Treatment of Nonmetastatic Muscle-Invasive Bladder Cancer: American Urological Association/American Society of Clinical Oncology/American Society for Radiation Oncology/Society of Urologic Oncology Clinical Practice Guideline Summary

Risk prediction of bladder cancer among person with diabetes: A derivation and validation study

AIMS

This study aimed to devise and validate a clinical scoring system for risk prediction of bladder cancer to guide urgent cystoscopy evaluation among people with diabetes.

METHODS

People with diabetes who received cystoscopy from a large database in the Chinese population (2009-2018). We recruited a derivation cohort based on random sampling from 70% of all individuals. We used the adjusted odds ratios (aORs) for independent risk factors to devise a risk score, ranging from 0 to 5: 0-2 'average risk' (AR) and 3-5 'high risk' (HR).

RESULTS

A total of 5905 people with diabetes, among whom 123 people with BCa were included. The prevalence rate in the derivation (n  = 4174) and validation cohorts (n  = 1731) was 2.2% and 1.8% respectively. Using the scoring system constructed, 79.6% and 20.4% in the derivation cohort were classified as AR and HR respectively. The prevalence rate in the AR and HR groups was 1.57% and 4.58% respectively. The risk score consisted of age (18-70: 0; >70: 2), male sex (1), ever/ex-smoker (1) and duration of diabetes (≥10 years: 1). Individuals in the HR group had 3.26-fold (95% CI = 1.65-6.44, p  = 0.025) increased prevalence of bladder than the AR group. The concordance (c-) statistics was 0.72, implying a good discriminatory capability of the risk score to stratify high-risk individuals who should consider earlier cystoscopy.

CONCLUSIONS

The risk prediction algorithm may inform urgency of cystoscopy appointments, thus allowing a more efficient use of resources and contributing to early detection of BCa among people planned to be referred.

Role of human papillomavirus and associated viruses in bladder cancer: An updated review

Bladder cancer (BC) is a complex disease affecting the urinary system and is regulated by several carcinogenic factors. Viral infection is one such factor that has attracted extensive attention in BC. Human papillomavirus (HPV) is the most common sexually transmitted infection, and although multiple researchers have explored the role of HPV in BC, a consensus has not yet been reached. In addition, HPV-associated viruses (e.g., human immunodeficiency virus, herpes simplex virus, BK virus, and JC virus) appear to be responsible for the occurrence and progression of BC. This study systematically reviews the relationship between HPV-associated viruses and BC to elucidate the role of these viruses in the onset and progression of BC. In addition, the study aims to provide a greater insight into the biology of HPV-associated viruses, and assess potential strategies for treating virus-induced BC. The study additionally focuses on the rapid development of oncolytic viruses that provide a potentially novel option for the treatment of BC.

Induction therapy with ipilimumab and nivolumab followed by consolidative chemoradiation as organ-sparing treatment in urothelial bladder cancer: study protocol of the INDIBLADE trial

Introduction

Studies that assessed the efficacy of pre-operative immune checkpoint blockade (ICB) in locally advanced urothelial cancer of the bladder showed encouraging pathological complete response rates, suggesting that a bladder-sparing approach may be a viable option in a subset of patients. Chemoradiation is an alternative for radical cystectomy with similar oncological outcomes, but is still mainly used in selected patients with organ-confined tumors or patients ineligible to undergo radical cystectomy. We propose to sequentially administer ICB and chemoradiation to patients with (locally advanced) muscle-invasive bladder cancer.

Methods

The INDIBLADE trial is an investigator-initiated, single-arm, multicenter phase 2 trial. Fifty patients with cT2-4aN0-2M0 urothelial bladder cancer will be treated with ipilimumab 3 mg/kg on day 1, ipilimumab 3 mg/kg plus nivolumab 1 mg/kg on day 22, and nivolumab 3 mg/kg on day 43 followed by chemoradiation. The primary endpoint is the bladder-intact event-free survival (BI-EFS). Events include: local or distant recurrence, salvage cystectomy, death and switch to platinum-based chemotherapy. We will also evaluate the potential of multiparametric magnetic resonance imaging of the bladder to identify non-responders, and we will assess the clearance of circulating tumor DNA as a biomarker for ICB treatment response.

Discussion

This is the first trial in which the efficacy of induction combination ICB followed by chemoradiation is being evaluated to provide bladder-preservation in patients with (locally advanced) urothelial bladder cancer.

Clinical Trial Registration

The INDIBLADE trial was registered on clinicaltrials.gov on January 21, 2022 (NCT05200988).

Effect of decreased renal function on poor oncological outcome after radical cystectomy

PURPOSE

To evaluate the impact of preoperative renal impairment on the oncological outcomes of patients with urothelial carcinoma who underwent radical cystectomy.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients with urothelial carcinoma who underwent radical cystectomy from 2004 to 2017. All patients who underwent preoperative ^99mTc-diethylenetriaminepentaacetic acid renal scintigraphy (DTPA) were identified. We divided the patients into two groups according to their glomerular filtration rates (GFRs): GFR group 1, GFR≥90 mL/min/1.73 m²; GFR group 2, 60≤GFR<90 mL/min/1.73 m². We included 89 patients in GFR group 1 and 246 patients in GFR group 2 and compared the clinicopathological characteristics and oncological outcomes between the two groups.

RESULTS

The mean time required for recurrence was 125.5±8.0 months in GFR group 1 and 85.7±7.4 months in GFR group 2 (p=0.030). The mean cancer-specific survival was 131.7±7.8 months in GFR group 1 and 95.5±6.9 months in GFR group 2 (p=0.051). The mean overall survival was 123.3±8.1 months in GFR group 1 and 79.5±6.6 months in GFR group 2 (p=0.004).

CONCLUSIONS

Preoperative GFR values in the range of 60≤GFR<90 mL/min/1.73 m² are independent prognostic factors for poor recurrence-free survival, cancer-specific survival, and overall survival in patients after radical cystectomy compared with GFR values of ≥90 mL/min/1.73 m².

Survival outcomes in patients with muscle invasive bladder cancer undergoing radical vs. partial cystectomy

PURPOSE

While radical cystectomy (RC) is the standard of care for muscle invasive bladder cancer (MIBC), partial cystectomy (PC) is an effective alternative in select patients. We sought to examine differences in survival for RC and PC in a hospital-based registry.

