphate synthase (FDPS) or using inhibitors such as zoledronic acid or simvastatin, led to a marked reduction in BLCA cell migration. Notably, this effect was reversed by administering geranylgeranyl pyrophosphate (GGPP), not farnesyl pyrophosphate (FPP) or cholesterol, indicating the specificity of geranylgeranylation for cell motility. Moreover, we found that RhoB, a Rho GTPase family member, was identified as a key effector of the impact of the MVA pathway on BLCA metastasis. The post-translational modification of RhoB by GGPP-mediated geranylgeranylation influenced its protein stability through the ubiquitin-proteasome pathway. Additionally, overexpression of RhoB was found to block the membrane translocation of integrin β1 in BLCA cells. In summary, our findings underscore the role of the MVA pathway in BLCA metastasis, providing insights into potential therapeutic targets of this malignancy.

Improving detection of carcinoma in situ in bladder cancer: urinary cytology vs the Xpert® BC Monitor

OBJECTIVE

To investigate and compare the performance of urinary cytology and the Xpert BC Monitor test in the detection of bladder cancer in various clinically significant patient cohorts, including patients with carcinoma in situ (CIS), in a prospective multicentre setting, aiming to identify potential applications in clinical practice.

PATIENTS AND METHODS

A total of 756 patients scheduled for transurethral resection of bladder tumour (TURBT) were prospectively screened between July 2018 and December 2020 at six German University Centres. Central urinary cytology and Xpert BC Monitor tests were performed prior to TURBT. The diagnostic performance of urinary cytology and the Xpert BC Monitor was evaluated according to sensitivity (SN), specificity (SC), negative predictive value (NPV) and positive predictive value (PPV). Statistical comparison of urinary cytology and the Xpert BC Monitor was conducted using the McNemar test.

RESULTS

Of 756 screened patients, 733 (568 male [78%]; median [interquartile range] age 72 [62-79] years) were included. Bladder cancer was present in 482 patients (65.8%) with 258 (53.5%) high-grade tumours. Overall SN, SC, NPV and PPV were 39%, 93%, 44% and 92% for urinary cytology, and 75%, 69%, 59% and 82% for the Xpert BC Monitor. In patients with CIS (concomitant or solitary), SN, SC, NPV and PPV were 59%, 93%, 87% and 50% for urinary cytology, and 90%, 69%, 95% and 50% for the Xpert BC Monitor. The Xpert BC Monitor missed four tumours (NPV = 98%) in patients with solitary CIS, while potentially avoiding 63.3% of TURBTs in inconclusive or negative cystoscopy and a negative Xpert result.

CONCLUSION

Positive urinary cytology may indicate bladder cancer and should be taken seriously. The Xpert BC Monitor may represent a useful diagnostic tool for correctly identifying patients with solitary CIS and unsuspicious or inconclusive cystoscopy.

The Management of Non-Muscle-Invasive Bladder Cancer in a Veteran Patient Population: Issues and Recommendations

The ability of the Veterans Health Administration System to care for veterans with bladder cancer is influenced by the increased complexity of both veterans and the system's capacity to do so, which is determined by personnel and equipment allocation. Herein, we review the guidelines for bladder cancer management in the context of this population and highlight unique veteran characteristics that impact the delivery of bladder cancer care within the Veterans Health Administration System. There are opportunities for standardization and implementation, which can improve the quality of this care, and we summarize the questions for which coordinated research efforts may provide answers.

Cancers attributable to tobacco smoking in Italy in 2020

BACKGROUND

Tobacco smoking is still frequent in Italy and a major cause of cancer globally. We estimated the burden of smoking-related cancer in Italy.

METHODS

To calculate the population attributable fraction (PAF), we adopted a counterfactual scenario for which all individuals never smoked. The PAF of current and former smoking and second-hand smoke (SHS) was estimated for cancers associated with these habits according to the International Agency for Research on Cancer. Relative risk estimates and prevalence of exposure were derived from large-scale studies and national surveys, respectively. A 20-year latency period between exposure and cancer was considered. Cancer incidence data for 2020 and mortality data for 2017 were obtained from the Italian Association of Cancer Registries.

