The use of molecular diagnostics in bladder cancer

Direct and indirect medical costs of bladder cancer in Iran

BACKGROUND

Bladder cancer is one of the most prevalent and costly cancers in the world. Estimating the economic burden of bladder cancer is essential for allocating resources to different sectors of health systems and determining the appropriate payment mechanisms. The present study aimed at estimating the economic burden of bladder cancer in Iran.

METHODS

In this study, we used a prevalence-based approach for estimating the economic burden of bladder cancer. Direct and indirect costs of bladder cancer were calculated using the cost of illness and human capital approaches. Data were collected using a researcher-made checklist obtained from several sources including Iran bladder cancer clinical practice guideline, the Statistical Center of Iran, Iran's Ministry of Cooperatives, Labor, and Social Welfare, Relative Value of Health Services (RVHS) book and Iranian Food and Drug Administration organization. The analyses were done by Microsoft Excel 2013 and Stata 13.

RESULTS

The number of the cases of 5-year prevalence of bladder cancer in Iran was estimated as 21,807 people in 2018. The economic burden of bladder cancer in Iran was estimated at US$ 86,695,474. Indirect medical costs constituted about two-third of the economic burden of bladder cancer, and mostly related to productivity loss due to mortality. Most of the direct medical costs (29.7%) were related to the stage T2-T3 and transurethral resection of bladder (31.01%) and radical cystectomy (19.99%) procedures.

CONCLUSION

Our results showed that the costs of bladder cancer, imposed on the healthcare system, were significant and mostly related to lost production costs. The implementation of screening and diagnostic programs can improve the survival rate and quality of life of patients and reduce the cost of lost productivity due to mortality in these patients.

A Randomized Feasibility Trial Comparing Surveillance Regimens for Patients with Low and Low-Intermediate Risk Non-Muscle Invasive Bladder Cancer

BACKGROUND

Surveillance regimens for non-muscle invasive bladder cancer (NMIBC) are disparate and controlled trials could inform guidelines. The feasibility of randomizing patients to variable frequency surveillance is unknown.

OBJECTIVES

To determine patient willingness to randomization to high frequency (HF) versus low frequency (LF) surveillance regimen for NMIBC and compare patient comfort and healthcare costs across regimens.

METHODS

A non-blinded, two-arm, randomized-controlled study of patients with low or low-intermediate risk NMIBC was conducted at two institutions where patients were offered randomization to HF vs. LF surveillance following initial tumor resection. The HF group underwent cystoscopy every three months for 2 years, then every 6 months for 2 years, then annually. The LF group underwent cystoscopy at 9 months following the 3-month cystoscopy, then annually. Assuming 75% of patients approached would agree to enrollment, a sample size of n = 35 patients per arm provided a one-sided 95% exact Clopper-Pearson confidence lower-limit of 60%.

RESULTS

Of 70 patients approached, 45 (64.3%) agreed to participate and 25 (35.7%) declined enrollment due to preference for HF. Twelve biopsies were performed, including 4 (19%) of 21 patients in the HF group and 8 (33.3%) of 24 patients in the LF group. Disease recurrence (low grade Ta) was observed in 3 (14.3%) and 5 (20.8%) patients in the HF and LF groups, respectively. No patients experienced high grade recurrence or progression. Both groups had similar patient-reported procedure-related discomfort and quality of life measures over time. Patient out-of-pocket cost and healthcare systems costs were $383.80 more per patient annually in the HF group.

CONCLUSIONS

Randomization to variable frequency surveillance is challenging as over a third of patients declined participation. However, these data provide important preliminary insights into the potential effects of surveillance frequency on oncologic and economic outcomes in patients with low and low-intermediate risk bladder cancer.

Kinematic and experimental investigation of manual resection tools for transurethral bladder tumor resection

BACKGROUND

Transurethral Resection of Bladder Tumors (TURBT) is a challenging procedure partly due to resectoscope limitations. To date, manual resection performance has not been fully characterized. This work characterizes manual resection performance in the bladder while analyzing the effect of resection location on accuracy.

METHODS

Kinematic simulations are used to assess kinematic measures of resection dexterity. An experimental protocol for manual resection accuracy assessment is developed. Cross correlations between the theoretical performance measures and the observed experimental accuracy are investigated.

RESULTS

Tangential accuracy correlates relatively strongly with normal singular value and moderately with tangential kinematic conditioning index and tangential minimum singular value. Simulations also clarified difficulties in resecting close to the bladder neck.

