A population-based study of patterns of care for muscle-invasive bladder cancer in Sweden

An overview of patients with urothelial bladder cancer over the past two decades: a Surveillance, Epidemiology, and End Results (SEER) study

Background

To explore the overall trends of incidence rate (IR), mortality and survival outcomes of patients with urothelial bladder cancer (UBC) over the past two decades.

Methods

Patients diagnosed with UBC from 1993 to 2012 were extracted from the Surveillance, Epidemiology and End Result (SEER) 18 database. Baseline characteristics and treatment types of included patients were collected retrospectively. Moreover, the age-adjusted IRs and annual percent changes (APCs) were obtained. Afterwards, we calculated the standardized mortality ratios (SMRs) for bladder cancer (BC), cardiovascular disease (CVD) and all-cause mortality by comparing UBC cases with the general population. Finally, survival outcomes of UBC patients were analyzed and compared.

Results

A total of 220,405 UBC patients were identified, including 167,036 (75.79%) male patients and 53,369 (24.21%) female patients, with an average age of 70.84 years old. Most patients were White (89.85%), with older age (71.67%, >65 years old), lower T stage diseases (78.11%, < T2) and lower median household income (55.37%). When compared with patients diagnosed between 1993 and 2002, those diagnosed between 2003 and 2012 had older age (mean: 71.15 vs. 70.16 years old, P<0.001), higher proportion of men (76.22% vs. 74.83%, P<0.001) and lower median household income (56.69% vs. 52.50%, P<0.01). Overall, the IR of UBC increased slightly before 2003 and maintained a stable trend of about 20 per 100,000 person-years after 2003. Additionally, CVD was recognized as an important cause of death (COD) of UBC patients. UBC patients were 44.5 times more likely to die of CVD when compared with the general population. Furthermore, the 3-, 5- and 10-year overall survival (OS) and cancer-specific survival (CSS) rates were 0.709, 0.609 and 0.421, and 0.861, 0.831 and 0.789, respectively. Finally, survival outcomes between patients diagnosed in the two periods (1993–2002 vs. 2003–2012) were not significantly different.

Conclusions

The IR of UBC increased slightly before 2003 and remained stable after 2003. UBC patients had higher CVD burden than the general population. Hence, cardiovascular health should be emphasized to reduce mortality after UBC diagnosis. Lastly, survival outcomes of UBC patients in the last two decades showed no significant difference.

Hospital-specific probability of cystectomy affects survival from muscle-invasive bladder cancer

OBJECTIVES

Radical cystectomies (RCs) are increasingly centralized, but bladder cancer can be diagnosed in every hospital The aim of this study is to assess the variation between hospitals of diagnosis in a patient's chance to undergo a RC before and after the volume criteria for RCs, to identify factors associated with this variation and to assess its effect on survival.

METHODS AND MATERIALS

Patients diagnosed with muscle-invasive bladder cancer (cT2-4a,N0/X,M0/X) without nodal or distant metastases between 2008 and 2016 were identified through the Netherlands Cancer Registry. Multilevel logistic regression analysis was used to investigate the hospital specific probability of undergoing a cystectomy. Cox proportional hazard regression analysis was used to assess the case-mix adjusted effect of hospital-specific probabilities on survival.

RESULTS

Of the 9,215 included patients, 4,513 (49%) underwent a RC. The percentage of RCs varied between 7% and 83% by hospital of diagnosis before the introduction of the first volume criteria (i.e., 2008-2009; minimum of 10 RCs). This variation decreased slightly to 17%-77% after establishment of the second volume criteria (i.e., 2015-2016; minimum of 20 RCs). Age, cT-stage and comorbidity were inversely and socioeconomic status was positively associated with RC. Both being diagnosed in a community hospital and/or being diagnosed in a hospital fulfilling the RC volume criteria were associated with increased use of RC compared to academic hospitals and hospitals not fulfilling the volume criteria. For each 10% increase in the percentage of RC in the hospital of diagnosis, 2-year case-mix adjusted survival increased 4% (hazard ratio 0.96, 95% confidence interval 0.94-0.98).

CONCLUSION

Probability of RC varied between hospitals of diagnosis and affected 2-year overall survival. Undergoing a RC was associated with age, cT-stage, socioeconomic status, type of hospital, and whether the hospital of diagnosis fulfilled the RC volume criteria. Future research is needed to identify patient, tumor, and hospital characteristics affecting utilization of curative treatment as this may benefit overall survival.

Insight into bladder cancer care: study protocol of a large nationwide prospective cohort study (BlaZIB)

BACKGROUND

Despite the embedding of bladder cancer management in European guidelines, large variation in clinical practice exists for applied diagnostics and treatments. This variation may affect patients' outcomes including complications, disease recurrence, progression, survival, and health-related quality of life (HRQL). Lack of detailed clinical data and HRQL data hampers a comprehensive evaluation of bladder cancer care. Through prospective data registration, this study aims to provide insight in bladder cancer care in the Netherlands and to identify barriers and modulators of optimal bladder cancer care.