RESULTS

Tobacco smoking caused, in men and women respectively, 90.0 % and 58.3 % of lung; 67.8 % and 53.5 % of pharyngeal; 47.0 % and 32.2 % of bladder; 45.9 % and 31.7 % of oral; 36.6 % and 23.6 % of esophageal; 23.0 % and 14.0 % of pancreatic cancer and lower percentages of cancers at other sites. Tobacco smoking accounted for 23.9 % and 7.7 % of new cancer cases in 2020, and 32.1 % and 11.3 % of cancer deaths in 2017 in men and women, respectively, corresponding to 17.3 % of cases and 24.5 % of cancer deaths overall. The PAF of lung cancer due to SHS in never smoking women married with smokers was 13.0 %.

CONCLUSIONS

Tobacco smoking is a primary cause of cancer in Italy in both sexes. Tobacco control policies are warranted.

Cost-effectiveness analysis of different treatment modalities in BCG-unresponsive NMIBC

OBJECTIVE

Radical cystectomy (RC) is the standard of care (SOC) in BCG-unresponsive NMIBC and is associated with a significant health-related quality-of-life burden. Recently, promising results have been published on Gemcitabine/Docetaxel, Pembrolizumab, and Hyperthermic Intravesical Chemotherapy (HIVEC) as salvage therapy options trying to increase the rate of bladder preservation. Here, we performed a Cost-Effectiveness-Analysis of those treatment modalities.

PATIENTS AND METHODS

We developed a Markov model from a payer's perspective drawing on clinical data of single-arm trials testing intravesical gemcitabine/docetaxel and pembrolizumab in BCG-unresponsive NMIBC, as well as clinical data from patients receiving hyperthermic intravesical chemotherapy HIVEC (n = 29) as intravesical salvage chemotherapy at our uro-oncological centre in Cologne. Costs were simulated utilising a non-commercial diagnosis-related groups grouper, utilities were derived from comparable cost-effectiveness studies. We used a Monte Carlo simulation to identify the optimal treatment, comparing the incremental cost effectiveness ratios (ICERs) at a willingness-to-pay threshold of €50 000 (euro)/quality-adjusted life year (QALY).

RESULTS

Over a horizon of 10 years, gemcitabine/docetaxel, HIVEC, and pembrolizumab were associated with costs of €48 353, €64 438, and €204 580, as well as a gain of QALYs of 6.16, 6.48, and 6.00, resulting in an ICER of €26 482, €42 567, and €184 533 respectively, in comparison to RC with total costs of €21 871 and a gain of QALYs of 5.01. Monte Carlo simulation identified HIVEC as the treatment of choice under assumption of a WTP of <€50 000.

CONCLUSION

Considering a WTP of <€50 000/QALY, gemcitabine/docetaxel and HIVEC are highly cost-effective therapeutic options in BCG-refractory NMIBC, while RC remains the cheapest option. At its current price, pembrolizumab would only be cost-effective assuming a price reduction of at least 70%.

Integrating Genetic Alterations and Histopathological Features for Enhanced Risk Stratification in Non-Muscle-Invasive Bladder Cancer

BACKGROUND

Urothelial carcinoma presents as non-muscle-invasive bladder cancer (NMIBC) in ~75% of primary cases. Addressing the limitations of the TNM and WHO04/16 classification systems, this study investigates genetic alterations, the mitotic activity index (MAI), and immunohistochemistry (IHC) markers CK20, p53, and CD25 as better prognostic biomarkers in NMIBC.

METHODS

Using the Oncomine™ Focus Assay for targeted next-generation sequencing (NGS), 409 single-nucleotide variations (SNVs) and 193 copy number variations (CNVs) were identified across 287 patients with TaT1 tumors.

