Diagnosis, treatment and survival from bladder, upper urinary tract, and urethral cancers: real-world findings from NHS England between 2013 and 2019

OBJECTIVE

We report NHS England data for patients with bladder cancer (BC), upper tract urothelial cancer (UTUC: renal pelvic and ureteric), and urethral cancers from 2013 to 2019.

MATERIALS AND METHODS

Hospital episode statistics, waiting times, and cancer registrations were extracted from NHS Digital.

RESULTS

Registrations included 128 823 individuals with BC, 16 018 with UTUC, and 2533 with urethral cancer. In 2019, 150 816 persons were living with a diagnosis of BC, of whom 113 067 (75.0%) were men, 85 117 (56.5%) were aged >75 years, and 95 553 (91.7%) were Caucasian. Incidence rates were stable (32.7-34.3 for BC, 3.9-4.2 for UTUC and 0.6-0.7 for urethral cancer per 100 000 population). Most patients 52 097 (mean [range] 41.3% [40.7-42.0%]) were referred outside the 2-week-wait pathway and 15 340 (mean [range] 12.2% [11.7-12.6%]) presented as emergencies. Surgery, radiotherapy, chemotherapy, or multimodal treatment use varied with disease stage, patient factors and Cancer Alliance. Between 27% and 29% (n = 6616) of muscle-invasive BCs did not receive radical treatment. Survival rates reflected stage, grade, location, and tumour histology. Overall survival rates did not improve over time (relative change: 0.97, 95% confidence interval 0.97-0.97) at 2 years in contrast to other cancers.

CONCLUSION

The diagnostic pathway for BC needs improvement. Increases in survival might be delivered through greater use of radical treatment. NHS Digital data offers a population-wide picture of this disease but does not allow individual outcomes to be matched with disease or patient features and key parameters can be missing or incomplete.

Photodynamic versus white-light-guided resection of first-diagnosis non-muscle-invasive bladder cancer: PHOTO RCT

BACKGROUND

Around 7500 people are diagnosed with non-muscle-invasive bladder cancer in the UK annually. Recurrence following transurethral resection of bladder tumour is common, and the intensive monitoring schedule required after initial treatment has associated costs for patients and the NHS. In photodynamic diagnosis, before transurethral resection of bladder tumour, a photosensitiser that is preferentially absorbed by tumour cells is instilled intravesically. Transurethral resection of bladder tumour is then conducted under blue light, causing the photosensitiser to fluoresce. Photodynamic diagnosis-guided transurethral resection of bladder tumour offers better diagnostic accuracy than standard white-light-guided transurethral resection of bladder tumour, potentially reducing the chance of subsequent recurrence.

OBJECTIVE

The objective was to assess the clinical effectiveness and cost-effectiveness of photodynamic diagnosis-guided transurethral resection of bladder tumour.

DESIGN

This was a multicentre, pragmatic, open-label, parallel-group, non-masked, superiority randomised controlled trial. Allocation was by remote web-based service, using a 1 : 1 ratio and a minimisation algorithm balanced by centre and sex.

SETTING

The setting was 22 NHS hospitals.

PARTICIPANTS

Patients aged ≥ 16 years with a suspected first diagnosis of high-risk non-muscle-invasive bladder cancer, no contraindications to photodynamic diagnosis and written informed consent were eligible.

INTERVENTIONS

Photodynamic diagnosis-guided transurethral resection of bladder tumour and standard white-light cystoscopy transurethral resection of bladder tumour.

MAIN OUTCOME MEASURES

The primary clinical outcome measure was the time to recurrence from the date of randomisation to the date of pathologically proven first recurrence (or intercurrent bladder cancer death). The primary health economic outcome was the incremental cost per quality-adjusted life-year gained at 3 years.