METHODS

This study is a nationwide prospective cohort study including all patients who were newly diagnosed with high-risk non-muscle invasive bladder cancer (HR-NMIBC; Tis and/or T1, N0, M0/x) or non-metastatic muscle invasive bladder cancer (MIBC; ≥T2, N0/x-3, M0/x) in the Netherlands between November 1st 2017 and October 31st 2019. Extensive data on patient- and tumor characteristics, diagnostics, treatment and follow-up up to 2 years after diagnosis will be collected prospectively from electronic health records in the participating hospitals by data managers of the Netherlands Cancer Registry (NCR). Additionally, patients will be requested to participate in a HRQL survey shortly after diagnosis and subsequently at 6, 12 and 24 months. The HRQL survey includes six standardized questionnaires, e.g. SCQ Comorbidity score, EQ-5D-5 L, EORTC-QLQ-C30, EORTC-QLQ-BLM30, EORTC-QLQ-NMIBC24 and BCI. Variation in care and deviation from the European guidelines will be assessed through descriptive analyses and multivariable multilevel analyses. Survival analyses will be used to assess the association between variation in care and relevant outcomes such as survival.

DISCUSSION

The results of this observational study will guide modifications of clinical practice and/or adaptation of guidelines and may set the agenda for new specific research questions in the management of bladder cancer.

TRIAL REGISTRATION

Retrospectively registered in the Netherlands Trial Register. Trial identification number: NL8106. Registered on October 22nd 2019.

Neoadjuvant treatment for muscle-invasive bladder cancer: The past, the present, and the future

BACKGROUND

Approximately half of patients who undergo radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC) will succumb to metastatic disease. We summarize the evidence for neoadjuvant radiation (NAR), chemo (NAC), and immunotherapy (checkpoint inhibition) prior to RC for MIBC.

MATERIALS AND METHODS

Data were obtained by a search of PubMed, ClinicalTrials.gov, and Cochrane databases for English language articles published from 1925 up to 2017.

RESULTS

NAC usage has increased over the last decade, while NAR is rarely administered. Although NAR results in downstaging, its impact on survival is inconclusive. Based on level I evidence, cisplatin-based NAC (CB-NAC) is considered standard of care in cT2-4aN0M0 MIBC. NAC results in a 6% absolute 10-year overall survival (OS) benefit. In-depth analyses of key randomized controlled trials showed that failure to correct for uniform staging, surgical variation, and patient selection compromises the ability to identify factors predictive of response to NAC. The benefit appears to be restricted to patients downstaged to ypT1N0 or less. In these patients, 5-year OS is 80% to 90%. Regarding a number needed to treat of 17, most patients with cT2-4aN0M0 MIBC will be exposed to toxicity without benefit. Possible approaches to reduce overtreatment are suggested in this article and include patient selection, the chosen NAC regimen, and emerging molecular data to predict responsiveness to NAC. Neoadjuvant immunotherapy with checkpoint inhibitors is a promising future perspective currently under investigation.

CONCLUSIONS

Past studies on NAR show inconclusive results and NAR is rarely administered. Instead, CB-NAC is advised in eligible patients with cT2-4aN0M0 MIBC prior to RC. In the near future, predictive biomarkers will be the key to tailor the use of CB-NAC and reduce harm to nonresponders.

Cohort profile: The Swedish National Register of Urinary Bladder Cancer (SNRUBC) and the Bladder Cancer Data Base Sweden (BladderBaSe)

PURPOSE

To monitor the quality of bladder cancer care, the Swedish National Register of Urinary Bladder Cancer (SNRUBC) was initiated in 1997. During 2015, in order to study trends in incidence, effects of treatment and survival of men and women with bladder cancer, we linked the SNRUBC to other national healthcare and demographic registers and constructed the Bladder Cancer Data Base Sweden (BladderBaSe).

PARTICIPANTS

The SNRUBC is a nationwide register with detailed information on 97% of bladder cancer cases in Sweden as compared with the Swedish Cancer Register. Participants in the SNRUBC have registered data on tumour characteristics at diagnosis, and for 98% of these treatment data have been captured. From 2009, the SNRUBC holds data on 88% of eligible participants for follow-up 5 years after diagnosis of non-muscle invasive bladder cancer, and from 2011, data on surgery details and complications for 85% of participants treated with radical cystectomy. The BladderBaSe includes all data in the SNRUBC from 1997 to 2014, and additional covariates and follow-up data from linked national register sources on comorbidity, socioeconomic factors, detailed information on readmissions and treatment side effects, and causes of death.