CONCLUSIONS

Measures to evaluate accuracy and dexterity of TURBT from a kinematic viewpoint are presented to provide a currently missing quantified dexterity baseline in manual TURBT. Limitations in various bladder regions are illustrated. Copyright © 2016 John Wiley & Sons, Ltd.

The burden of bladder cancer care: direct and indirect costs

PURPOSE OF REVIEW

Bladder cancer is a common, complex, and costly disease. Every year in the USA, bladder cancer is responsible for 70 ,000 diagnosed cases and over 15, 000 deaths. Once diagnosed, patients with nonmuscle invasive bladder cancer (NMIBC) are committed to a lifetime of invasive procedures and potential hospitalizations that result in substantial direct and indirect costs.

RECENT FINDINGS

Bladder cancer is the most costly cancer among the elderly, estimated at nearly $4 billion per year, and has the highest cost of any cancer when categorized on a per patient basis. The direct economic cost of NMIBC is fueled by the need for lifelong cystoscopic examination and variations in treatment algorithms. This fiscal burden is further compounded by the indirect impact on psychological health and quality of life of patients and their families. Despite the development of new technologies, such as novel urinary biomarkers and innovative cystoscopic methods, no alternative to cystoscopic surveillance has been established.

SUMMARY

The management of patients with NMIBC is responsible for a substantial financial burden with indirect costs that extend beyond quantifiable direct costs.

The costs of non-muscle invasive bladder cancer

Bladder cancer is a common diagnosis, affecting 70,000 Americans each year. Because the diagnosis, management, and long-term follow-up of non-muscle invasive bladder cancer requires advanced imaging and invasive testing, economic evaluations have shown bladder cancer to be the costliest cancer to treat in the US on a per capita basis. Adjunctive tests for surveillance have not obviated the need for cystoscopy and cytology. Indirect costs to patients include loss of work, decreased productivity, and diminished quality of life associated with diagnosis, treatment, and surveillance. Improved value may be achieved with better compliance with evidence-based practices for non-muscle invasive bladder cancer care.

Economic aspects of bladder cancer: what are the benefits and costs?

OBJECTIVE

Bladder cancer (BC) has the highest lifetime treatment costs per patient of all cancers. The high recurrence rate and ongoing invasive monitoring requirement are the key contributors to the economic and human toll of this disease. The purpose of this paper was to utilize the recent literature to identify opportunities for improving the benefits and costs of BC care.

METHODS

A PubMed search was performed of recent publications concerning (BC) cost-effectiveness. We reviewed studies, reviews, opinion papers and cost-effectiveness analyses, focusing primarily on non-muscle-invasive bladder cancer (Ta/T1; NMIBC).

RESULTS

New diagnostic tools such as urine markers may assist in more cost-effectively detecting BC at an earlier stage, however, these markers cannot replace the cystoscopy, which is the current standard of care. A photodynamic diagnostic tool (PDD) using hexylaminolevulinate (Hexvix) enhances tumor visibility and improves transurethral resection of bladder cancer (TURB) results, potentially reducing recurrence rates and lowering treatment costs. While the importance of BC research has been acknowledged, research investment has been continuously reduced during the last 5 years.

CONCLUSIONS

The economic burden of BC is well-characterized in the literature. This study suggests that new technologies (i.e., urine-based tests, PDD) and therapeutic regimes (intravesical chemotherapy, adjuvant immunotherapy) have significant potential to improve the diagnosis, treatment and on-going monitoring of BC patients, with potential improvements in clinical outcomes and concurrent cost-savings. A renewed interest and investment in BC research are required to ensure future advancements.

Surveillance of patients with bladder carcinoma using fluorescent in-situ hybridization on bladder washings

OBJECTIVES

To compare the sensitivity and specificity of the UroVysion (Abbott Laboratories Inc., Downers Grove, IL, USA) fluorescent in-situ hybridization (FISH) assay to that of urinary cytology obtained from bladder irrigation during cystoscopic surveillance in patients with bladder carcinoma.

PATIENTS AND METHODS

The medical records were retrospectively reviewed for 41 consecutive patients screened at the authors' institution between August 2000 and December 2006 for recurrence of pathologically confirmed bladder cancer. All 162 cytology examinations and 141 FISH assay results obtained from bladder washing were included. Recurrence was determined by cystoscopy, bladder biopsy and upper-tract imaging. Sensitivity, specificity, positive predictive and negative predictive values were assessed using a chi-square distribution with one degree of freedom.