RESULTS

We enrolled 538 participants from 22 UK hospitals between 11 November 2014 and 6 February 2018. Of these, 269 were allocated to photodynamic diagnosis and 269 were allocated to white light. A total of 112 participants were excluded from the analysis because of ineligibility (n = 5), lack of non-muscle-invasive bladder cancer diagnosis following transurethral resection of bladder tumour (n = 89) or early cystectomy (n = 18). In total, 209 photodynamic diagnosis and 217 white-light participants were included in the clinical end-point analysis population. All randomised participants were included in the cost-effectiveness analysis. Over a median follow-up period of 21 months for the photodynamic diagnosis group and 22 months for the white-light group, there were 86 recurrences (3-year recurrence-free survival rate 57.8%, 95% confidence interval 50.7% to 64.2%) in the photodynamic diagnosis group and 84 recurrences (3-year recurrence-free survival rate 61.6%, 95% confidence interval 54.7% to 67.8%) in the white-light group (hazard ratio 0.94, 95% confidence interval 0.69 to 1.28; p = 0.70). Adverse event frequency was low and similar in both groups [12 (5.7%) in the photodynamic diagnosis group vs. 12 (5.5%) in the white-light group]. At 3 years, the total cost was £12,881 for photodynamic diagnosis-guided transurethral resection of bladder tumour and £12,005 for white light. There was no evidence of differences in the use of health services or total cost at 3 years. At 3 years, the quality-adjusted life-years gain was 2.094 in the photodynamic diagnosis transurethral resection of bladder tumour group and 2.087 in the white light group. The probability that photodynamic diagnosis-guided transurethral resection of bladder tumour was cost-effective was never > 30% over the range of society's cost-effectiveness thresholds.

LIMITATIONS

Fewer patients than anticipated were correctly diagnosed with intermediate- to high-risk non-muscle-invasive bladder cancer before transurethral resection of bladder tumour and the ratio of intermediate- to high-risk non-muscle-invasive bladder cancer was higher than expected, reducing the number of observed recurrences and the statistical power.

CONCLUSIONS

Photodynamic diagnosis-guided transurethral resection of bladder tumour did not reduce recurrences, nor was it likely to be cost-effective compared with white light at 3 years. Photodynamic diagnosis-guided transurethral resection of bladder tumour is not supported in the management of primary intermediate- to high-risk non-muscle-invasive bladder cancer.

FUTURE WORK

Further work should include the modelling of appropriate surveillance schedules and exploring predictive and prognostic biomarkers.

TRIAL REGISTRATION

This trial is registered as ISRCTN84013636.

FUNDING

This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 40. See the NIHR Journals Library website for further project information.

A Randomized Trial of PHOTOdynamic Surgery in Non-Muscle-Invasive Bladder Cancer

PDD or WL Resection of Tumors in NMIBCIn this open-label trial, patients with intermediate- or high-risk non-muscle-invasive bladder cancer at diagnosis were randomly assigned to photodynamic diagnosis or white light-guided transurethral resection of bladder tumor. Three-year recurrence-free rates were 57.8% and 61.6% in the PDD and WL groups, respectively, with no difference in quality-adjusted life years between the treatment groups at 3 years.

Adjuvant Intravesical Chemohyperthermia Versus Passive Chemotherapy in Patients with Intermediate-risk Non-muscle-invasive Bladder Cancer (HIVEC-II): A Phase 2, Open-label, Randomised Controlled Trial

BACKGROUND

Adjuvant intravesical chemotherapy following tumour resection is recommended for intermediate-risk non-muscle-invasive bladder cancer (NMIBC).

OBJECTIVE

To assess the efficacy and safety of adjuvant intravesical chemohyperthermia (CHT) for intermediate-risk NMIBC.

DESIGN, SETTING, AND PARTICIPANTS

HIVEC-II is an open-label, phase 2 randomised controlled trial of CHT versus chemotherapy alone in patients with intermediate-risk NMIBC recruited at 15 centres between May 2014 and December 2017 (ISRCTN 23639415). Randomisation was stratified by treating hospital.

INTERVENTIONS

Patients were randomly assigned (1:1) to adjuvant CHT with mitomycin C at 43°C or to room-temperature mitomycin C (control). Both treatment arms received six weekly instillations of 40 mg of mitomycin C lasting for 60 min.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was 24-mo disease-free survival as determined via cystoscopy and urinary cytology. Analysis was by intention to treat.

