Healthcare economics of bladder cancer: cost-enhancing and cost-reducing factors

Depression and anxiety among patients treated for bladder cancer: examining clinical, demographic, and psychosocial predictors

INTRODUCTION AND OBJECTIVE

The significant impact of bladder cancer and treatment on patient health related quality of life (HRQoL) and emotional wellbeing has been documented. Increasing evidence from cancer research emphasizes the importance of examining patients supportive care needs and received social support as factors that could influence their emotional adjustment. The purpose of the study was to assess the demographic and clinical predictors of depression and anxiety among bladder cancer patients and its associations with patient reported supportive care needs and perceived availability of social support.

METHODS

A cross-sectional design was used to investigate the study questions. Bladder cancer patients were recruited from the Bladder Cancer Advocacy Network (BCAN) to complete a questionnaire that included the Hospital Anxiety and Depression Scale (HADS), bladder cancer patient need survey (BCNAS-32), and the social provisions scale (SPS). The inclusion criteria restricted our sample to include bladder cancer patients who were English speakers, aged 18-85 years, and were able and willing to provide informed consent. Patients who had metastatic disease, cancer recurrence, or other primary cancers at the time of assessment were excluded from the study.

RESULTS

Participants included 159 bladder cancer patients. The mean age was 62±9.4 years and 51% were male. Almost two-thirds (62%) of patients reported a diagnosis of muscle invasive bladder cancer (MIBC), 25% patient reported clinically significant levels of anxiety, 17% reported clinically significant levels of depression, and 13% and 17% reported abnormal borderline abnormal levels for anxiety and depression, respectively. Univariate regression analyses revealed significant associations between HADS total score, HADS depression and anxiety subscales, patient age, physical functioning/daily living needs, sexuality needs, and perceived social support with higher total scores, anxiety, and depression scores associated with younger age, higher unmet needs, and lower levels of social support. Multivariate regression analyses, showed similar findings confirming the associations depicted by the univariate regression analyses.

CONCLUSIONS

Bladder cancer patients experience significant levels of depression and anxiety and these levels are associated with patient age, supportive care unmet needs and lack of social support. Patient focused interventions could be tailored to address these issues with the goal to improve patient HRQoL and emotional adjustment.

Pharmacologic Therapies for Non-Muscle Invasive Bladder Cancer: Current and Future Treatments

Bladder cancer is the sixth most common malignancy in the United States and 70% of cases are non-muscle invasive at the time of diagnosis. Effective treatment is crucial to prevent progression, which occurs in about 30% of patients. The American Urological Association (AUA) guidelines recommend treatment of non-muscle invasive bladder cancer (NMIBC) with intravesical Bacille Calmette-Guerin (BCG) and chemotherapy. However, ongoing shortages and high rates of BCG unresponsiveness creates a major need for novel therapies. In this narrative review, we discuss the evolving landscape of therapeutic options for NMIBC. Pembrolizumab, an anti-programmed cell death (PD)-1 antibody, was the first systemic therapy to be FDA-approved for BCG-unresponsive, high-risk disease. Promising new agents under investigation include various other checkpoint inhibitors and adenovirus-based therapies including CG0070 and nadofaragene firadenovec (rAd-IFNa/Syn3). Finally, new mechanisms of drug delivery are under investigation, including delivery with the GemRIS (TAR-200) device and delivery of intravesical chemotherapy at higher temperatures. With the promise of novel therapies on the horizon, we can expect the role of urologists in the management of NMIBC to evolve and expand.