RESULTS

There were 24 men and 17 women (male to female ratio 0.59), the mean (range) age was 56 (33-73) years and the mean follow-up 30 (2-57) months. At the initial diagnosis, 35 of the 41 patients (85%) had superficial tumours (stage <or= T1), while six (15%) had muscle-invasive tumours (stage >or=T2). Twenty-six (63%) had low-grade and 15 (37%) had high-grade tumours. In 16 of 141 (11%) of the FISH assays and 16 of 162 (10%) of the cytological samples that were collected from bladder irrigations, there were too few cells for an adequate analysis. The FISH assay correctly correlated with subsequent cystoscopy, bladder biopsy or upper-tract imaging in 110/125 (88%) cases but not in 15/125 (12%). Cytology correctly correlated with the subsequent evaluation in 112/146 (77%) cases but did not in 34/146 (23%). When the FISH was compared with cytology in this setting, the sensitivity was 77% (30/39) vs 74% (37/50; P > 0.1), the specificity was 93% (80/86) vs 78% (75/96; P < 0.01), the positive predictive value was 83% (30/36) vs 64% (37/58; P < 0.05), and the negative predictive value was 90% (80/89) vs 85% (75/88; P > 0.1), respectively.

CONCLUSION

The UroVysion FISH assay obtained from bladder washings during cystoscopic surveillance of patients with a history of bladder cancer provides a similar specificity but greater sensitivity than that of cytology for detecting bladder cancer recurrences. Given the better specificity and similar sensitivity of UroVysion compared with urine cytology obtained from bladder washings, a reasonable approach might be to use the UroVysion assay as the primary marker for recurrence, with urine cytology used as a complementary examination.

Two-dimensional agnor evaluation as a prognostic variable in urinary bladder carcinoma: A different approach via total agnor area/nucleus area per cell

Traditional criterions are not sufficient to predict accurately the recurrence of transitional cell carcinoma of the urinary bladder. Therefore, we aimed to evaluate the AgNORs via total AgNOR area/nucleus area (TAA/NA) for each cell as a prognostic parameter, in TCC of urinary bladder. Tumor tissues of 20 consecutive cases of male bladder cancer patients were divided into two groups as middle differentiated (LG) and high grade (HG). The extra-tumoral tissue (ETT) samples of 10 males served as control group. A second control group (HC) consisted of five healthy and normal bladder tissue samples. The 3 microm of sections from each paraffin embedded tumoral, extra-tumoral and normal tissue samples served as patient and control groups. After deparaffinization and rehydratation steps, silver (AgNO(3)) staining of nucleolar organizer regions-associated proteins (AgNORs) was performed. Instead of Giemsa stain, we used Hematoxylin for contra staining. The images of the 100 analyzable nuclei from each tissue sample, transferred by means of a video camera and video capture card from microscope and recorded onto a computer. Software was prepared in Delphi language for analysis. Mean (E+02) TAA/NA values of HC, ETT, LG and HG groups were 6.97+2.80, 5.70+1.82, 7.80+3.22 and 9.24+3.88, respectively. Statistical comparisons have shown significant differences between all groups. In conclusion, mean TAA/NA per cell has a potential to be a prognostic parameter. Therefore, further evaluation of big patient series will be useful.

Detection of newly diagnosed bladder cancer, bladder cancer recurrence and bladder cancer in patients with hematuria using quantitative rt-PCR of urinary survivin

BACKGROUND/AIMS

Survivin mRNA in urine was measured to detect newly diagnosed bladder cancer, bladder cancer recurrence and bladder cancer in patients with hematuria.

METHODS

We have investigated urinary survivin mRNA of 118 voided urine specimens, including 24 patients with bladder cancer, 50 with bladder cancer history, 68 not known to harbor bladder cancer, and 55 with hematuria using quantitative reverse transcriptase polymerase chain reaction. beta-Actin mRNA expression was also examined and used as an endogenous control to ensure validity of the assay for each sample.

RESULTS

The survivin expression in urological patient urine had sensitivities and specificities for all patients of 79 and 93%, for detection of newly diagnosed bladder cancer 83 and 95%, for bladder cancer recurrence 82 and 90%, and for bladder cancer in patients with hematuria 80 and 90%.

CONCLUSION

Our results indicate that quantitative reverse transcriptase polymerase chain reaction of urinary survivin is a sensitive, noninvasive and highly specific assay to detect both newly diagnosed bladder cancer and bladder cancer recurrence. Furthermore, this assay may be useful in stratifying the hematuria population in urological practice.