RESULTS

FGFR3 and PIK3CA alterations were significantly more prevalent in Ta tumors, while T1 tumors had significant ERBB2 alterations. Low-grade (LG) tumors were enriched with FGFR3 alterations, while high-grade (HG) tumors were significantly associated with ERBB2 alterations, as well as FGFR1 and CCND1 amplifications. FGFR3 alterations were linked to shorter recurrence-free survival (RFS; p = 0.033) but improved progression-free survival (PFS; p < 0.001). Conversely, ERBB2 alterations (p < 0.001), ERBB3 mutations (p = 0.044), and both MYC (p < 0.001) and MYCN (p = 0.011) amplifications were associated with shorter PFS. Survival analysis of gene sets revealed inverse associations between PIK3CA and ERBB2 (p = 0.003), as well as PIK3CA and MYC (p = 0.005), with PFS.

CONCLUSIONS

In multivariate Cox regression, MAI was the strongest predictor for PFS. Integrating genetic alterations and histopathological features may improve risk stratification in NMIBC.

Randomized clinical trial on the use of IMAGE1 S LIGHT (SPIES) vs. white light in the prevention of recurrence during transurethral resection of bladder tumors: Analysis after 12-month follow-up

INTRODUCTION

The improved image resolution of IMAGE1 S technology will increase tumor detection, achieve a greater number of complete resections, and would probably have an impact on the reduction of recurrences.

AIM

The primary objective was to compare the recurrence rates of IMAGE1 S vs. white light during transurethral resection of the bladder (TUR); the secondary objective was to compare the complication rates according to Clavien-Dindo (CD) at 12 months of follow-up.

METHODS

Prospective, randomized 1:1, blinded clinical trial. Recurrence and complication rates according to CD were analyzed using chi-square/U Mann-Whitney tests and recurrence-free survival (RFS) using Kaplan-Meier curves. The European Association of Urology (EAU) 2021 scoring model was used.

RESULTS

The analysis included 103 participants; 49 were assigned to the IMAGE1 S group and 54 to the white light group. Recurrence rates were 12.2% and 25.9%, respectively (P = .080). The low and intermediate risk group had a lower recurrence rate with IMAGE1 S (7.7% vs. 30.8%, P = .003) and a higher RFS with IMAGE1 S (85.2% vs. 62.8% Log Rank: 0.021), with a Hazard Ratio of 0.215 (95% CI: 0.046-0.925). No differences were observed in the high and very high-risk groups. Complications were mostly grade I and rates were similar between both groups (IMAGE1 S 20.4% vs. white light 7.4% P = .083).

CONCLUSIONS

There were no differences in the recurrence rates between groups. However, the low and intermediate risk group had a lower recurrence rate with IMAGE1 S. In addition, perioperative complication rates were not higher.

Differences in Clinical Outcomes and Survival Among Primary, Secondary, and Concomitant Carcinoma In Situ of the Bladder

PURPOSE

Carcinoma in situ (CIS) is a flat, high-grade, and aggressive form of urothelial carcinoma with a high risk of progression to muscle-invasive disease and metastasis. This study aimed to investigate differences in clinical outcomes and survival among patients with primary, secondary, and concomitant CIS of the bladder.

METHODS

A total of 209 patients diagnosed with CIS between 2010 and 2022 in our department with a minimum follow-up of 12 months were retrospectively analyzed. Patients with muscle-invasive cancer at diagnosis, those with recurrence within one month after diagnosis, and those with primary malignant melanoma were excluded. The recurrence, progression, and cancer-specific mortality rates of patients receiving Bacillus Calmette-Guérin therapy for CIS were analyzed.

RESULTS

A total of 96 patients with primary (n = 18), secondary (n = 29), and concomitant CIS (n = 49) were included in the analysis. The median follow-up was 52.2 months. Patients with secondary CIS had a significantly higher recurrence rate than those with concomitant CIS (58.6% vs. 32.7%, p = 0.016). However, no significant difference in progression rates was observed among the three groups. Furthermore, no significant association was observed between CIS subtypes and recurrence-free survival (RFS) (HR = 1.45, 95% CI 0.96-2.46, p = 0.16) or progression-free survival (PFS) (HR = 2.20, 95% CI 0.99-4.87, p = 0.054).

CONCLUSION

Secondary CIS had a significantly higher recurrence rate than concomitant CIS. However, no statistically significant association was observed between CIS subtypes and RFS or PFS.