Immune Checkpoint Inhibitors in the Management of Urothelial Carcinoma

Urothelial carcinoma is one of the most common cancers in the United States, yet outcomes are historically suboptimal. Since 2016, the approval of five programmed cell death 1 and programmed death-ligand 1 immune checkpoint inhibitors for locally advanced and metastatic urothelial carcinoma has led to improved oncologic outcomes for many patients in the second-line setting. Two checkpoint inhibitors, pembrolizumab and atezolizumab subsequently earned approval for first-fine therapy with restricted indications. More recently, pembrolizumab was approved for bacillus Calmette-Guérin-unresponsive high-risk non-muscle invasive bladder cancer, opening the door for other immune checkpoint inhibitors to be integrated into treatment in earlier disease stages. Recent bacillus Calmette-Guérin shortages have highlighted the need for alternative treatment options for patients with non-muscle invasive bladder cancer. Currently, there are no FDA-approved checkpoint inhibitors for non-metastatic muscle-invasive bladder cancer. Furthermore, many patients are ineligible for standard cisplatin-based chemotherapy regimens. Numerous ongoing clinical trials are employing immune checkpoint inhibitors for muscle-invasive bladder cancer patients in the neoadjuvant, adjuvant, perioperative, and bladder-sparing setting. Although up to 10% of urothelial carcinoma tumors arise in the upper urinary tract, few studies are designed for this population. We highlight the need for more trials designed for patients with upper tract disease. Overall, there are numerous clinical trials investigating the safety and efficacy of immune checkpoint inhibitors in all stages of disease as single-agents and combined with dual-immune checkpoint inhibition, chemotherapy, radiotherapy, and other pharmacologic agents. As the field continues to evolve rapidly, we aim to provide an overview of recent and ongoing immunotherapy clinical trials in urothelial carcinoma.

The Real-World Lifetime Economic Burden of Urothelial Carcinoma by Stage at Diagnosis

BACKGROUND

Urothelial carcinoma (UC) is generally diagnosed early and may incur significant lifetime costs. This study estimated, from the payer's perspective, the lifetime costs among patients diagnosed with UC according to stage at diagnosis.

METHODS

This retrospective analysis of the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database identified patients ≥66 years with newly diagnosed UC from 2004-2013. Patients were followed from UC diagnosis to death or last follow-up to estimate lifetime costs. Costs were allocated to 3 phases: diagnosis (≤3 months after diagnosis), terminal (≤3 months before death), and continuation (months between diagnosis and terminal phases). Survival-adjusted lifetime costs (total and major UC-related) were estimated for patients with UC based on stage at diagnosis (stages 0 through IV) and in a subgroup of patients receiving ≥1 systemic line of chemotherapy (LOC).

RESULTS

The sample included 15,588 patients: 3,446 stage 0 (8% ≥1 LOC; median [IQR] follow-up in months: 44 [23-71]); 3,902 stage I (12% ≥1 LOC; 33 [15-62]); 4,301 stage II (26% ≥1 LOC; 17 [7-39]); 1,612 stage III (25% ≥1 LOC; 17 [7-42]); and 2,327 stage IV (33% ≥1 LOC; 8 [3-18]). Median age was 78 years and 72% were male. Mean lifetime costs were lowest for stage IV patients (stage 0, $151,626; stage 1, $150,123; stage II, $149,728; stage III, $190,996; stage IV, $117,503). Hospitalizations not involving a cystectomy contributed about half of lifetime costs across all stages. Cystectomy contributed 2-13% of the total lifetime UC costs ($3,356 stage 0; $7,011 stage I; $11,855 stage II; $25,509 stage III; $11,693 stage IV). UC-related office visits contributed 8-15% of lifetime costs ($11,717 stage 0; $14,611 stage I; $19,882 stage II; $21,480 stage III; $17,820 stage IV).

CONCLUSION

UC continues to be a costly cancer with stage III patients having highest lifetime costs. Hospitalizations drive most of the lifetime costs across all stages; most of these hospitalizations did not involve costs related to cystectomy. Treatment plans requiring shorter and fewer hospitalizations may lessen the economic burden of UC.

N-Glycoproteomic Profiling Reveals Alteration In Extracellular Matrix Organization In Non-Type Bladder Carcinoma

Treatment of advanced and metastatic bladder carcinoma is often ineffective and displays variable clinical outcomes. Studying this aggressive molecular subtype of bladder carcinoma will lead to better understanding of the pathogenesis which may lead to the identification of new therapeutic strategies. The non-type bladder subtype is phenotypically mesenchymal and has mesenchymal features with a high metastatic ability. Post-translational addition of oligosaccharide residues is an important modification that influences cellular functions and contributes to disease pathology. Here, we report the comparative analysis of N-linked glycosylation across bladder cancer subtypes. To analyze the glycosite-containing peptides, we carried out LC-MS/MS-based quantitative proteomic and glycoproteomic profiling. We identified 1299 unique N-linked glycopeptides corresponding to 460 proteins. Additionally, we identified 118 unique N-linked glycopeptides corresponding to 84 proteins to be differentially glycosylated only in non-type subtypes as compared to luminal/basal subtypes. Most of the altered glycoproteins were also observed with changes in their global protein expression levels. However, alterations in 55 differentially expressed glycoproteins showed no significant change at the protein abundance level, representing that the glycosylation site occupancy was changed between the non-type subtype and luminal/basal subtypes. Importantly, the extracellular matrix organization pathway was dysregulated in the non-type subtype of bladder carcinoma. N-glycosylation modifications in the extracellular matrix organization proteins may be a contributing factor for the mesenchymal aggressive phenotype in non-type subtype. These aberrant protein glycosylation would provide additional avenues to employ glycan-based therapies and may lead to the identification of novel therapeutic targets.