RESULTS

A total of 259 patients (131 CHT vs 128 control) were randomised. At 24 mo, 42 patients (32%) in the CHT group and 49 (38%) in the control group had experienced recurrence. Disease-free survival at 24 mo was 61% (95% confidence interval [CI] 51-69%) in the CHT arm and 60% (95% CI 50-68%) in the control arm (hazard ratio [HR] 0.92, 95% CI 0.62-1.37; log-rank p = 0.8). Progression-free survival was higher in the control arm (HR 3.44, 95% CI 1.09-10.82; log-rank p = 0.02) on intention-to-treat analysis but was not significantly higher on per-protocol analysis (HR 2.87, 95% CI 0.83-9.98; log-rank p = 0.06). Overall survival was similar (HR 2.55, 95% CI 0.77-8.40; log-rank p = 0.09). Patients undergoing CHT were less likely to complete their treatment (n =75, 59% vs n = 111, 89%). Adverse events were reported by 164 patients (87 CHT vs 77 control). Major (grade III) adverse events were rare (13 CHT vs 7 control).

CONCLUSIONS

CHT cannot be recommended over chemotherapy alone for intermediate-risk NMIBC. Adverse events following CHT were of low grade and short-lived, although patients were less likely to complete their treatment.

PATIENT SUMMARY

The HIVEC-II trial investigated the role of heated chemotherapy instillations in the bladder for treatment of intermediate-risk non-muscle-invasive bladder cancer. We found no cancer control benefit from heated chemotherapy instillations over room-temperature chemotherapy. Adverse events following heated chemotherapy were low grade and short-lived, although these patients were less likely to complete their treatment.

Professional roles of female urologists: A webinar-based survey of perceptions and obstacles to career development

BACKGROUND

Urology, traditionally a maledominated specialty, keeping pace with the quickly changing gender landscape, has been characterized by waves of feminization. This study aims to understand the perspectives of women urologists on the obstacles to their career development, and the impact of such hurdles on their professional roles in urological education, practice, and leadership.

METHODS

119 female urology residents/consultants were surveyed via a webinar-based platform, covering relevant questions on domains of Academia, Mentorship, Leadership, Parenting, and Charity. Statistical analysis was done using frequency distribution based on the responses.

RESULTS

46.8% of the respondents felt that there is an under-representation of women in academia. 'Having a good mentor' was the most important factor for a novice to succeed in academia (68%). The most important trait in becoming a good leader was 'good communication skills' (35%), followed by 'visionary' (20%). The greatest challenge faced by leaders in the medical field was considered as 'time management' (31.9%). Only 21.2% of the participants felt difficulty in having a work-personal life balance, whereas 63.8% of them found it difficult only 'sometimes'. As a working parent, 'the guilt that they are not available all the time' was considered the most difficult aspect (59.5%), and 'more flexible schedule' was needed to make their lives as a working parent easier (46.8%). 34% of the respondents were affiliated with some charitable organizations. The biggest drive to do charity was their satisfaction with a noble cause (72.3%).

CONCLUSIONS

Need for increased encouragement and recruitment of females into urology, and to support and nurture them in their career aspirations.

UK national bladder outlet obstruction surgery snapshot audit

OBJECTIVES

To determine the preoperative assessment and perioperative outcomes of men undergoing bladder outlet obstruction (BOO) surgery in the UK.

PATIENTS AND METHODS

A retrospective cohort study was conducted of all men undergoing BOO surgery in 105 UK hospitals over a 1-month period. The study included 1456 men, of whom 42% were catheter dependent prior to undergoing surgery.

RESULTS

There was no evidence that a frequency-volume chart or urinary symptom questionnaire had been completed in 73% or 50% of men, respectively in the non-catheter-dependent group. Bipolar transurethral resection of the prostate (TURP) was the most common BOO surgical procedure performed (38%). Monopolar TURP was the next most prevalent modality (23%); however, minimally invasive BOO surgical procedures combined accounted for 17% of all procedures performed. Of the cohort 5% of men had complications within 30 days of surgery, only 1% had Clavien-Dindo Grade ≥III complications. Less than 1% of the cohort received a blood transfusion after BOO surgery and 2% were re-admitted to hospital after their BOO surgery. In total only 4% of the whole cohort were catheter dependent after BOO surgery. Pre- and postoperative paired International Prostate Symptom Score scores reviewed suggest that minimally invasive surgical procedures achieved comparable levels of improvement in both symptoms and bother at 3 months postoperatively in men who were not catheter dependent preoperatively.