Comparison of staging MRI to re-resection for localised bladder cancer: Narrative review

Introduction

Bladder cancer (BCa) is characterised by high prevalence, multifocality, and frequent recurrence, imposing significant clinical and economic burdens. Accurate staging, particularly distinguishing non-muscle-invasive bladder cancer (NMIBC) from muscle-invasive bladder cancer (MIBC) disease, is crucial for guiding treatment decisions. This narrative review explores the potential implications of incorporating multiparametric magnetic resonance imaging (mpMRI) and the Vesical Imaging Reporting Data System (VI-RADS) into BCa staging, focusing on repeat transurethral resection of bladder tumour (re-TURBT).

Methods

A comprehensive search of PubMed, EMBASE, and MEDLINE databases identified studies published from 2018 to 2023 discussing mpMRI or VI-RADS in the context of re-TURBT for BCa staging. Studies meeting inclusion criteria underwent qualitative analysis.

Results

Six recent studies met inclusion criteria. VI-RADS scoring, accurately predicted muscle invasion, aiding in NMIBC/MIBC differentiation. VI-RADS scores of ≥3 indicated MIBC with high sensitivity and specificity. VI-RADS potentially identified patients benefiting from re-TURBT and those for whom it could be safely omitted.

Discussion

mpMRI and VI-RADS offer promising prospects for BCa staging, potentially correlating more closely with re-TURBT and radical cystectomy histopathology than initial TURBT. However, validation and careful evaluation of clinical integration are needed. Future research should refine patient selection and optimise mpMRI's role in BCa management.

Conclusion

VI-RADS scoring could revolutionise BCa staging, especially regarding re-TURBT. There is potential that VI-RADS correlates more with the histopathology of re-TURBT and radical cystectomy than initial TURBT. While promising, ongoing research is essential to validate utility, refine selection criteria, and address economic considerations. Integration of VI-RADS into BCa staging holds potential benefits for patients and health care systems.

Advances in Liquid Biopsy for Diagnosis of Bladder Cancer

Bladder cancer (BCa) is the most common malignancy of the urinary system. It has a high recurrence rate and requires longterm follow-up. Significant advances in BCa research have been made in recent years; however, the initial diagnosis and follow-up of BCa relies on cystoscopy, which is an invasive and expensive procedure. Over the past decade, liquid biopsies (e.g., blood and urine) have proven to be highly efficient methods for the discovery of BCa biomarkers. This noninvasive sampling method is used to analyze unique tumor components released into body fluids and enables serial sampling and longitudinal monitoring of tumor progression. Several liquid biopsy biomarkers have been studied extensively and have shown promising results in the clinical applications of BCa, including early detection, microscopic residual disease detection, recurrence prediction, and treatment response. Therefore, this review aims to provide an update on various new liquid biopsy markers and the advantages and current limitations of liquid biopsy in the diagnosis of BCa.

Plasma-Derived Cell-Free DNA as a Biomarker for Early Detection, Prognostication, and Personalized Treatment of Urothelial Carcinoma

Bladder cancer (BC) is one of the most common malignancies in the United States, with over 80,000 new cases and 16,000 deaths each year. Urothelial carcinoma (UC) is the most common histology and accounts for 90% of cases. BC management is complicated by recurrence rates of over 50% in both muscle-invasive and non-muscle-invasive bladder cancer. As such, the American Urological Association (AUA) recommends that patients undergo close surveillance during and after treatment. This surveillance is in the form of cystoscopy or imaging tests, which can be invasive and costly tests. Considering this, there have been recent pushes to find complements to bladder cancer surveillance. Cell-free DNA (CfDNA), or DNA released from dying cells, and circulating tumor DNA (ctDNA), or mutated DNA released from tumor cells, can be analyzed to detect and characterize the molecular characteristics of tumors. Research has shown promising results for ctDNA use in the BC care realm. A PubMed literature review was performed finding studies discussing cfDNA and ctDNA in BC detection, prognostication, and monitoring for recurrence. Keywords used included bladder cancer, cell-free DNA, circulating tumor DNA, urothelial carcinoma, and liquid biopsy. Studies show that ctDNA can serve as prognostic indicators of both early- and late-stage BC, aid in risk stratification prior to major surgery, assist in detection of disease progression and metastatic relapse, and can assess patients who may respond to immunotherapy. The benefit of ctDNA is not confined to BC, as studies have also suggested its promise as a biomarker for neoadjuvant chemotherapy in upper-tract UC. However, there are some limitations to ctDNA that require improvements in ctDNA-specific detection methods and BC-specific mutations before widespread utilization can be achieved. Further prospective, randomized trials are needed to elucidate the true potential ctDNA has in advancements in BC care.