Phase I neoadjuvant study of intravesical recombinant fowlpox-GM-CSF (rF-GM-CSF) or fowlpox-TRICOM (rF-TRICOM) in patients with bladder carcinoma

Intravesical BCG is a highly effective treatment for high-grade nonmuscle invasive bladder cancer and carcinoma in situ (CIS); however, for patients who are either resistant or become unresponsive to BCG therapy there is a need for alternative treatment approaches. This study examined the safety and feasibility of intravesically administered recombinant fowlpox virus encoding GM-CSF (Arm A) or TRICOM (Arm B); and the local and systemic immunologic responses generated to the vector(s). Twenty bladder cancer patients scheduled for cystectomy as their standard of care received preoperatively four weekly doses of intravesical recombinant fowlpox. Treatment was well tolerated, however, three patients experienced transient elevations of liver transaminases, with one rising to the level of a DLT. Cystectomy derived tumor and normal bladder mucosa demonstrated mRNA for the virally encoded LacZ gene supporting effective infection/transfection. Detected serum antibody to the LacZ encoding β-galactosidase indicated successful expression of vector-encoding gene products and the ability to immunize via the bladder site. H&E and IHC using a panel of immune cell specific antigens demonstrated immune cell infiltration of the bladder wall. These findings demonstrate good safety profile, successful infection/transfection, ability to generate systemic immune response, and local recruitment of immune cell populations with intravesical administration of fowlpox-based constructs encoding for GM-CSF(rF-GM-CSF) or TRICOM (rF-TRICOM), and support further evaluation of this treatment modality for bladder cancer.

Role of the androgen signaling axis in genitourinary malignancies

As we learn more about the molecular biology of genitourinary malignancies, novel therapeutic strategies can be developed. This is especially crucial for prostate, renal, and bladder cancer, where mortality rates remain high especially in advanced disease states. The androgen signaling axis and the androgen receptor (AR) are areas that are actively being explored for their role in these diseases. Although long been associated with prostate cancer development and progression, the role of AR in renal cell carcinoma (RCC) and bladder cancer is becoming recognized as well. This review will highlight the current research into the role of the androgen signaling axis in genitourinary malignancies and how this pathway is being used to expand our therapeutic armamentarium.

Preoperative nutritional factors and outcomes after radical cystectomy: A narrative review

Only a few nutritional factors have been identified to predict the risk of developing complications after radical cystectomy (RC). This narrative review delineates the current known effects of preoperative nutritional status factors in this context. The report highlights the heterogeneity between study methods and results. We determined that low albuminemia values increase mortality risk and overall complications. In addition, obesity tends to increase the risk of developing venous thromboembolism and adverse events. Additional prospective studies, using standardized methods to both define and report complications, should be conducted to strengthen the connections between preoperative nutritional status factors and post-RC complications. Furthermore, intervention studies testing the impact of strategies to improve nutritional status on the risk of complications after RC are also needed.

Halting Schistosoma haematobium - associated bladder cancer

Background

At present schistosomiasis is endemic in 78 countries affecting more than 260 million people. Schistosomiasis haematobia alone affects more than 112 millions.

Material and Methods

We performed a computerized search of Pubmed database with keywords: bladder cancer cost and schistosomiasis mass treatment.

Results

Bladder cancer is an important sequelae of this infection. In low-resource countries, where this disease is endemic, individuals inflicted with bladder cancer have very limited access to treatment and death is most probably certain.