CONCLUSIONS

There has been a substantial shift in the available choice of procedure for BOO surgery around the UK in recent years. However, men can be reassured that overall BOO surgery treatments are safe and effective. Evidence of adherence to guidelines in the preoperative assessment of men with lower urinary tract symptoms undergoing surgery was poorly documented and must be improved.

Short-changed during the bacillus Calmette–Guérin shortages?

Objective:

Intravesical bacillus Calmette–Guérin (BCG) is the first-line treatment of choice for high-risk non-muscle-invasive bladder cancer (NMIBC). Our aim was to evaluate the long-term impact of BCG shortages on oncological outcomes.

Methods:

All patients undertaking an initial course of intravesical BCG for intermediate or high risk NMIBC at a single UK cancer centre between August 2012 and August 2014 were evaluated. Compliance was defined as completing 12 doses of BCG within the first year following diagnosis.

Results:

Due to BCG shortages, 25/114 (22%) patients were compliant with planned maintenance treatment. Compared to the compliant cohort, the non-compliant due to BCG shortages cohort had a higher rate of disease recurrence (35.3% vs. 24%), required more additional intravesical treatments (14.7% vs. 12%) and had a higher rate of radical cystectomy (11.8% vs. 4%). Disease-free survival was superior in the compliant cohort at two years (88% vs. 79.5%) and at 4.5 years (72% vs. 56.1%). There was no statistically significant difference, likely due to the sample size.

Conclusions:

The consequences of undertreatment due to BCG shortages can impact long-term cancer outcomes. Increased vigilance, robust long-term surveillance and alternative treatment strategies are required for NMIBC patients affected by shortages in BCG supplies.

Level of evidence:

Level 2b

Interprofessional research teams in radiography - where the magic happens

Based on publications and professional experiences, this article, intended for academic and clinical therapy/diagnostic radiographers, considers conducting research in interprofessional teams, including its values and how to go about achieving it. Whilst there is a growing number of journal papers published by interprofessional teams, almost nothing is published about how best to build interprofessional research relationships or harness the potential of the different professional experience to deliver novel research within the radiography literature. Thus, this article draws heavily on our experiences of creating, working within and leading interprofessional teams which have a specific focus on conducting radiography-related research. Suggestions are proposed about how to create an interprofessional research team and how to get the best out of it. Values of working within an interprofessional research team, to self, to research quality and to the end users of the research are considered.

Quality of life in patients undergoing surveillance for non-muscle invasive bladder cancer-a systematic review

Background

The main objective of this study was to evaluate the various instruments available to evaluate the quality of life (QoL) in patients diagnosed with non-muscle invasive bladder cancer (NMIBC) undergoing surveillance.

Methods

A PubMed literature review was carried out with query terms (“Urinary Bladder Neoplasms” [Mesh] OR “Bladder malignancy”) AND (“quality of life”) including all studies up to June 2020. This resulted in 576 peer-reviewed articles. A further 12 articles from additional sources were included. A total of 473 articles were eliminated due to lack of relevance to the topic of concern. A further 93 articles evaluating NMIBC and articles evaluating Radiotherapy were excluded and a total of 22 studies were studied.

Results

In total, 22 studies were identified. The vast majority of studies were prospective descriptive studies (n=9), while there were 7 cross-sectional surveys and 6 randomised controlled trials. Most studies evaluated the impact of intravesical treatment on QoL. NMIBC survivors had significantly lower QoL compared to the general population, Surveillance strategies involving repeated intravesical therapies and cystoscopies have a negative impact on QoL with impaired physical function and mental health.

Conclusions

This article emphasizes the importance of assessing the QoL in patients with NMIBC undergoing long term surveillance, as they represent the majority of bladder cancer patients. Development and validation of specific instruments to measure QoL in patients with NMIBC are desperately needed to assess, better understand, and manage the burden of disease and healthcare in this group of patients.