MATERIAL AND METHODS

We identified patients diagnosed with cT2-4 bladder cancer who underwent RC or PC from 2003 to 2015 in the National Cancer Database (NCDB). Using inverse probability treatment weighting (IPTW) to control for known confounders, we compared the primary outcome of overall survival (OS) in patients who underwent RC vs. PC. Kaplan-Meier survival analysis, univariable and multivariable Cox proportional hazards modeling were used. We performed a secondary survival analysis for a subcohort of patients with cT2, cN0, tumor size ≤5 cm, and no concurrent carcinoma in situ (CIS), who may be optimal candidates for PC.

RESULTS

A total of 22,534 patients met inclusion criteria, of which 6.9% (1,457) underwent PC. RC had longer median OS than PC (67.8 vs. 54.1 months) and on Cox regression analysis (HR 0.88, 95% CI, 0.80-0.95, P = 0.002). However, in our subcohort, there was no difference in OS between RC and PC (HR 1.02, 95% CI, 0.9-1.2, P = 0.74). PC was associated with increased time from surgery to any systemic therapy or death in the subcohort.

CONCLUSIONS

Among patients with clinically organ-confined MIBC, PC appears to afford similar survival outcomes to RC in a large national data set. The safety and tolerability of PC may warrant consideration in highly selected patients.

Safety and efficacy of the pan-FGFR inhibitor erdafitinib in advanced urothelial carcinoma and other solid tumors: A systematic review and meta-analysis

Objective

This review aimed to comprehensively analyze the safety and efficacy of erdafitinib in treating advanced and metastatic urothelial carcinoma and other solid tumors.

Methods

PubMed, Embase, and ClinicalTrials.gov were searched until 10 February 2022. The safety outcome as adverse events and efficacy outcomes, including objective response rate, stable disease rates, and progressive disease rates, were selected and analyzed by comprehensive meta-analysis version 3.0 and STATA 15.0.

Results

The most common all-grade adverse events were hyperphosphatemia, dry mouth, stomatitis, diarrhea, and dysgeusia. The occurrence of ≥3 adverse events was relatively low, and stomatitis and hyponatremia were the most common. Moreover, eye disorders could not be ignored. Efficacy in urothelial carcinoma patients was obviously better than in other solid tumor patients, with a higher objective response rate (0.38 versus 0.10) and lower progressive disease rate (0.26 versus 0.68). All responses occurred in patients with fibroblast growth factor receptor (FGFR) alteration. In those patients, a specific FGFR alteration (FGFR3-TACC3) was observed to have a maximum response.

Conclusion

Erdafitinib has satisfactory clinical activity for metastatic urothelial carcinoma and other solid tumors, while the toxicity is acceptable. With more RCTs and combination therapy trials published, erdafitinib will be applied widely.

The evolving role of checkpoint inhibitors in the treatment of urothelial carcinoma

The most prevalent pathological subtype of bladder and upper urinary tract malignancy is urothelial carcinoma (UC). Traditional therapies mainly include surgical resection, chemotherapy and radiotherapy. Checkpoint inhibitors, which are monoclonal antibodies developed to specifically target immune checkpoint molecules, have recently emerged as potential treatment options for UC patients, especially those targeting the programmed cell death protein 1 (PD-1) and its ligand (PD-L1). However, anti-PD-1/PD-L1 therapy does not work for a considerable number of UC patients. Current antitumour immunotherapy research hotspots include seeking biomarkers that might predict therapeutic effects and exploring novel immune checkpoint molecules crucial for the antitumour immune response. Hence, we will recapitulate the latest preclinical and clinical trials of 5 PD-1/PD-L1 inhibitors, 1 cytotoxic T-lymphocyte-associated protein 4 inhibitor and combination therapies for UC treatment, including combined immunotherapy and immunotherapy with chemotherapy or radiotherapy. We will also summarize other potential immune checkpoint molecules found in ongoing UC studies. Moreover, we will highlight the role of biomarkers linked with the oncological efficacy of anti-PD-1/PD-L1 immunotherapy and address the mechanisms of immunotherapy drug resistance in UC, with the hope of providing more systematic guidance for its application and development.

Prognosis and immune infiltration analysis of endoplasmic reticulum stress-related genes in bladder urothelial carcinoma

Background: Abnormal activation of endoplasmic reticulum (ER) stress sensors and their downstream signalling pathways is a key regulator of tumour growth, tumour metastasis and the response to chemotherapy, targeted therapy and immunotherapy. However, the study of ER stress on the immune microenvironment of bladder urothelial carcinoma (BLCA) is still insufficient.

Methods: Firstly, 23 ER stress genes were selected to analyse their expression differences and prognostic value in BLCA based on the existing BLCA genome atlas data. According to the expression level of ER stress-related genes in BLCA, two independent clusters were identified using consensus cluster analysis. Subsequently, the correlation between these two clusters in terms of the immune microenvironment and their prognostic value was analysed. Finally, we analysed the prognostic value of the key ER stress gene HSP90B1 in BLCA and its corresponding mechanism that affects the immune microenvironment.

Results: Consensus clustering showed a worse prognosis and higher expression of immunoassay site-related genes (HAVCR2, PDCD1, CTLA4, CD274, LAG3, TIGIT and PDCD1LG2) in cluster 1 compared with cluster 2. Additionally, both TIMER and CIBERSORT algorithms showed that the expression of immune infiltrating cells in cluster 1 was significantly higher than that in cluster 2. Subsequently, HSP90B1 was identified as a key ER stress gene in BLCA, and its high expression indicated poor prognosis and was closely related to PD1. We also analysed the correlation between HSP90B1 expression and immune-infiltrating cell related biomarkers, which showed positive results. Finally, we verified the prognostic value of HSP90B1 in BLCA using an immunohistochemical assay in a tissue microarray of 100 patients with BLCA, validating the potential of HSP90B1 as a prognostic biomarker in patients with BLCA.

Conclusion: Our work reveals that ER stress genes play a crucial role in the BLCA immunological milieu, and HSP90B1 is a potential prognostic biomarker and therapeutic target for cancer immunotherapy.

Immune Checkpoint Inhibitors as a Neoadjuvant/Adjuvant Treatment of Muscle-Invasive Bladder Cancer: A Systematic Review

Simple Summary

Bladder cancer is the ninth most common cancer worldwide. Immune checkpoint inhibitors, a novel class of immunotherapy drugs that restore natural antitumoral immune activity, have been applied to improve the overall survival and to reduce the morbidity and mortality of bladder cancer both in neoadjuvant and adjuvant settings. However, some patients do not respond to checkpoint inhibitors. Consequently, the capability for identifying patients eligible for this type of immunotherapy represent one of the efforts of ongoing studies. We aim to summarize the most recent evidence on immune checkpoint inhibitors in neoadjuvant and adjuvant setting in the treatment of muscle-invasive bladder cancer.