Conclusion

Mass treatment with praziquantel is an easy, safe and inexpensive treatment that could save the lives of thousands and reduce the morbidity of millions.

What factors are associated with unplanned return following transurethral resection of bladder tumor? An analysis of a large single institution's experience

OBJECTIVE

This study sought to evaluate factors associated with unplanned hospital return (UR) following transurethral resection of bladder tumor (TURBT), the largest source of readmission among ambulatory urological procedures.

MATERIALS AND METHODS

A retrospective review of TURBTs at a single academic institution between April 2011 and August 2014 was performed. Demographics, comorbidities, length of stay, tumor size and multiple other factors were recorded. UR was recorded within 30 days of surgery. Bivariate and multivariable analyses were performed to determine factors associated with UR.

RESULTS

Among 708 patients undergoing TURBT, 23.9% were female with a mean age of 70 years. The rate of UR was 10.9%. The most common cause of UR was gross hematuria, accounting for 70%. On bivariate analysis, Foley catheter placement in the operating room, non-aspirin anticoagulation and index length of stay longer than 24 h were associated with hematuria-related UR (p < 0.05). Preoperative antibiotics, female gender and aspirin therapy were associated with lower rates of hematuria-related UR (p < 0.05), while tumor size, distance of residence to the hospital, and Foley on hospital discharge (rather than from the operating room) had no association (p > 0.05). On multivariable analysis, only Foley placement in the operating room remained associated with higher rates of hematuria-related UR, while preoperative antibiotics, female gender and aspirin therapy remained associated with a lower likelihood of this event.

CONCLUSIONS

UR following TURBT is common and typically results from gross hematuria. Patients with postoperative Foley catheterization in the operating room may require additional counseling or supervision before discharge, and should be considered for discharge with a Foley rather than having a prompt voiding trial.

FGFR3b Extracellular Loop Mutation Lacks Tumorigenicity In Vivo but Collaborates with p53/pRB Deficiency to Induce High-grade Papillary Urothelial Carcinoma

Missense mutations of fibroblast growth factor receptor 3 (FGFR3) occur in up to 80% of low-grade papillary urothelial carcinoma of the bladder (LGP-UCB) suggesting that these mutations are tumor drivers, although direct experimental evidence is lacking. Here we show that forced expression of FGFR3b-S249C, the most prevalent FGFR3 mutation in human LGP-UCB, in cultured urothelial cells resulted in slightly reduced surface translocation than wild-type FGFR3b, but nearly twice as much proliferation. When we expressed a mouse equivalent of this mutant (FGFR3b-S243C) in urothelia of adult transgenic mice in a tissue-specific and inducible manner, we observed significant activation of AKT and MAPK pathways. This was, however, not accompanied by urothelial proliferation or tumorigenesis over 12 months, due to compensatory tumor barriers in p16-pRB and p19-p53-p21 axes. Indeed, expressing FGFR3b-S249C in cultured human urothelial cells expressing SV40T, which functionally inactivates pRB/p53, markedly accelerated proliferation and cell-cycle progression. Furthermore, expressing FGFR3b-S243C in transgenic mouse urothelium expressing SV40T converted carcinoma-in-situ to high-grade papillary urothelial carcinoma. Together, our study provides new experimental evidence indicating that the FGFR3 mutations have very limited urothelial tumorigenicity and that these mutations must collaborate with other genetic events to drive urothelial tumorigenesis.

Comparative analysis of the incidence of bladder cancer in the communities of Andalusia, Catalonia and Madrid in 2011

OBJECTIVES

To determine the incidence of bladder cancer (BC) in the autonomous communities that include the largest number of cases in the national hospital BC registry (Andalusia, Catalonia and Madrid) and report the clinical, pathological and diagnostic differences and similarities of BC in these regions.

MATERIAL AND METHODS

An observational epidemiological study was performed in 2011 in 12 public hospitals with reference population areas according to the National Health System (Spain). Demographic and clinical variables were collected from new cases and relapses, with histopathologic confirmation of BC. The raw incidence rate was calculated using the number of diagnosed cases in all the participating centers compared with the aggregate total population assigned to each center. The raw rates by age and sex were obtained from the National Institute of Statistics (2011) by weighting the assigned population with the distribution by age and sex.