CALIBER: a phase II randomized feasibility trial of chemoablation with mitomycin-C vs surgical management in low-risk non-muscle-invasive bladder cancer

OBJECTIVES

To evaluate the activity of intravesical mitomycin-C (MMC) to ablate recurrent low-risk non-muscle-invasive bladder cancer (NMIBC) and assess whether it may enable patients to avoid surgical intervention for treatment of recurrence.

PATIENTS AND METHODS

CALIBER is a phase II feasibility study. Participants were randomized (2:1) to treatment with four once-weekly MMC 40-mg intravesical instillations (chemoablation arm) or to surgical management. The surgical group was included to assess the feasibility of randomization. The primary endpoint was complete response to intravesical MMC in the chemoablation arm at 3 months, reported with exact 95% confidence intervals (CIs). Secondary endpoints included time to subsequent recurrence, summarized by Kaplan-Meier methods.

RESULTS

Between February 2015 and August 2017, 82 patients with visual diagnosis of recurrent low-risk NMIBC were enrolled from 24 UK hospitals (chemoablation, n = 54; surgical management, n =28). The median follow-up was 24 months. Complete response at 3 months was 37.0% (20/54; 95% CI 24.3-51.3) with chemoablation and 80.8% (21/26; 95% CI 60.6-93.4) with surgical management. Amongst patients with complete response at 3 months, a similar proportion was recurrence-free by 12 months in both groups (84%). Amongst those with residual disease at 3 months, the 12-month recurrence-free proportion was lower in the surgical management group (40.0%) than in the chemoablation group (84%). Recruitment stopped early as chemoablation did not meet the prespecified threshold of 45% complete responses at 3 months.

CONCLUSION

Intravesical chemoablation in low-risk NMIBC is feasible and safe, but did not demonstrate sufficient response in the present trial. After chemoablation there may be a reduction in recurrence rate, even in non-responders, that is greater than with surgery alone. Further research is required to investigate the role and optimal schedule of neoadjuvant intravesical chemotherapy prior to surgery for NMIBC.

Patterns of use of chemotherapy with radiotherapy in the treatment of muscle-invasive bladder cancer: Data from the RAIDER randomized trial of adaptive radiotherapy

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Background: Level 1 evidence exists for the use of both neoadjuvant chemotherapy (NAC) and concomitant radiosensitization (CRS) to improve outcomes in patients receiving radical radiotherapy (RT) for muscle invasive bladder cancer, but uptake has been patchy. We report here the current patterns of usage in an ongoing trial of adaptive radiotherapy. Methods: RAIDER is an international randomized phase II trial recruiting patients with unifocal T2-T4a urothelial carcinoma of the bladder suitable for RT (ISCRTN:26779187). Patients are randomized in a 1:1:2 ratio to one of 3 arms: Standard whole bladder RT (control); Standard dose adaptive tumour focused RT; Dose escalated (DE) adaptive tumour boost RT. Standard dose patients are treated to either 64Gy/32f or 55Gy/20f and DE patients to 70Gy in 32f or 60Gy in 20f. Patients are encouraged to receive NAC and CRS. The primary endpoint is the rate of late toxicity 6-18 months post treatment in arm 3, with secondary endpoints of patient reported and disease related outcomes. Results: To August 2019, 285 patients had been recruited. Median age is 72 years (IQR 67-79). Stage of disease is T2 79%, T3 19%, T4 2%; 19% have hydronephrosis. Patients receiving NAC were more likely to be PS 0 at trial entry (70% v 45%). Variation in frequency of CRS use is seen across sites, with some offering to >90% of participants and some <50%. Data on NAC and CRS use is available for 249 patients recruited to date is shown in table. Conclusions: In this ongoing clinical trial the majority of patients are receiving NAC and/or CRS. However, uptake is not universal with ~30% of patients not receiving low dose CRS, including some who have received NAC. Clinical trial information: 26779187. [Table: see text]

Development and validation of a haematuria cancer risk score to identify patients at risk of harbouring cancer

BACKGROUND

A lack of consensus exists amongst national guidelines regarding who should be investigated for haematuria. Type of haematuria and age-specific thresholds are frequently used to guide referral for the investigation of haematuria.