Using Tree Analysis Pattern and SELDI-TOF-MS to Discriminate Transitional Cell Carcinoma of the Bladder Cancer from Noncancer Patients

OBJECTIVE

To determine whether SELDI protein profiling of urine coupled with a tree analysis pattern could differentiate TCC from noncancer patients.

METHODS

The ProteinChip Arrays were performed on a ProteinChip PBS II reader of the ProteinChip Biomarker System. The study was divided into two phases: a preliminary phase with construction of tree analysis pattern, and a testing phase with test urine samples. Generation of the tree analysis pattern was performed by a training data set consisting of 104 samples. The validity of the tree analysis pattern was then challenged with a test set of 68 samples.

RESULTS

Average of 187 mass peaks was detected in the urine samples, and five of these peaks were used to construct the tree analysis pattern. The classification pattern correctly predicted 91.67-94.64% of the samples for both of the two groups in the training set, for an overall correct classification of about 93%. The pattern correctly predicted 72.0% (49 of 68) of the test samples, with 71.4% (25 of 35) of the TCC samples, 72.7% (24 of 33) of the noncancer samples.

CONCLUSIONS

The high sensitivity and specificity obtained by the urine protein profiling approach demonstrate that SELDI-TOF-MS combined with a tree analysis pattern can both facilitate discriminate TCC bladder cancer with noncancer and provide an innovative clinical diagnostic platform improve the detection of TCC bladder cancer patients.

Urine markers for bladder cancer surveillance: a systematic review

INTRODUCTION

The follow-up of patients with urothelial cell carcinoma (UCC) of the bladder is done by cystoscopy and, in most cases, cytology. The last decade, many urine-based tests for UCC have been developed and tested in different populations. For the urological practice, considering the amount of follow-up cystoscopies, especially urine markers for recurrent disease would be useful. Therefore, we reviewed the literature on these markers for recurrent UCC and compared our findings with recent review-articles.

METHODS

We performed a PubMed search. In case of primary and recurrent disease, the study was included if the patients under surveillance were reported separately. Patients with no evidence of disease at surveillance cystoscopy were considered to determine specificity. A marker was included if at least 2 studies from 2 different institutions/authors were available.

RESULTS

The literature review yielded 64 articles. We found 18 markers (BTAstat, BTAtrak, NMP22, FDP, ImmunoCyt, Cytometry, Quanticyt, Hb-dipstick, LewisX, FISH, Telomerase, Microsatellite, CYFRA21-1, UBC, Cytokeratin20, BTA, TPS, Cytology) that met our criteria. BTAstat, NMP22, ImmunoCyt and cytology were evaluated in more than 750 patients. Telomerase, Cytokeratin20 and Hb-dipstick were tested in less than 250 patients. The highest median sensitivities were reported for CYFRA21-1 (85%), Cytokeratin20 (85%) and Microsatellite analysis (82%). The highest specificities were reported for Cytology (94%), BTA (92%) and Microsatellite analysis (89%). In comparison with recent reviews, median sensitivity was>or=5% lower for the surveillance group in 13/18 urine-based tests while specificity remained relatively constant between different patient groups.

CONCLUSIONS

To our knowledge, this is the first review that assesses sensitivity and specificity of urine markers solely for UCC surveillance. In our view, Microsatellite analysis, ImmunoCyt, NMP22, CYFRA21-1, LewisX and FISH are the most promising markers for surveillance at this time. Nevertheless, clinical evidence is insufficient to warrant the substitution of the cystoscopic follow-up scheme by any of the currently available urine marker tests. Future studies may test some of the most sensitive and specific assays to reduce the cystoscopy frequency. However, our results show that initiators of these studies should anticipate a lower sensitivity than reported in the current literature.

Detection of mucin 7 gene expression in exfoliated cells in urine from patients with bladder tumor

OBJECTIVES

To determine whether mucin (MUC) 7 gene expression can be used as a bladder tumor marker for transitional cell carcinoma in patients with bladder carcinoma.

METHODS

Cells from the urine of 65 patients with bladder cancer, 15 patients with a negative bladder biopsy for bladder cancer, and 30 healthy volunteers were compared for the following parameters: tumor stage, grade, size, and number, urinary cytology, and expression of MUC7. Nested reverse transcriptase-polymerase chain reaction (RT-PCR) was used to determine MUC7 expression (348 base pairs).