RESULTS

The 3 autonomous communities recorded 51% of the 4285 cases included in the national registration, with relapses corresponding to 42.8% of these cases. The raw annual incidence rate for new episodes was 22.6 (95% CI: 20.7; 24.6) in Andalusia, 23.5 (95% CI: 20.9; 26.0) in Catalonia and 22.0 (95% CI: 19.9; 24.1) in Madrid.

CONCLUSIONS

Except for the larger proportion of smokers and lower tumor grade of lesions in Andalusia, the 3 autonomous communities studied are similar in terms of clinical characteristics, comorbidities, patient symptoms and diagnostic processes for BC.

Surgical advances in bladder cancer: at what cost?

Bladder cancer is the most expensive cancer to treat from diagnosis to death. Frequent disease recurrence, intense follow-up, and expensive, invasive techniques for diagnosis and treatment drive these costs for non-muscle invasive bladder cancer. Fluorescence cystoscopy increases the detection of superficial bladder cancer and reduces costs by improving the quality of resection and reducing recurrences. Radical cystectomy with intestinal diversion is the mainstay of treatment of invasive disease; however it is associated with substantial cost and morbidity. Increased efforts to improve the surgical management of bladder cancer while reducing the cost of treatment are increasingly necessary.

Adherence to surveillance guidelines after radical cystectomy: a population-based analysis

OBJECTIVES

Surveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database.

METHODS AND MATERIALS

The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients aged ≥66 years diagnosed with nonmetastatic bladder cancer who had undergone radical cystectomy between 2000 and 2007. Medicare claims information identified recommended surveillance tests for 2 years after cystectomy as outlined in the NCCN guidelines. Adherence was defined as receipt of urine cytology and imaging of the chest, abdomen, and pelvis in each year. We evaluated the effect of patient and provider characteristics on adherence, controlling for demographic and disease characteristics.

RESULTS

Of 3,757 patients who had undergone radical cystectomy, 2,990 (80%) were alive after 2 years. Adherence to all recommended investigations was 17% for the first and the second years following surgery. Among patients surviving 2 years, only 9% had complete surveillance in both years. In either year, adherence was less likely in patients with advanced pathologic stage (III/IV) (adjusted odds ratio [AOR] = 0.74, 95% CI: 0.60-0.91) and unmarried patients (AOR = 0.82, 95% CI: 0.68-0.99). Adherence was more likely in patients treated by high-volume surgeons (AOR = 2.00, 95% CI: 1.70-2.36) and those who saw a medical oncologist (AOR = 1.52, 95% CI: 1.27-1.82). We also observed significant geographic variability in adherence.

CONCLUSION

Patterns of surveillance after radical cystectomy deviate considerably from NCCN recommendations. Despite increased utilization of radiographic imaging investigations, the omission of urine cytology significantly contributed to the low rate of overall adherence to surveillance guidelines. Uniform adherence to surveillance guidelines was observed in patients treated by high-volume surgeons. This suggests an important opportunity for quality improvement in bladder cancer care.

The effect of gartanin, a naturally occurring xanthone in mangosteen juice, on the mTOR pathway, autophagy, apoptosis, and the growth of human urinary bladder cancer cell lines

Garcinia mangostana, often referred to as mangosteen, is a fruit grown in Southeast Asia and has been used for centuries as a local beverage and natural medicine. Its bioactive compounds, xanthones (i.e., gartanin, α-mangostin, etc), have reported effects on ailments ranging from skin infections and inflammation to urinary tract infections. We demonstrate that mangosteen xanthones (i.e., gartanin and α-mangostin) at pharmacologically achievable concentrations inhibit the growth of cancer cell lines from different stages of human urinary bladder cancer. The growth inhibitory effects of gartanin in mouse embryonic fibroblasts are at least in part dependent on the existence of p53 or TSC1. Indeed, further studies have shown that gartanin treatment of bladder cancer cell lines T24 and RT4 resulted in a marked suppression of p70S6 and 4E-BP1 expression and induction of autophagy, suggesting the inhibition of the mTOR pathway. In addition, gartanin downregulated the expression of Bcl-2 and activated the p53 pathway leading to apoptosis induction. Together, these results suggested that gartanin is a multiple targeting agent that is suitable for further study into its chemopreventive properties for human urinary bladder cancer.