OBJECTIVES

To develop and externally validate the haematuria cancer risk score (HCRS) to improve patient selection for the investigation of haematuria.

METHODS

Development cohort comprise of 3539 prospectively recruited patients recruited at 40 UK hospitals (DETECT 1; ClinicalTrials.gov: NCT02676180) and validation cohort comprise of 656 Swiss patients. All patients were aged >18 years and referred to hospital for the evaluation of visible and nonvisible haematuria. Sensitivity and specificity of the HCRS in the validation cohort were derived from a cut-off identified from the discovery cohort.

RESULTS

Patient age, gender, type of haematuria and smoking history were used to develop the HCRS. HCRS validation achieves good discrimination (AUC 0.835; 95% CI: 0.789-0.880) and calibration (calibration slope = 1.215) with no significant overfitting (P = 0.151). The HCRS detected 11.4% (n = 8) more cancers which would be missed by UK National Institute for Health and Clinical Excellence guidelines. The American Urological Association guidelines would identify all cancers with a specificity of 12.6% compared to 30.5% achieved by the HCRS. All patients with upper tract cancers would have been identified.

CONCLUSION

The HCRS offers good discriminatory accuracy which is superior to existing guidelines. The simplicity of the model would facilitate adoption and improve patient and physician decision-making.

Does urinary cytology have a role in haematuria investigations?

OBJECTIVES

To determine the diagnostic accuracy of urinary cytology to diagnose bladder cancer and upper tract urothelial cancer (UTUC) as well as the outcome of patients with a positive urine cytology and normal haematuria investigations in patients in a multicentre prospective observational study of patients investigated for haematuria.

PATIENT AND METHODS

The DETECT I study (clinicaltrials.gov NCT02676180) recruited patients presenting with haematuria following referral to secondary case at 40 hospitals. All patients had a cystoscopy and upper tract imaging (renal bladder ultrasound [RBUS] and/ or CT urogram [CTU]). Patients, where urine cytology were performed, were sub-analysed. The reference standard for the diagnosis of bladder cancer and UTUC was histological confirmation of cancer. A positive urine cytology was defined as a urine cytology suspicious for neoplastic cells or atypical cells.

RESULTS

Of the 3 556 patients recruited, urine cytology was performed in 567 (15.9%) patients from nine hospitals. Median time between positive urine cytology and endoscopic tumour resection was 27 (IQR: 21.3-33.8) days. Bladder cancer was diagnosed in 39 (6.9%) patients and UTUC in 8 (1.4%) patients. The accuracy of urinary cytology for the diagnosis of bladder cancer and UTUC was: sensitivity 43.5%, specificity 95.7%, positive predictive value (PPV) 47.6% and negative predictive value (NPV) 94.9%. A total of 21 bladder cancers and 5 UTUC were missed. Bladder cancers missed according to grade and stage were as follows: 4 (19%) were ≥ pT2, 2 (9.5%) were G3 pT1, 10 (47.6%) were G3/2 pTa and 5 (23.8%) were G1 pTa. High-risk cancer was confirmed in 8 (38%) patients. There was a marginal improvement in sensitivity (57.7%) for high-risk cancers. When urine cytology was combined with imaging, the diagnostic performance improved with CTU (sensitivity 90.2%, specificity 94.9%) superior to RBUS (sensitivity 66.7%, specificity 96.7%). False positive cytology results were confirmed in 22 patients, of which 12 (54.5%) had further invasive tests and 5 (22.7%) had a repeat cytology. No cancer was identified in these patients during follow-up.

CONCLUSIONS

Urine cytology will miss a significant number of muscle-invasive bladder cancer and high-risk disease. Our results suggest that urine cytology should not be routinely performed as part of haematuria investigations. The role of urine cytology in select cases should be considered in the context of the impact of a false positive result leading to further potentially invasive tests conducted under general anaesthesia.