FINDINGS TO DATE

Studies based on data in the SNRUBC have shown inequalities in survival and treatment indication by gender, regions and hospital volume. The BladderBaSe includes 38 658 participants registered in SNRUBC with bladder cancer diagnosed from 1 January 1997 to 31 December 2014. The BladderBaSe initiators are currently in collaboration with researchers from the SNRUBC investigating different aspects of bladder cancer survival.

FUTURE PLANS

The SNRUBC and the BladderBaSe project are open for collaborations with national and international research teams. Collaborators can submit proposals for studies and study files can be uploaded to servers for remote access and analysis. For more information, please contact the corresponding author.

Patterns of care in patients with muscle-invasive bladder cancer - a retrospective cohort study

A potential reason for poor survival among patients with muscle-invasive bladder cancer (MIBC) in Poland is initial disqualification from curative treatment due to advanced stage of the disease or low performance status. The aim of this study was to describe patterns of care in patients with newly diagnosed MIBC.

This is a multicentre retrospective cohort study involving 296 consecutive patients with primary histologically diagnosed MIBC. Therapeutic decisions and potentially underlying clinical factors were analysed.

Full clinical data was available for 285 patients. One hundred and sixty-four (57.5%) patients were qualified for radical cystectomy (RC), 32 (11.2%) patients for a second step of transurethral resection of the bladder tumour (TURBT) intentionally followed by systemic chemotherapy, four (1.4%) patients after complete TURBT were qualified for adjuvant intravesical chemotherapy only, while the remaining 85 (29.8%) patients were qualified for palliative treatment in the form of chemotherapy and/or radiotherapy and/or best supportive care. Patients disqualified from curative treatment were older (78 vs. 69 years, p < 0.02), had lower BMI values (24.5 vs. 25.7 kg/m², p < 0.02), lower haemoglobin concentration (11.6 vs. 12.9 mg/l, p < 0.02), declared lower rate of nicotine abuse (50.5% vs. 72.1%, p < 0.02), and had a shorter time interval between first symptom and diagnosis (30 vs. 60 days, p = 0.02).

As the majority of Polish patients with primary MIBC receive curative treatment, the stage of the disease alone seems not to be the leading cause of poor survival. However, appropriateness of qualification for RC and treatment quality needs to be assessed for final conclusion on the factors influencing outcomes of treatment in Poland.

Gender-related differences in urothelial carcinoma of the bladder: a population-based study from the Swedish National Registry of Urinary Bladder Cancer

OBJECTIVE

The aim of this investigation was to describe tumour characteristics, treatments and survival in patients with urinary bladder cancer (UBC) in a national population-based cohort, with special reference to gender-related differences.

MATERIAL AND METHODS

All primary UBC patients with urothelial pathology reported to the Swedish National Registry of Urinary Bladder Cancer (SNRUBC) from 1997 to 2011 were included in the study. Groups were compared regarding tumour, node, metastasis classification, primary treatment and survival.

RESULTS

In total, 30,310 patients (74.9% male, 25.1% female) with UBC were analysed. A larger proportion of women than men had stage T2-T4 (p < 0.001), and women also had more G1 tumours (p < 0.001). However, compared to women, a larger proportion of men with carcinoma in situ or T1G3 received intravesical treatment with bacillus Calmette-Guérin or intravesical chemotherapy, and a larger proportion of men with stage T2-T4 underwent radical cystectomy (38% men vs 33% women, p < 0.0001). The cancer-specific survival at 5 years was 77% for men and 72% for women (p < 0.001), and the relative survival at 5 years was 72% for men and 69% for women (p < 0.001).

CONCLUSIONS

In this population-based cohort comprising virtually all patients diagnosed with UBC in Sweden between 1997 and 2011, female gender was associated with inferior cancer-specific and relative survival. Although women had a higher rate of aggressive tumours, a smaller proportion of women than men received optimal treatment.

SEOM clinical guidelines for the treatment of invasive bladder cancer

The purpose of this article is to provide updated recommendations for the diagnosis and treatment of muscle- invasive and metastatic bladder cancer. The diagnosis of muscle-invasive bladder cancer is made by transurethral resection and following histopathologic evaluation. Invasive bladder cancer should be staged according to the UICC system. Patients with confirmed muscle-invasive bladder cancer should be staged by computed tomography scans of the chest, abdomen and pelvis. Radical cystectomy is the treatment of choice for both sexes and lymph node dissection should be an integral part of cystectomy. In muscle- invasive bladder cancer (cT2-4aN0M0) patients with good performance status (PS 0-1) and correct renal function, neoadjuvant chemotherapy should be recommended. Adjuvant chemotherapy is widely used in high-risk patients with pathologic stage T3 or T4 and/or positive nodes and within clinical trials. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well informed and compliant patients for whom cystectomy is not considered for clinical or personal reasons. In metastatic disease, the first-line treatment for patients is cisplatin-containing combination chemotherapy. Recently, vinflunine has been approved in Europe for second-line treatment and is an option for second-line therapy in patients progressing to first-line platinum-based chemotherapy.