Kava chalcone, flavokawain A, inhibits urothelial tumorigenesis in the UPII-SV40T transgenic mouse model

Flavokawain A (FKA) is the predominant chalcone identified from the kava plant. We have previously shown that FKA preferentially inhibits the growth of p53 defective bladder cancer cell lines. Here, we examined whether FKA could inhibit bladder cancer development and progression in vivo in the UPII-SV40T transgenic model that resembles human urothelial cell carcinoma (UCC) with defects in the p53 and the retinoblastoma (Rb) protein pathways. Genotyped UPII-SV40T mice were fed orally with vehicle control (AIN-93M) or FKA (6 g/kg food; 0.6%) for 318 days starting at 28 days of age. More than 64% of the male mice fed with FKA-containing food survived beyond 318 days of age, whereas only about 38% of the male mice fed with vehicle control food survived to that age (P = 0.0383). The mean bladder weights of surviving male transgenic mice with the control diet versus the FKA diet were 234.6 ± 72.5 versus 96.1 ± 69.4 mg (P = 0.0002). FKA was excreted primarily through the urinary tract and concentrated in the urine up to 8.4 μmol/L, averaging about 38 times (males) and 15 times (females) more concentrated than in the plasma (P = 0.0001). FKA treatment inhibited the occurrence of high-grade papillary UCC, a precursor to invasive urothelial cancer, by 42.1%. A decreased expression of Ki67, survivin, and X-linked inhibitor of apoptotic proteins (XIAP) and increased expression of p27 and DR5, and the number of terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL)-positive apoptotic cells were observed in the urothelial tissue of FKA-fed mice. These results suggest a potential of FKA in preventing the recurrence and progression of non-muscle-invasive UCC.

Body mass and smoking are modifiable risk factors for recurrent bladder cancer

BACKGROUND

In the Western world, bladder cancer is the fourth most common cancer in men and the eighth most common in women. Recurrences frequently occur, and continued surveillance is necessary to identify and treat recurrent tumors. Efforts to identify risk factors that are potentially modifiable to reduce the rate of recurrence are needed.

METHODS

Cigarette smoking behavior and body mass index were investigated at diagnosis for associations with bladder cancer recurrence in a population-based study of 726 patients with bladder cancer in New Hampshire, United States. Patients diagnosed with non-muscle invasive urothelial cell carcinoma were followed to ascertain long-term prognosis. Analysis of time to recurrence was performed using multivariate Cox regression models.

RESULTS

Smokers experienced shorter time to recurrence (continuing smoker hazard ratio [HR] = 1.51, 95% confidence interval [CI] = 1.08-2.13). Although being overweight (body mass index > 24.9 kg/m(2) ) at diagnosis was not a strong independent factor (HR = 1.33, 95% CI = 0.94-1.89), among continuing smokers, being overweight more than doubled the risk of recurrence compared to smokers of normal weight (HR = 2.67, 95% CI = 1.14-6.28).

CONCLUSIONS

These observational results suggest that adiposity is a risk factor for bladder cancer recurrence, particularly among tobacco users. Future intervention studies are warranted to evaluate whether both smoking cessation and weight reduction strategies reduce bladder tumor recurrences.

Bladder cancer in Spain 2011: population based study

PURPOSE

We estimate the annual incidence of bladder cancer in Spain and describe the clinical profile of patients with bladder cancer enrolled in a population based study.

MATERIALS AND METHODS

Using the structure of the Spanish National Health System as a basis, in 2011 the AEU (Spanish Association of Urology) conducted this study with a representative sample from 26 public hospitals and a reference population of 10,146,534 inhabitants, comprising 21.5% of the Spanish population.

RESULTS

A total of 4,285 episodes of bladder cancer were diagnosed, of which 2,476 (57.8%) were new cases and 1,809 (42.2%) were cases of recurrence, representing an estimated 11,539 new diagnoses annually in Spain. The incidence of bladder cancer in Spain, age adjusted to the standard European population, was 20.08 cases per 100,000 inhabitants (95% CI 13.9, 26.3). Of patients diagnosed with a first episode of bladder cancer 84.3% were male, generally older than 59 years (81.7%) with a mean ± SD age of 70.5 ± 11.4 years. Of these patients 87.5% presented with some type of clinical symptom, with macroscopic hematuria (90.8%) being the most commonly detected. The majority of primary tumors were nonmuscle invasive (76.7%) but included a high proportion of high grade tumors (43.7%). According to the ISUP (International Society of Urologic Pathology)/WHO (2004) classification 51.1% was papillary high grade carcinoma. Carcinoma in situ was found in 2.2% of primary and 5.8% of recurrent cases.