Urease-powered nanobots for radionuclide bladder cancer therapy

Bladder cancer treatment via intravesical drug administration achieves reasonable survival rates but suffers from low therapeutic efficacy. To address the latter, self-propelled nanoparticles or nanobots have been proposed, taking advantage of their enhanced diffusion and mixing capabilities in urine when compared with conventional drugs or passive nanoparticles. However, the translational capabilities of nanobots in treating bladder cancer are underexplored. Here, we tested radiolabelled mesoporous silica-based urease-powered nanobots in an orthotopic mouse model of bladder cancer. In vivo and ex vivo results demonstrated enhanced nanobot accumulation at the tumour site, with an eightfold increase revealed by positron emission tomography in vivo. Label-free optical contrast based on polarization-dependent scattered light-sheet microscopy of cleared bladders confirmed tumour penetration by nanobots ex vivo. Treating tumour-bearing mice with intravesically administered radio-iodinated nanobots for radionuclide therapy resulted in a tumour size reduction of about 90%, positioning nanobots as efficient delivery nanosystems for bladder cancer therapy.

MIR145 Core Promoter Methylation in Pretreatment Cell-Free DNA: A Liquid Biopsy Tool for Muscle-Invasive Bladder Cancer Treatment Outcome

PURPOSE

The lack of personalized management of bladder cancer (BlCa) results in patients' lifelong post-treatment monitoring with invasive interventions, underlying the urgent need for tailored and minimally invasive health care services. On the basis of our previous findings on miR-143/145 cluster methylation in bladder tumors, we evaluated its clinical significance in pretreatment cell-free DNA (cfDNA) of patients with BlCa.

MATERIALS AND METHODS

Methylation analysis was performed in our screening cohort (120 patients with BlCa; 20 age-matched healthy donors) by bisulfite-based pyrosequencing. Tumor recurrence/progression for patients with non-muscle-invasive bladder cancer, and progression and mortality for patients with muscle-invasive bladder cancer (MIBC) were used as clinical end point events in survival analysis. Bootstrap analysis was applied for internal validation of Cox regression models and decision curve analysis for assessment of clinical benefit on disease prognosis.

RESULTS

Decreased methylation of MIR145 core promoter in pretreatment cfDNA was associated with short-term disease progression (multivariate Cox: hazard ratio [HR], 2.027 [95% CI, 1.157 to 3.551]; P = .010) and poor overall survival (multivariate Cox: HR, 2.098 [95% CI, 1.154 to 3.817]; P = .009) of patients with MIBC after radical cystectomy (RC). Multivariate models incorporating MIR145 promoter methylation in cfDNA with tumor stage clearly ameliorated patients' risk stratification, highlighting superior clinical benefit in MIBC prognostication.

CONCLUSION

Reduced pretreatment cfDNA methylation of MIR145 core promoter was markedly correlated with increased risk for short-term progression and worse survival of patients with MIBC after RC and adjuvant therapy, supporting modern personalized and minimally invasive prognosis. Methylation profiling of MIR145 core promoter in pretreatment cfDNA could serve as a minimally invasive and independent predictor of MIBC treatment outcome and emerge as a promising marker for blood-based test in BlCa.

Office-based management of Non-Muscle Invasive Bladder Cancer (NMIBC): A position paper on current state of the art and future perspectives

To the Editor, Bladder cancer is one of the most common cancers in humans, representing the 7th and 17th type of neoplasm in both genders. Its incidence and mortality are quite heterogeneous in different countries and are due to different risk factors, quality and prevalence of healthcare and the possibility of early diagnosis and treatment of the tumor and its potential recurrences [...].