Abstract

Bladder cancer is the ninth most common cancer worldwide. Over 75% of non-muscle invasive cancer patients require conservative local treatment, while the remaining 25% of patients undergo radical cystectomy or radiotherapy. Immune checkpoint inhibitors represent a novel class of immunotherapy drugs that restore natural antitumoral immune activity via the blockage of inhibitory receptors and ligands expressed on antigen-presenting cells, T lymphocytes and tumour cells. The use of immune checkpoint inhibitors in bladder cancer has been expanded from the neoadjuvant setting, i.e., after radical cystectomy, to the adjuvant setting, i.e., before the operative time or chemotherapy, in order to improve the overall survival and to reduce the morbidity and mortality of both the disease and its treatment. However, some patients do not respond to checkpoint inhibitors. As result, the capability for identifying patients that are eligible for this immunotherapy represent one of the efforts of ongoing studies. The aim of this systematic review is to summarize the most recent evidence regarding the use of immune checkpoint inhibitors, in a neoadjuvant and adjuvant setting, in the treatment of muscle-invasive bladder cancer.

Intravesical immunotherapy with a GM-CSF armed oncolytic vesicular stomatitis virus improves outcome in bladder cancer

A significant proportion of non-muscle invasive bladder cancer cases will progress to muscle invasive disease. Transurethral resection followed by Bacillus Calmette Guerin immunotherapy can reduce this risk, while cystectomy prior to muscle invasion provides the best option for survival. Currently, there are no effective treatments for Bacillus Calmette Guerin refractory disease. A novel oncolytic vesicular stomatitis virus containing the human GM-CSF transgene (VSVd51-hGM-CSF) was rescued and tested as a potential bladder-sparing therapy for aggressive bladder cancer. The existing variant expressing mouse GM-CSF was also used. Measurement of gene expression and protein level alterations of canonical immunogenic cell death associated events on mouse and human bladder cancer cell lines and spheroids showed enhanced release of danger signals and immunogenic factors following infection with VSVd51-m/hGM-CSF. Intravesical instillation of VSVd51-mGM-CSF into MB49 bladder cancer bearing C57Bl/6 mice demonstrated enhanced activation of peripheral and bladder infiltrating effector immune cells, along with improved survival and reduced tumor volume. Importantly, virus-mediated anti-tumor immunity was recapitulated in bladder cancer patient-derived organoids. These results suggest that VSVd51-hGM-CSF is a promising viro/immunotherapy that could benefit bladder cancer patients.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Identification of a novel metabolism-related gene signature associated with the survival of bladder cancer

Background

Bladder cancer (BC) is one of the most common malignancies and has a relatively poor outcome worldwide. In this study, we attempted to construct a novel metabolism-related gene (MRG) signature for predicting the survival probability of BC patients.

Methods

First, differentially expressed MRGs between BC and normal samples were identified and used to construct a protein-protein interaction (PPI) network and perform mutation analysis. Next, univariate Cox regression analysis was utilized to select prognostic genes, and multivariate Cox regression analysis was applied to establish an MRG signature for predicting the survival probability of BC patients. Moreover, Kaplan-Meier (KM) survival analysis and receiver operating characteristic (ROC) analysis were performed to evaluate the predictive capability of the MRG signature. Finally, a nomogram based on the MRG signature was established to better predict the survival of BC.

Results

In the present study, 27 differentially expressed MRGs were identified, most of which presented mutations in BC patients, and LRP1 showed the highest mutation rate. Next, an MRG signature, including MAOB, FASN and LRP1, was established by using univariate and multivariate Cox regression analysis. Furthermore, survival analysis indicated that BC patients in the high-risk group had a dramatically lower survival probability than those in the low-risk group. Finally, Cox regression analysis showed that the risk score was an independent prognostic factor, and a nomogram integrating age, pathological tumor stage and risk score was established and presented good predictive ability.

Conclusion

We successfully constructed a novel MRG signature to predict the prognosis of BC patients, which might contribute to the clinical treatment of BC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-09006-w.

Role of blue-light cystoscopy in detecting invasive bladder tumours: data from a multi-institutional registry

OBJECTIVES

To evaluate the role of blue-light cystoscopy (BLC) in detecting invasive tumours that were not visible on white-light cystoscopy (WLC).

PATIENTS AND METHODS

Using the multi-institutional Cysview registry database, patients who had at least one white-light negative (WL-)/blue-light positive (BL+) lesion with invasive pathology (≥T1) as highest stage tumour were identified. All WL-/BL+ lesions and all invasive tumours in the database were used as denominators. Relevant baseline and outcome data were collected.

RESULTS

Of the 3514 lesions (1257 unique patients), 818 (23.2%) lesions were WL-/BL+, of those, 55 (7%) lesions were invasive (48 T1, seven T2; 47 unique patients) including 28/55 (51%) de novo invasive lesions (26 unique patients). In all, 21/47 (45%) patients had WL-/BL+ concommitant carcinoma in situ and/or another T1 lesions. Of 22 patients with a WL-/BL+ lesion who underwent radical cystectomy (RC), high-risk pathological features leading to RC was only visible on BLC in 18 (82%) patients. At time of RC, 11/22 (50%) patients had pathological upstaging including four (18%) with node-positive disease.

CONCLUSIONS

A considerable proportion of invasive lesions are only detectable by BLC and the rate of pathological upstaging is significant. Our present findings suggest an additional benefit of BLC in the detection of invasive bladder tumours that has implications for treatment approach.

Genomic analysis of response to bacillus Calmette-Guérin (BCG) treatment in high-grade stage 1 bladder cancer patients

Background

Intravesical bacillus Calmette-Guérin (BCG) therapy is standard treatment for high-risk non-muscle invasive bladder cancer (NMIBC) but overall efficacy is low, and no reliable predictive biomarkers currently exist to refine patient selection. We performed genomic analysis on high-grade (HG) T1 NMIBCs to determine if response to therapy is predicted by certain mutational and/or expressional changes.

Methods

Patients with HG T1 NMIBC treated with induction BCG were stratified by response into durable and non-durable responders. Baseline tumor samples were subjected to targeted DNA sequencing and whole-exome RNAseq. Genomic variants differing significantly between response groups were analyzed using Ingenuity Pathway Analysis (IPA) software. Variant selection was refined to target potential biomarker candidates for responsiveness to BCG.