CONCLUSIONS

The incidence of bladder cancer in Spain, age adjusted to the standard European population, confirms that Spain has one of the highest incidences in Europe. Most primary nonmuscle invasive bladder cancer corresponded to high risk patients but with a low detected incidence of carcinoma in situ.

A pilot study combining a GC-sensor device with a statistical model for the identification of bladder cancer from urine headspace

There is a need to reduce the number of cystoscopies on patients with haematuria. Presently there are no reliable biomarkers to screen for bladder cancer. In this paper, we evaluate a new simple in–house fabricated, GC-sensor device in the diagnosis of bladder cancer based on volatiles. Sensor outputs from 98 urine samples were used to build and test diagnostic models. Samples were taken from 24 patients with transitional (urothelial) cell carcinoma (age 27-91 years, median 71 years) and 74 controls presenting with urological symptoms, but without a urological malignancy (age 29-86 years, median 64 years); results were analysed using two statistical approaches to assess the robustness of the methodology. A two-group linear discriminant analysis method using a total of 9 time points (which equates to 9 biomarkers) correctly assigned 24/24 (100%) of cancer cases and 70/74 (94.6%) controls. Under leave-one-out cross-validation 23/24 (95.8%) of cancer cases were correctly predicted with 69/74 (93.2%) of controls. For partial least squares discriminant analysis, the correct leave-one-out cross-validation prediction values were 95.8% (cancer cases) and 94.6% (controls). These data are an improvement on those reported by other groups studying headspace gases and also superior to current clinical techniques. This new device shows potential for the diagnosis of bladder cancer, but the data must be reproduced in a larger study.

[Intravesical chemotherapy]

Bladder cancer care continues to represent a significant financial burden on the population and on the healthcare system. The incidence of bladder cancer has increased over the last two decades. Therapeutic advances have occurred in bladder cancer care, but at an increased cost to payers, providers, and patients. Intravesical treatment of non-muscle invasive tumors represents one of the main costs. For this reason therapeutic schedules need to be rationalized. In this perspective, we present some critical remarks on: the use of gemcitabine in clinical practice; the real impact of the perioperative chemotherapy, emphasizing the cost and effectiveness in high-risk patients, and finally the optimization of intravesical treatments. There is a need for the scientific community to focus on their resources and convey efforts not in the treatment of low-risk cancers (present in significant numbers in various studies), which the Anglo-Saxons call "nuisance tumor" since they can be treated easily and effectively at low cost, but definitely to engage in the study of the treatment of cancer at high risk of recurrence and progression, and it is on this field that the cost (economic, management, subjective) / benefit ratio must be assessed.

Office-based Bladder Tumor Fulguration and Surveillance: Indications and Techniques

This article summarizes the current literature on office-based management of low-grade, noninvasive bladder cancer. Discussion includes differences in recurrence and progression rates between neoplasm grades and stages, role of visual grading for diagnosis, cost advantages of treatment outside the operating room, and a step-by-step description of office-based procedures.

Plasma microRNA profiles for bladder cancer detection

BACKGROUND

Bladder cancer (BC) is a burdensome disease with significant morbidity, mortality, and cost. The development of novel plasma-based biomarkers for BC diagnosis and surveillance could significantly improve clinical outcomes and decrease health expenditures. Plasma miRNAs are promising biomarkers that have yet to be rigorously investigated in BC.

OBJECTIVE

To determine the feasibility and efficacy of detecting BC with plasma miRNA signatures.

MATERIALS AND METHODS

Plasma miRNA was isolated from 20 patients with bladder cancer and 18 noncancerous controls. Samples were analyzed with a miRNA array containing duplicate probes for each miRNA in the Sanger database. Logistic regression modeling was used to optimize diagnostic miRNA signatures to distinguish between muscle invasive BC (MIBC), non-muscle-invasive BC (NMIBC) and noncancerous controls.