Noninvasive Tests for Bladder Cancer Detection and Surveillance: A Systematic Review of Commercially Available Assays

BACKGROUND

An important reason for the high health care costs associated with bladder cancer is the need for frequent cystoscopy for detection and surveillance of this disease. Cytologic analysis of voided urine specimens can assist, but is too inaccurate to replace cystoscopy. In an effort to create reliable, objective, noninvasive mechanisms for detecting bladder cancer, a number of urine-based molecular tests have been developed with the ultimate goal of reducing the frequency of cystoscopy.

OBJECTIVE

To summarize the performance of urine-based biomarker tests, currently commercially available in the US, as part of the initial workup for hematuria and for bladder cancer surveillance.

METHODS

In accordance with PRISMA guidelines we performed a systematic review of the literature on the performance of NMP22, BTA, UroVysion, ImmunoCyt/uCyt, CxBladder, and Bladder EpiCheck. Median sensitivity, specificity, negative (NPV) and positive predictive values (PPV) were calculated for each test based on the included studies.

RESULTS

Twenty-eight studies met inclusion criteria for the performance of five urine-based biomarker tests in the setting hematuria workup. Median sensitivity ranged from 65.7% -100% and specificity ranged from 62.5% -93.8%. Median NPV ranged from 94.2% -98.3% and PPV ranged from 29% -58.7%. Fourteen studies met inclusion criteria for the performance of six tests in the setting of bladder cancer surveillance. Median sensitivity ranged from 22.6% -92.0% and specificity from 20.5% -97.9%. Median NPV ranged from 52.9% -96.5% and PPV ranged from 48.1% -75.7%.

CONCLUSIONS

Our analysis finds that while these tests may provide some clinical utility, none of the assays have thus far demonstrated objective evidence to supplant the gold diagnostic standard.

Development of a prognostic model for long-term survival of young patients with bladder cancer: a retrospective analysis of the SEER Database

OBJECTIVES

This study aims to present the clinical characteristics of young patients with bladder cancer (YBCa), evaluate related risk factors and construct a nomogram based on data acquired from the Surveillance, Epidemiology, and End Results (SEER) Database.

DESIGN

Retrospective analysis of the SEER Database (2004-2015) for primary YBCa.

SETTING AND PARTICIPANTS

Data for YBCa (defined as those aged 40 years or younger) were extracted from the SEER Database, which covers approximately 28% of the US population, using the SEER*Stat software (V.8.4.0.1). A total of 1233 YBCa were identified. Patients were randomly assigned to the training and validation sets. The database included clinicopathological features, demographic information and survival outcomes, such as age, gender, race, year of diagnosis, marital status at diagnosis, primary tumour site, histological type, tumour grade, tumour, node, metastases (TNM) staging, treatment regimen for the primary tumour, cause of death and survival time. A nomogram model was developed using univariate and multivariate analyses. The prediction model was validated using the consistency index (C-index), calibration curve and receiver operating characteristic curve.

PRIMARY OUTCOME MEASURES

3-year, 5-year and 10-year overall survival (OS).

RESULTS

1233 YBCa from 2004 to 2015 were randomly assigned to the training set (n=865) and validation set (n=368). Age, marital status, tumour grade, histological type and TNM staging were included in the nomogram. The C-index of the model was 0.876. The 3-year, 5-year and 10-year OS area under the curve values for the training and validation sets were 0.949, 0.923 and 0.856, and 0.919, 0.890 and 0.904, respectively. Calibration plots showed that the nomogram had a robust predictive accuracy.

CONCLUSIONS

To our knowledge, this is the first study to establish a precise nomogram predicting the 3-year, 5-year and 10-year OS in YBCa based on multivariate analyses. Our nomogram may serve as a valuable reference for future diagnostics and individualised treatments for YBCa. However, external validation is warranted to assess the accuracy and generalisability of our prognostic model.