Population-based analyses of radical cystectomy and urinary diversion for bladder cancer in northern Italy

OBJECTIVE

•To provide updated figures on urinary diversion, length of stay and mortality after cystectomy in two regions of northern Italy.

PATIENTS AND METHODS

•Discharge records of patients undergoing cystectomy for bladder cancer in 2000-2008 were extracted from the regional archives of hospital discharges. •Data on partial vs radical cystectomy and type of urinary diversion were obtained from intervention codes. •The influence of demographic characteristics, year of intervention, presence of comorbidities and hospital cystectomy volume on the adoption of a continent diversion and on in-hospital mortality was assessed through multilevel models.

RESULTS

•The crude cystectomy rate was close to 10 per 100,000. •The share of partial cystectomies declined from 5.5% in 2000-2002 to 3.0% in 2006-2008. •A continent diversion was adopted in 35% of radical cystectomies, with higher rates in young male patients treated in high-volume hospitals. •Median length of stay declined from 20 days in 2000-2002 to 18 in 2006-2008; in-hospital mortality decreased from 3.2% to 2.2%.

CONCLUSION

•This first population-based report on cystectomies for bladder cancer from continental Europe evidences a limited role of partial cystectomy, a high proportion of continent diversion and a decreasing trend of length of stay and in-hospital mortality.

Urinary diversion after cystectomy for bladder cancer: a population-based study in Sweden

OBJECTIVE

To investigate the type of urinary diversion performed after cystectomy in patients with muscle-invasive bladder cancer in Sweden, using data from a population-based national register.

MATERIAL AND METHODS

Since 1997, the Swedish Bladder Cancer Register has included more than 90% of all patients with newly diagnosed bladder cancer. The different types of urinary diversion performed in 1997-2003 were analysed, comparing non-continent diversion (ileal conduit) with continent reconstruction (bladder substitution or continent cutaneous diversion).

RESULTS

During the study period, 3463 patients were registered with clinical T2-T4 non-metastatic bladder cancer. Cystectomy was performed in 1141 patients with ileal conduit in 732 (64%) and continent reconstruction in 409 (36%). Ileal conduit was used more frequently in females than males (p = 0.019), in patients older than 75 years (p < 0.00001), and in those with less favourable TNM classification. Continent reconstruction was done more often at university hospitals than at county hospitals (p < 0.00001), but rarely in the northern and western healthcare regions compared with other regions (p < 0.00001). Nationwide, the proportion of registered continent reconstructions decreased, although the absolute number was relatively stable (50-60 per year).

CONCLUSIONS

Continent reconstruction after cystectomy for muscle-invasive bladder cancer is performed more often in some healthcare regions and in patients at university hospitals than in county hospitals, indicating a substantial provider influence on the choice of urinary diversion. Over time, the proportion of these procedures has decreased, while the absolute number has remained low and stable; therefore, concentration in high-volume hospitals specialized in bladder cancer and continent reconstruction seems appropriate.

Variations in treatment policies and outcome for bladder cancer in the Netherlands

AIM

To describe the population-based variation in treatment policies and outcome for bladder cancer in the Netherlands.

METHODS

All newly diagnosed patients with primary bladder cancers during 2001-2006 were selected from the Netherlands Cancer Registry (n = 29,206). Type of primary treatment was analysed according to Comprehensive Cancer Centre region, hospital type (academic, non-academic teaching or other hospitals) and volume (< or =5, 6-10 or >10 cystectomies yearly). For stage II-III patients undergoing cystectomy we analyzed the proportion of lymph node dissections and 30-days mortality.

RESULTS

44% of patients with stage II-III bladder cancer underwent cystectomy, while 26% were not treated with curative intent. Cystectomy was the preferred option in three of nine regions, radiotherapy in two, and two regions waived curative treatment more often. Between 2001 and 2006 the number of cystectomies increased with 20% (n = 108). Twenty-one percent (n = 663) of these procedures were performed in 44 low-volume hospitals. In 79% of the cystectomies lymph node dissections were performed, more often in high and medium-volume centers (82% and 81% respectively) than in low-volume hospitals (71%, the odds ratio being 1.5). The overall 30-days post-operative mortality rate was 3.4% and increased with older age. It was significantly lower in high-volume centers (1.2%).

CONCLUSION

Treatment policies for muscle-invasive bladder cancer in the Netherlands showed regional preferences and a gradual increase of cystectomy. Cystectomy albeit considered as golden standard, was performed in a minority of the muscle-invasive cases. In high-volume institutions, lymph node dissection rates were higher and post-operative mortality rates were lower.