RESULTS

Seventy-nine differentially expressed plasma miRNAs (local false discovery rate [FDR] <0.5) in patients with or without BC were identified. Some diagnostically relevant miRNAs, such as miR-200b, were up-regulated in MIBC patients, whereas others, such as miR-92 and miR-33, were inversely correlated with advanced clinical stage, supporting the notion that miRNAs released in the circulation have a variety of cellular origins. Logistic regression modeling was able to predict diagnosis with 89% accuracy for detecting the presence or absence of BC, 92% accuracy for distinguishing invasive BC from other cases, 100% accuracy for distinguishing MIBC from controls, and 79% accuracy for three-way classification between MIBC, NIMBC, and controls.

CONCLUSIONS

This study provides preliminary data supporting the use of plasma miRNAs as a noninvasive means of BC detection. Future studies will be required to further specify the optimal plasma miRNA signature, and to apply these signatures to clinical scenarios, such as initial BC detection and BC surveillance.

Predictive value of urinary interleukin-8 cutoff point for recurrences after transurethral resection plus induction bacillus Calmette-Guérin treatment in non-muscle-invasive bladder tumors

BACKGROUND

This study was designed to investigate whether there is a correlation between interleukin (IL)-8 secretion rate and recurrences in induction bacillus Calmette-Guérin (BCG) immunotherapy following transurethral resection (TUR) in cases of primary non-muscle-invasive bladder cancer (NMIBC).

PATIENTS AND METHODS

A total of 41 patients with NMIBC were randomized to receive a 6-week course with a standard dose of 81 mg intravesical BCG. Voided urine samples were collected immediately before and after (at 2 and 4 hours) BCG instillation. IL-8 was measured using enzyme-linked immunosorbent assay. Patients were monitored according to European Association of Urology Guidelines.

RESULTS

Patients were monitored for a mean duration of 21.0 +/- 13.86 months. The mean time to recurrence for the 15 patients who had recurrences was 11.2 months. After adjusting for risk factors, the change in IL-8 levels at 2 hours after the first BCG compared with the levels before BCG instillation was found to be significantly predictive of recurrence (P = .047), and the best cutoff point was estimated as 112 pg/mL. The sensitivity of this measure for prediction of recurrences was 53.3%, specificity was 88.5%, positive predictive value was 72.7%, and negative predictive value was 76.7%. Comparison of patients who had values below and above this cutoff point revealed that the recurrence-free survival rate was 76.7% versus 27.3%, and the expected recurrence-free survival time was 34.9 months versus 18.8 months (P = .006).

CONCLUSION

Besides numerous other prognostic factors that have been suggested so far, a cutoff point of 112 pg/mL for IL-8 levels measured 2 hours after the first BCG instillation appears to be a good predictive factor for successful outcome in BCG treatment following TUR.

Clinical experience with survivin as a biomarker for urothelial bladder cancer

OBJECTIVES

This study was carried out as a prospective pilot study to evaluate the potential of survivin mRNA measurement in patients suspicious for urothelial bladder cancer (BC). Data were also analyzed for possible influences of secondary urological findings on survivin measurements.

METHODS

Survivin was measured by an mRNA assay in voided urine samples of 50 patients with suspicion of new or recurrent BC prior to transurethral resection. Sample evaluation was possible in 49 cases. Histopathology revealed no malignancy in 17 (35%) and BC in 32 (65%) patients. Survivin mRNA was quantitated by real-time PCR from frozen cell pellets of centrifuged urine samples. A ROC analysis of the survivin data was performed.

RESULTS

ROC analysis identified the best cut-off level at 10,000 mRNA copies, resulting in a sensitivity of 53% and a specificity of 88%. Seven of the 20 pTa tumors (35%), all four pT1 (100%) and all four muscle-invasive tumors (100%) were detected. Of four patients with carcinoma in situ (Cis), 50% could be identified. Only two patients (4%) were assessed as false positive. Histologically confirmed cystitis and concomitant urological findings (inflammatory cells in urine, microhematuria and others) had no detectable influence on survivin measurements.

CONCLUSION

In present group of patients, survivin was a reliable biomarker for high-grade urothelial BC (sensitivity 83%), but not for low grade (sensitivity 35%) urothelial BC with a high specificity (88%). No confounders influencing the results of survivin measurements could be identified.