Results

Among 42 patients, the median follow-up was 51.7 months and 40.5% (n=17) were durable BCG responders. Deleterious mutations in the RNA sequence of JCHAIN, S100A7, CLEC2B, and ANXA10 were more common in non-durable responders. Mutations in MCL1 and MSH6 detected on targeted sequencing were more commonly found in durable responders. Of all deleterious DNA and RNA mutations identified, only MCL1 was significantly associated with longer recurrence free survival (RFS) (P=0.031).

Conclusions

Differences in the genomic profiles of HG T1 NMIBC tumors exist between those who show durable response to BCG and those who do not. Using pathway analysis, those differences imply upregulation of several interconnected inflammatory pathways among responders. Specific variants identified here, namely MCL1, are candidates for further study and, if clinically validated, may serve as useful biomarkers in the future.

Treating Elderly Patients With Muscle-Invasive Bladder Cancer

Bladder cancer is an extremely common cancer that primarily affects individuals aged >65 years. In caring for patients with bladder cancer, clinicians must also consider care of older persons in general. Management of muscle-invasive bladder cancer (MIBC) involves multidisciplinary treatment planning, because curative-intent therapy includes either surgery or radiation, with consideration of the role of systemic therapy. As clinicians develop a treatment plan, considering a geriatric oncology perspective may enhance patient care and influence outcomes for this large and growing population. Similarly, treatment plan development must also consider aspects unique to an older patient population, such as altered organ function, increased comorbidity, decreased functional reserve, and perhaps altered goals of treatment. Thus a thorough evaluation inclusive of disease assessment and geriatric assessment is essential to care planning. Population-based data show that as patients with MIBC age, use of standard therapies declines. Given the complexities of coordinating a multidisciplinary care plan, as well the complexities of treating a heterogeneous and potentially vulnerable older patient population, clinicians may benefit from upfront assessments to inform and guide the process. This review highlights the unique treatment planning considerations for elderly patients diagnosed with MIBC.

Role of lymph node dissection at the time of open or minimally invasive nephroureterectomy

Unlike urothelial carcinoma of the bladder, there is no guideline-based consensus on whether a lymph node dissection (LND) should be performed at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Variable lymphatic drainage based on primary tumor location, lack of prospective trials, and difficulties in developing a risk-adapted approach to LND for UTUC are all challenges to the development of an established approach. The UTUC literature consists of an evidence pool that has historically been limited to single-institution series with heterogenous inclusion criteria for LND and variable LND templates. Areas of controversy exist regarding migration to the great vessel LN beds for mid and distal tumors. A lack of template standardization limits the interpretation of studies relative to one another and a lack of uniformity in reporting templates may lead to inaccuracies in the estimation of lymph node metastasis landing sites. Most clinicians agree that there is a staging benefit to LND for UTUC. Although the data is somewhat heterogenous, it demonstrates a prognostic and staging benefit to LND in higher stages of UTUC. Unlike the staging benefits provided by LND for UTUC, the therapeutic benefits are not as clearly established. Several studies have evaluated differences in cancer-specific survival (CSS) and demonstrated LND to be an independent predictor of CSS when compared to patients not undergoing LND. However, this finding is not consistent across all studies and the literature is again limited by inclusion heterogeneity and inconsistent or lack or template-based resections. LND for UTUC at the time of RNU is a safe and feasible procedure that seems to especially benefit patients with muscle-invasive or locally advanced disease. Prospective, randomized studies with strict inclusion criteria and defined anatomic templates are needed to definitely characterize the role of LND for UTUC.

Erratum: Outcomes of Trimodal Therapy for cT2-3 Urothelial Carcinoma in a Racially Diverse Population: A Single Institution Experience in the Bronx

[This corrects the article DOI: 10.3233/BLC-200332.].

Well-being and Perceptions of Supportive Resources among Caregivers of Patients with Bladder Cancer

BACKGROUND: The unique burden of treatment and survivorship of patients with bladder cancer can negatively impact caregiver experience and their use of supportive care resources. OBJECTIVE: To assess caregivers’ well-being and their perception of potential supportive resources. METHODS: In this cross-sectional survey, caregivers of patients with bladder cancer (N = 630) were recruited through the nationwide Bladder Cancer Advocacy Network Patient Survey Network. We used stakeholder-developed questionnaires to examine caregiver well-being (i.e., physical well-being, tiredness, fear, worry, sadness), the perceived helpfulness of potential resources (i.e., web-based and print-based information, specialized support, personal stories of other caregivers, phone-call and online chat with other caregivers), and influencing factors. RESULTS: Caregivers more frequently reported emotional well-being as a moderate to serious problem (67% for fear, 78% for worry, 66% for sadness) compared with physical well-being (30%) and tiredness (47%). Decreased well-being was associated with female gender of the caregiver, higher than high school education, or caring for a patient with advanced (versus non-invasive) bladder cancer. Of six potential resources, “web-based information” was perceived as “very helpful” among 79% of respondents, followed by “personal stories from other caregivers” (62%). Caregiver preferences for “web-based information” was not associated with any specific demographic or clinical factors. CONCLUSIONS: Caregivers reported moderate to serious problems with emotional and physical well-being. Web-based platforms were perceived as beneficial supportive resources for bladder cancer caregivers. Future intervention research should target the influencing factors identified in this study to optimize the health outcomes of caregivers and enhance the supportive care resources for improving their well-being.

Gemcitabine based trimodality treatment in patients with muscle invasive bladder cancer: May neutrophil lymphocyte and platelet lymphocyte ratios predict outcomes?

PURPOSE

Cisplatin based chemoradiation has been commonly used as a definitive treatment for muscle-invasive bladder cancer (MIBC). The aim of the current study is to evaluate oncologic results and toxicity profile of bladder-sparing treatment with external beam radiotherapy (EBRT) and gemcitabine chemotherapy (ChT) in patients with MIBC.