RESULTS

MUC7 in the urine samples of the control group was negative (no false-positive results, specificity 100%). Among the 15 patients with nonmalignant disease, MUC7 was negative in 13 (specificity 87%). In the 2 patients with positive MUC7, the histologic examination showed chronic inflammation. Among the 65 patients with bladder transitional cell carcinoma, MUC7 was positive in 44 (68%). Nested RT-PCR for MUC7 was positive in 25 (61%) of 41 with superficial stages (pTa and pT1) versus 16 (76%) of 21 patients with Stage pT2 or advanced stages. Nested RT-PCR for MUC7 was positive in 5 (42%) of 12 patients with grade 1 disease, 22 (65%) of 34 patients with grade 2 disease, and 17 (89%) of 19 patients with grade 3 disease. We demonstrated no correlation between MUC7 and the clinicopathologic features (tumor stage, grade, or size) of urinary bladder tumors.

CONCLUSIONS

Our results indicate that MUC7 is a potential marker for bladder cancer. This noninvasive detection method assesses urothelial cells from voided urine specimens using RT-PCR.

The health economics of bladder cancer: a comprehensive review of the published literature

The aim of this paper was to conduct a critical systematic review of the available literature on the clinical and economic burden of bladder cancer in developed countries, with a focus on the cost effectiveness of interventions aimed at reducing that burden.Forty-four economic studies were included in the review. Because of long- term survival and the need for lifelong routine monitoring and treatment, the cost per patient of bladder cancer from diagnosis to death is the highest of all cancers, ranging from 96000-187000 US dollars (2001 values) in the US. Overall, bladder cancer is the fifth most expensive cancer in terms of total medical care expenditures, accounting for almost 3.7 billion US dollars (2001 values) in direct costs in the US. Screening for bladder cancer in the general population is currently not recommended. The economic value of relatively new and less expensive urine assays and molecular urinary tumour markers has not been assessed. However, the literature suggests that screening patients suspected of having bladder cancer and using less invasive diagnostic procedures is cost effective. Very few cost-effectiveness studies have evaluated intravesical therapies such as bacillus Calmette-Guérin and mitomycin in the management of superficial disease and no robust recommendations can be drawn. Economic analyses suggest that non-surgical treatment strategies for the management of invasive disease aiming at bladder preservation may not be cost effective, because they have not consistently demonstrated survival benefits and do not eliminate the need for subsequent radical cystectomy. The literature suggests that the current conventional frequent follow-up and monitoring of patients can be cost effectively replaced by less frequent and less invasive monitoring, and should rely more heavily on intravesical chemotherapy to reduce the need for cystoscopies. Bladder cancer is a fairly common and costly malignancy. Nevertheless, the existing literature only contributes marginally to our knowledge concerning the burden of bladder cancer and the economic value of various interventions. The limited value of the literature in this area may be attributed to (i) being published as abstracts rather than full peer-reviewed evaluations; (ii) employing questionable methodologies; and (iii) being in many cases nearly obsolete, rendering them less relevant to, if not in conflict with, current clinical practice. Consequently, opportunities exist to conduct meaningful economic research in all areas of the management of bladder cancer, including screening, diagnosis, follow-up and treatment, especially with respect to new and innovative pharmaceutical and other technologies.

DNA damage in cytologically normal urothelial cells of patients with a history of urothelial cell carcinoma

In order to determine if patients with a history of previous urothelial cell carcinoma (UCC) but with current normal urinary cytology have DNA damage in urothelial cells, the single-cell gel electrophoresis (comet) assay was conducted with cells obtained by urinary bladder washings from 44 patients (28 with a history of previous UCC). Increased DNA damage was observed in cytologically "normal" urothelial cells of patients with a history of UCC when compared with referents with no similar history and after correcting the data for smoking status and age (P < 0.018). Increased DNA damage also correlated with the highest tumor grade, irrespective of time or course of the disease after clinical intervention (Kendall tau correlation, 0.37, P = 0.016). Moreover, aneuploidy, as assessed by DNA content ratio (DCR; 75th/25th percentile of total DNA fluorescence of 50 comets/patient) was unaltered by smoking status, but increased with UCC grade: 1.39 +/- 0.12 (median +/- 95% confidence interval; referents); 1.43 +/- 0.11 (Grade I UCC; P = 0.264, against referents); 1.49 +/- 0.16 (Grade II UCC; P = 0.057); 1.57 +/- 0.16 (Grade III UCC; P = 0.003). Micronucleated urothelial cells (MNC) were also scored on Giemsa-stained routine cytological smears and were found not to correlate with DNA damage or DCR. MNC frequencies were higher for patients with a history of UCC and/or smoking than referents with neither history, but there was no statistical difference between groups. Taken together, these results suggest that the normal-appearing urothelium of patients resected for UCC still harbor genetically unstable cells.