MATERIALS AND METHODS

Between April 2005 and November 2018 44 patients with nonmetastatic and N0 MIBC were treated with transurethral resection of bladder (TURB), EBRT and concurrent gemcitabine. All patients were staged using thorax-abdomen-pelvic CT and pelvic MRI. EBRT was delivered using 3D conformal technique or intensity modulated radiotherapy. Patients received 50 Gy in 25 to 28 fractions to full bladder followed by a boost dose of 10 Gy in 5 fractions to empty bladder with weekly concurrent gemcitabine of 50 mg/m². All patients were evaluated for age, gender, smoking status, neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) at diagnosis, presence of hydroureteronephrosis (HUN), preoperative tumor size, tumor multifocality, presence of CIS, clinical tumor stage. Acute/late genitourinary (GUS) and gastrointestinal (GIS) toxicity, recurrence status, cancer specific survival (CSS) and overall survival (OS) were evaluated. Statistical analysis was performed using SPSS v21.0. Kaplan-Meier survival estimates were calculated to describe CSS and OS. The effect of different parameters on survival was investigated using the log rank test.

RESULTS

Median age of the patients was 72 years (interquartile [IQR]; 66-80). The median tumor size was 30 mm (IQR, 15-59 mm). Thirty-two (77%) patients had T2, 6 (14%) patients had T3, and 4 (9%) patients had T4a disease. Median NLR was 2.6 (IQR, 1.7-3.8) and median PLR was 126.47 (IQR, 77.4-184.8). Median follow-up time was 21 months (range, 6-153 months). At the first TURB performed 6 weeks after CRT, complete response, partial response, stable disease, and progression was detected in 37 (84%), 3 (7%), 1 (2%), and 3 (7%) patients, respectively. One- and 2-year OS, CSS, LRFS, and DMFS rates were 86% and 64%; 88% and 66%; 65% and 44%; 68% and 48%, respectively. In univariate analysis; prognostic factors were age and presence of HUN for OS and DMFS; age, HUN, presence of CIS, NLR, and PLR for DSS; HUN, NLR, and PLR for LRFS, respectively. In multivariate analysis, the independent predictor was the presence of HUN for OS, LRFS, and DMFS; NLR for DSS; PLR for LRFS and age for DMSF. For a subgroup of 17 patients with complete TURB and no CIS and HUN symptoms, 2-year OS, DSS, LRFS, and DMFS rates were 88%, 88%, 72%, and 79%, respectively. The treatment was well-tolerated and all patients completed the planned EBRT and ChT. No acute or late ≥ grade 3 toxicity was observed. Grade II acute GIS toxicity was detected in 3 (7%) patients and grade II acute GUS toxicity was detected in 9 (21%) patients, respectively. Grade II late GUS toxicity was observed in 2 (5%) patients.

CONCLUSION

Gemcitabine based trimodality treatment is well-tolerated with similar oncologic outcomes reported in the literature. Older age, presence of CIS and high NLR and PLR values seem to deteriorate DSS.

16-Hydroxycleroda-3,13-dien-15,16-olide Induces Apoptosis in Human Bladder Cancer Cells through Cell Cycle Arrest, Mitochondria ROS Overproduction, and Inactivation of EGFR-Related Signalling Pathways

A clerodane diterpene compound 16-hydroxycleroda-3,13-dien-15,16-olide (CD) is considered a therapeutic agent with pharmacological activities. The present study investigated the mechanisms of CD-induced apoptosis in T24 human bladder cancer cells. CD inhibited cell proliferation in a concentration and time-dependent manner. CD-induced overproduction of reactive oxygen species and reduced mitochondrial membrane potential, associated with reduced expression of Bcl-2 and increased levels of cytosolic cytochrome c, cleaved PARP-1 and caspase-3. In addition, CD treatment led to cell cycle arrest at the G0/G1 phase and inhibited expression of cyclin D1 and cyclin-dependent kinases 2 and 4 and led to increased levels of p21, p27Kip1 and p53. All of these events were accompanied with a reduction of pEGFR, pMEK1/2, pERK1/2, pAkt, pmTOR, pP70S6K1, HIF-1α, c-Myc and VEGF. RNAseq-based analysis revealed that CD-induced cell death was characterised by an increased expression of stress and apoptotic-related genes as well as inhibition of the cell cycle-related genes. In summary, CD induces apoptosis in T24 bladder cancer cells through targeting multiple intracellular signaling pathways as a result of oxidative stress and cell cycle arrest.

Oblongifolin C reverses GEM resistance via suppressing autophagy flux in bladder cancer cells

A number of previous studies have demonstrated that inhibiting autophagy can increase the cellular cytotoxicity of chemotherapeutic agents in urothelial cancer cells. However, the mechanistic roles of autophagy in gemcitabine (GEM) resistant bladder cancer cells have not been thoroughly investigated. In the present study, immunohistochemistry staining of autophagy marker LC3 was performed in bladder cancer and healthy control tissues and demonstrated an essential role of autophagy in cancer development. A GEM-resistant cell line was established to assess the effects of autophagy on the acquisition of GEM resistance. Western blotting of autophagy markers in GEM-resistant bladder cancer cells suggested that GEM resistance was caused, at least partially, by GEM-induced autophagy. GEM resistance was demonstrated to be reversed by the inhibition of autophagy by 3-methyladenine. In addition, oblongifolin C (OC), a novel autophagic flux inhibitor purified from traditional Chinese medicine, was found to enhance the efficiency of GEM in GEM-resistant bladder cancer cells by inhibiting autophagic flux. In conclusion, data from the present study suggest that autophagy serves an important role in bladder cancer development and GEM resistance. OC treatment has the ability to reverse GEM-resistance in bladder cancer cells by suppressing autophagic flux, thereby providing a potential adjunctive therapeutic option for bladder cancer GEM treatment.

Endoclips as novel fiducial markers in trimodality bladder-preserving therapy of muscle-invasive bladder carcinoma: feasibility and patient outcomes

Hypothesis:

Endoclip can be used as fiducial marker in urology.

Objective:

To assess the feasibility, cost effectiveness and reliability of endoclips as novel fiducial markers in precision radiotherapy, as part of a trimodality bladder-preserving treatment (TBPT) of muscle-invasive bladder carcinoma.

Materials and Methods:

This retrospective study was performed at Weifang People's Hospital (Weifang, China) from January 2015 to June 2018. A total of 15 patients underwent TBPT. Endoclips were applied to healthy edges of the resected bladder wall as novel fiducial markers. Radio-sensitizing chemotherapy and routine precision radiotherapy were given. The number and position of the endoclips during radiotherapy sessions were monitored. Complications and tumor recurrence were analyzed.

Results:

The mean age (±standard deviation) of the patients was 67±10 years (range 46-79). There were 3 females and 12 males. Forty-nine endoclips were applied in all patients (3.3±0.8). The tumor was completely visibly resected in all patients. The number of endoclips remained the same through the planned last radiotherapy session (3.3±0.8), i.e., none were lost. All endoclips were removed after the last radiotherapy session. The average number of follow-up months was 38.9±13.2 (range 11-52). There were no procedure-related complications at discharge or follow-up. At one-year, overall recurrence-free survival was 93.3%. Two patients had recurrences at 18 months and 10 months after TBPT, respectively, and salvage radical cystectomy was performed with no further recurrences. Another patient died due to metastasis 9 months after the completion of therapy.

Conclusions:

Endoclips are reliable, safe and cost-effective as novel fiducial markers in precision-radiotherapy post-TBPT.

An evaluation of the efficacy and safety of erdafitinib for the treatment of bladder cancer

INTRODUCTION

Treatment of unresectable or metastatic urothelial carcinoma (UC) has historically relied upon platinum-based chemotherapy and, more recently, immune checkpoint inhibitors. When tumors progress despite those therapies, remaining effective options are limited.

AREAS COVERED

In this review, the authors review the advancement in genomic targets in UC, most notably fibroblast growth factor receptor (FGFR). FGFR has been identified as a target in UC as it is commonly genomically altered (activating mutations or fusions), and may be enriched in UC subtypes that are relatively resistant to immune checkpoint blockade. Erdafitinib, a potent and selective inhibitor of FGFRs, represents the first targeted therapy approved for the treatment of UC by virtue of a confirmed response rate of 40% in an open-label, single-armed phase II trial in molecularly selected tumors. The authors provide their expert opinion of its approval and place it in the context of the current and forthcoming treatment strategies for metastatic UC.

EXPERT OPINION

The approval of erdafitinib provides clinicians with an important new treatment option for patients with metastatic UC and projects forward into an era of enhanced molecular precision in identifying effective therapies in UC.

Comparing Survival Outcomes and Costs Associated With Radical Cystectomy and Trimodal Therapy for Older Adults With Muscle-Invasive Bladder Cancer

Importance

Radical cystectomy is the guidelines-recommended treatment of muscle-invasive bladder cancer, but a resurgence of trimodal therapy has occurred. Limited comparative data are available on outcomes and costs attributable to these 2 treatments.

Objective

To compare the survival outcomes and costs between trimodal therapy and radical cystectomy in older adults with muscle-invasive bladder cancer.

Design, Setting, and Participants

This population-based cohort study used data from the Surveillance, Epidemiology, and End Results-Medicare linked database. A total of 3200 older adults (aged ≥66 years) with clinical stage T2 to T4a bladder cancer diagnosed from January 1, 2002, to December 31, 2011, and with claims data available through December 31, 2013, were included in the analysis. Patients who received radical cystectomy underwent either only surgery or surgery in combination with radiotherapy or chemotherapy. Patients who received trimodal therapy underwent transurethral resection of the bladder followed by radiotherapy and chemotherapy. Propensity score matching by sociodemographic and clinical characteristics was used. Data analysis was performed from August 1, 2017, to March 11, 2018.

Main Outcomes and Measures

Overall survival and cancer-specific survival were evaluated using the Cox proportional hazards regression model and the Fine and Gray competing risk model. All Medicare health care costs for inpatient, outpatient, and physician services within 30, 90, and 180 days of treatment were compared. The total amount spent nationwide was estimated, using 180-day medical costs between treatments, by the total number of new cases of muscle-invasive bladder cancer in the United States in 2011.

Results

Of the 3200 patients who met the inclusion criteria, 2048 (64.0%) were men and 1152 (36.0%) were women, with a mean (SD) age of 75.8 (6.0) years. After propensity score matching, 687 patients (21.5%) underwent trimodal therapy and 687 patients (21.5%) underwent radical cystectomy. Patients who underwent trimodal therapy had significantly decreased overall survival (hazard ratio [HR], 1.49; 95% CI, 1.31-1.69) and cancer-specific survival (HR, 1.55; 95% CI, 1.32-1.83). No differences in costs at 30 days were observed between trimodal therapy ($15 233 in 2002 vs $18 743 in 2011) and radical cystectomy ($17 990 in 2002 vs $21 738 in 2011). However, median total costs were significantly higher with trimodal therapy than with radical cystectomy at 90 days ($80 174 vs $69 181; median difference, $8964; Hodges-Lehmann 95% CI, $3848-$14 079) and at 180 days ($179 891 vs $107 017; median difference, $63 771; Hodges-Lehmann 95% CI, $55 512-$72 029). Extrapolating these figures to the total US population revealed $335 million in excess spending for trimodal therapy compared with the less costly radical cystectomy ($492 million) for patients who received a muscle-invasive bladder cancer diagnosis in 2011.

Conclusions and Relevance

Trimodal therapy was associated with significantly decreased overall survival and cancer-specific survival as well as $335 million in excess spending in 2011. These findings have important health policy implications regarding the appropriate use of high value-based care among older adults with invasive bladder cancer who are candidates for either radical cystectomy or trimodal therapy.

Comparison of Preoperative Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios in Bladder Cancer Patients Undergoing Radical Cystectomy

Introduction

Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been proven to be significant prognostic factors in many cancers. We aimed to retrospectively investigate the prognostic value of NLR and PLR in patients with bladder cancer undergoing radical cystectomy.

Materials and Methods

The study comprised patients from 2010 to 2018 who were diagnosed with bladder cancer and received radical cystectomy. Clinical and pathological parameters were collected. Receiver operating characteristic curves of NLR and PLR were plotted for overall survival (OS) and cancer-specific survival (CSS). The best cutoff value of NLR and PLR were determined using X-tile software. The prognostic value of NLR and PLR for OS and CSS was analyzed using the Kaplan-Meier method and Cox regression models.

Results

A total of 223 patients were enrolled with a medium follow-up period of 57 months. Receiver operating characteristic curves showed that PLR was superior to NLR as a prognostic factor in patients with bladder cancer undergoing radical cystectomy. Univariate analysis revealed that NLR (p=0.032 and p=0.041) and PLR (p=0.003 and p=0.003) were significantly associated with both OS and CSS, respectively. Multivariate analysis identified only PLR as independent prognostic factors for OS (p=0.046) and CSS (p=0.039), respectively.

Conclusions

The present findings suggested that compared with NLR, PLR was a superior prognostic factor of OS and CSS in bladder cancer patients indicated to radical cystectomy.

Antiproliferative and toxicogenomic effects of resveratrol in bladder cancer cells with different TP53 status

The antitumor activity of resveratrol, a polyphenolic compound found mainly in grapes, has been studied in several types of cancer. In bladder cancer, its antiproliferative effects have already been demonstrated; however, its mechanism of action is not completely understood. The aim of this study was to evaluate resveratrol antitumor activity (12.5, 25, 50, 100, 150, 200, and 250 μM) and its possible mechanisms of action in bladder tumor cells with different TP53 gene status (RT4, grade 1, TP53 wild type; 5637-grade 2 and T24-grade 3, TP53 mutated). Cell proliferation, clonogenic survival, morphological changes, cell cycle progression, apoptosis rates, genotoxicity, global methylation, immunocytochemistry for p53 and PCNA and relative expression profiles of the AKT, mTOR, RASSF1A, HOXB3, SRC, PLK1, and DNMT1 were evaluated. Resveratrol decreased cell proliferation and induced DNA damage in all cell lines. Regarding the long-term effects, resveratrol reduced the number of colonies in all cell lines; however, TP53 wild type cells were more resistant. Increased rates of apoptosis were found in the TP53 wild type cells and this was accompanied by AKT, mTOR, and SRC downregulation. In addition, the resveratrol antiproliferative effects in wild type TP53 cells were accompanied by modulation of the DNMT1 gene. In the TP53 mutated cells, cell cycle arrest at S phase with PLK1 downregulation was observed. Additionally, there was modulation of the HOXB3/RASSF1A pathway and nuclear PCNA reduction in the highest-grade cells. In conclusion, resveratrol has antiproliferative activity in bladder tumor cells; however, the mechanisms of action are dependent on TP53 status. Environ. Mol. Mutagen., 60:740-751, 2019. © 2019 Wiley Periodicals, Inc.

Single-port Robotic Intracorporeal Ileal Conduit Urinary Diversion During Radical Cystectomy Using the SP Surgical System: Step-by-step Technique

OBJECTIVE

To describe the step-by-step technique for robotic intracorporeal ileal conduit urinary diversion (ICUD) following radical cystectomy performed by using the novel da Vinci SP surgical system (Intuitive Surgical, Sunnyvale, CA).

METHODS

Four consecutive patients (2 males and 2 females) were initially counseled for robotic cystectomy with ICUD performed by using the da Vinci SP surgical system. Surgeries were performed by duplicating the steps of the institutional approach for intracorporeal ICUD performed with the multiarms robotic platform. Perioperative outcomes were analyzed. Data were collected under institutional review board approval (IRB 13-780).

RESULTS

Single-port robot-assisted radical cystectomy with ICUD was successfully completed in 3 patients (2 males and 1 female). Mean robotic operative time for ICUD was 75 minutes (range 67-90). There was no conversion to standard multiarms robotic approach. One patient needed to be converted to extracorporeal urinary diversion due to severe adhesions of small bowels. No additional ports were placed. Neither transfusions nor intraoperative complications occurred. All patients were discharged on postoperative day 5. One patient reported self-limited nausea and vomiting after discharge (Clavien grade I).

CONCLUSION

In our preliminary experience, ICUD after robot-assisted radical cystectomy is feasible using the da Vinci SP surgical system. Further comparative studies with open and multiarms robotic approaches are warranted.

Epidemiology of Bladder Cancer: A Systematic Review and Contemporary Update of Risk Factors in 2018

CONTEXT

Bladder cancer (BC) is a significant health problem, and understanding the risk factors for this disease could improve prevention and early detection.

OBJECTIVE

To provide a systematic review and summary of novel developments in epidemiology and risk factors for BC.

EVIDENCE ACQUISITION

A systematic review of original articles was performed by two pairs of reviewers (M.G.C., I.J., F.E., and K.P.) using PubMed/Medline in December 2017, updated in April 2018. To address our primary objective of reporting contemporary studies, we restricted our search to include studies from the last 5yr. We subdivided our review according to specific risk factors (PICO [Population Intervention Comparator Outcome]).

EVIDENCE SYNTHESIS

Our search found 2191 articles, of which 279 full-text manuscripts were included. We separated our manuscripts by the specific risk factor they addressed (PICO). According to GLOBOCAN estimates, there were 430000 new BC cases and 165000 deaths worldwide in 2012. Tobacco smoking and occupational exposure to carcinogens remain the factors with the highest attributable risk. The literature was limited by heterogeneity of data.

CONCLUSIONS

Evidence is emerging regarding gene-environment interactions, particularly for tobacco and occupational exposures. In some populations, incidence rates are declining, which may reflect a decrease in smoking. Standardisation of reporting may help improve epidemiologic evaluation of risk.

PATIENT SUMMARY

Bladder cancer is common worldwide, and the main risk factors are tobacco smoking and exposure to certain chemicals in the working and general environments. There is ongoing research to identify and reduce risk factors, as well as to understand the impact of genetics on bladder cancer risk.

Bladder Preservation With Twice-a-Day Radiation Plus Fluorouracil/Cisplatin or Once Daily Radiation Plus Gemcitabine for Muscle-Invasive Bladder Cancer: NRG/RTOG 0712-A Randomized Phase II Trial

PURPOSE

Fluorouracil plus cisplatin and radiation twice a day (FCT) is an established chemoradiation (CRT) regimen for selective bladder-sparing treatment of muscle-invasive bladder cancer. Gemcitabine and once daily radiation (GD) is a well-supported alternative. The current trial evaluates these regimens.

METHODS

Patients with cT2-4a muscle-invasive bladder cancer were randomly assigned to FCT or GD. Patients underwent transurethral resection and induction CRT to 40 Gy. Patients who achieved a complete response (CR) received consolidation CRT to 64 Gy and others underwent cystectomy. We administered adjuvant gemcitabine/cisplatin chemotherapy. The primary end point was the rate of freedom from distant metastasis at 3 years (DMF3). The trial was not statistically powered to compare regimens, but to assess whether either regimen exceeded a DMF3 benchmark of 75%. Toxicity and efficacy end points, including CR and bladder-intact distant metastasis free survival at 3 years (BI-DMFS3), were assessed.

RESULTS

From December 2008 to April 2014, 70 patients were enrolled, of which 66 were eligible for analysis, 33 per arm. Median follow-up was 5.1 years (range, 0.4 to 7.8 years) for eligible living patients. DMF3 was 78% and 84% for FCT and GD, respectively. BI-DMFS3 was 67% and 72%, respectively. Postinduction CR rates were 88% and 78%, respectively. Of 33 patients in the FCT arm, 21 (64%) experienced treatment-related grade 3 and 4 toxicities during protocol treatment, with 18 (55%), two (6%), and two patients (6%) experiencing grade 3 and 4 hematologic, GI, and genitourinary toxicity, respectively. For the 33 patients in the GD arm, these figures were 18 (55%) overall and 14 (42%), three (9%) and two patients (6%), respectively.

CONCLUSION

Both regimens demonstrated DMF3 greater than 75%. There were fewer toxicities observed in the GD arm. Either gemcitabine and once daily radiation or a cisplatin-based regimen could serve as a base for future trials of systemic therapy.

Neoadjuvant Chemotherapy Before Bladder-Sparing Chemoradiotherapy in Patients With Nonmetastatic Muscle-Invasive Bladder Cancer

BACKGROUND

Cisplatin-based neoadjuvant chemotherapy (NAC) before cystectomy improves survival in muscle-invasive urothelial bladder cancer (MIBC). The use of NAC before chemoradiation (CRT) has been limited, as these patients are often elderly, frail, and ineligible for cisplatin. However, the role of NAC in fit, cisplatin-eligible patients who opt for bladder preservation warrants further evaluation.

PATIENTS AND METHODS

Patients with MIBC treated with NAC followed by CRT at the Princess Margaret and Durham Regional cancer centers from 2008 to 2017 were retrospectively reviewed. Gemcitabine-cisplatin NAC was given for 2 to 4 cycles, followed by reassessment for CRT. External-beam radiotherapy (60-66 Gy) over 6 weeks was given with concurrent weekly cisplatin at 40 mg/m². Kaplan-Meier method was used for survival analyses.

RESULTS

We identified 57 consecutive patients. Median age was 72 (range 45-87), and all had an Eastern Cooperative Oncology Group performance status of 0 (60%) or 1 (40%). Stage II disease (65%), stage III disease (25%), and regional nodal metastases (11%) were included. Most completed planned NAC (95%). All patients completed external-beam radiotherapy, and 84% completed at least 60% of the planned concurrent weekly cisplatin doses. Median (range) follow-up was 19.3 (4.8-96.1) months. Median overall survival (OS) was not reached. Two-year OS and disease-specific survival rates were 74% (95% confidence interval, 57.7-84.9) and 88% (95% confidence interval, 78.5-98.1), respectively. Two-year bladder-intact disease-free survival was 64%. Salvage cystectomy was performed in 14%. Distant relapse occurred in 11%, and 9% died of metastatic disease. OS was associated with baseline hydronephrosis and with bladder-intact disease-free survival with residual disease on cystoscopy.

CONCLUSION

NAC followed by CRT can result in encouraging outcomes and tolerability in cisplatin-eligible patients.

Invasive non-urachal adenocarcinoma of the bladder: analysis of the National Cancer Database

PURPOSE

To review the United States National Cancer Database (NCDB) from 2004 to 2015 and analyze survival outcomes of invasive non-urachal adenocarcinoma based on treatment modality.

METHODS

The NCDB 2004-2015 bladder dataset was queried for adenocarcinoma histology, excluding urachal variant, and limited to patients with clinical stage T2-T4 disease. Treatment modality was categorized as no treatment, cystectomy (partial or radical), external beam radiation therapy (EBRT), or EBRT plus cystectomy. Our primary outcome was overall survival. Cox regression (CR) and Kaplan-Meier (KM) analysis were performed.

RESULTS

851 patients were identified with invasive (cT2-T4) adenocarcinoma of the bladder. Treatment modalities included 398 (47.8%) no treatment, 298 (35.8%) cystectomy, 124 (14.9%) EBRT, and 31 (3.7%) EBRT plus cystectomy. On KM analysis excluding those with metastatic disease, the 5-year survival was significantly better (p < 0.001) for patients who underwent cystectomy (39.6%), versus no treatment (21.0%), EBRT (18.6%), or EBRT plus cystectomy (26.9%) (log rank, p < 0.001). On CR for mortality, age (HR 1.030, p < 0.001), Charlson score 1 (HR 1.287, p = 0.034), cT4 (HR 1.768, p < 0.001), and receiving treatment at a low-volume center (HR 1.289, p = 0.026) were associated with worsened survival; however, cystectomy (HR 0.593, p < 0.001) was the only factor associated with improved survival. For those undergoing cystectomy, the mean length of stay was 8.5 days and the 30-day readmission rate was 7.0%.

CONCLUSIONS

Invasive non-urachal adenocarcinoma of the bladder is a rare diagnosis. Survival benefits in patients without metastatic disease are seen only in those patients undergoing definitive surgery.

Web-Based Tool to Facilitate Shared Decision Making With Regard to Neoadjuvant Chemotherapy Use in Muscle-Invasive Bladder Cancer

PURPOSE

Level 1 evidence supports the use of neoadjuvant chemotherapy (NAC) for the treatment of muscle-invasive bladder cancer (MIBC), but observational data demonstrate that this approach is underused. A barrier to shared decision making is difficulty in predicting and communicating survival estimates after cystectomy with or without NAC.

METHODS

We included patients with MIBC from the National Cancer Database treated with cystectomy. A state-transition model was constructed for calculating 5-year death risk using baseline patient-, tumor-, and facility-level variables. Internal-external cross-validation by geographic region was performed. The effect of NAC was integrated using a literature-derived hazard ratio. Bladder cancer-specific and other-cause mortality was estimated from all-cause mortality rates from US life tables. From the state-transition model, a Web-based tool was developed and pilot usability testing performed.

RESULTS

A total of 9,824 patients with MIBC who underwent cystectomy were eligible for inclusion. Median overall survival was 39.6 months (95% CI, 37.4 to 42.4 months). Increasing age, higher clinical T stage, higher comorbidity index, and black race were associated with shorter survival. Private insurance, higher income, and cystectomy at a high-volume facility were associated with longer survival. The prediction model was well calibrated across geographic regions, with observed-to-predicted 5-year death risks ranging from 0.85 to 1.17. Absolute risk reductions with NAC varied from 8.6% to 10.1%. The Web-based tool allowed input of the predictor variables and a user-defined hazard ratio associated with the effect of NAC to generate individualized survival estimates. The tool demonstrated good usability with clinicians.

CONCLUSION

A Web-based tool was developed to individualize outcome prediction and communication in patients with MIBC treated with cystectomy with or without NAC to facilitate shared decision making.