Pembrolizumab for Previously Treated Advanced or Metastatic Urothelial Cancer: An Evidence Review Group Perspective of a NICE Single Technology Appraisal

Pembrolizumab is an intravenously administered monoclonal antibody licensed for locally advanced or metastatic urothelial carcinoma after platinum-containing chemotherapy. This summary presents the perspective of Warwick Evidence, the Evidence Review Group (ERG) appointed by the National Institute of Health and Care Excellence (NICE) for the single technology appraisal of pembrolizumab for this indication. Pembrolizumab is manufactured by Merck, Sharp and Dohme (MSD). The major source of clinical effectiveness was the KEYNOTE-045 trial, where 542 patients received either pembrolizumab or clinician's choice of docetaxel, paclitaxel or vinflunine as a second-line treatment. No indirect treatment comparison was performed. The clinical effectiveness was assessed using hazard ratios for overall survival (OS) and progression-free survival (PFS) of the intention-to-treat (ITT) population, together with the subpopulations positive for programmed cell death 1 ligand 1 (PD-L1) expression (combined positive score [CPS] ≥ 1%) and strongly positive for PD-L1 expression (CPS ≥ 10%). In the ITT population, OS improved with pembrolizumab (HR 0.73, 95% CI 0.59-0.91) while PFS outcomes showed no difference (HR 0.98, 95% CI 0.81-1.19). Pembrolizumab demonstrated a better safety profile than its combined comparators, with fewer patients experiencing adverse events (60.9 vs 90.2%). Similar results were observed in populations expressing PD-L1. MSD estimated the cost effectiveness of pembrolizumab using a de novo partitioned survival model. The model had three health states: pre-progression, post-progression and death, where OS and PFS estimates excluded patients who received vinflunine. The largest uncertainty was over the selection of the parametric models used to extrapolate OS and PFS and the time point for when to begin their extrapolation. The company preferences for extrapolation were not well supported and the ERG disagreed with their selection for OS. Utility values were also contentious, with the company preferring to use pooled time-to-death-based utilities pooled across treatment arms, whilst the ERG preferred pooled progression-based utilities. The company preferred to use data from patients receiving vinflunine when calculating the utility values, which the ERG disagreed with as this is not recommended treatment within the UK. The company assumed a lifetime treatment effect for their model; however, the lack of evidence made it difficult to confidently provide a realistic estimate of treatment effect duration. Various durations were explored (3, 5 and 10 years). The first appraisal committee meeting concluded that pembrolizumab was not cost effective, largely due to uncertainty in the OS and PFS extrapolations. The company's second submission included an additional 4 months follow-up to survival data. The company in this new submission maintained their original assumptions in their base-case analysis, changing only the choice of parametric curve for PFS. This change resulted in the OS and PFS curves intersecting at 6 years in the pembrolizumab arm, at which point PFS identically followed OS. This resulted in no patients in the post-progression health state beyond this time point, and therefore, the majority of pembrolizumab's benefit came from pre-progression survival. Given the unclear PFS benefit, the ERG found this implausible and maintained their original base-case model assumptions. Considerable uncertainty remained over the specification of the extrapolations and the duration of treatment effect. Based on a new-value proposition submitted by the company, the appraisal committee concluded that pembrolizumab had plausible potential to be cost effective. Pembrolizumab was referred for funding through the Cancer Drugs Fund, so that further data could be collected with the aim of diminishing the outstanding uncertainties pertaining to its clinical effectiveness.

An Investigation into the Use of Traditional Chinese Medicine in the Treatment of Orofacial Disorders

While on student elective from the Dental School of Bristol University, the authors had the chance to study the basic principles of traditional Chinese medicine and to observe the treatment of orofacial disease in a modern general hospital in Shanghai and in a specialist stomatological hospital at Beijing Medical University. The background to traditional herbal medicine and various forms of acupuncture encountered during their visit is discussed, as are some case histories. They report that clinical experience in China suggests that the combination of traditional Chinese and Western treatment techniques offers better results than either method alone.

The British Association of Urological Surgeons radical cystectomy audit 2014/2015: An update on current practice, and an analysis of the effect of centre and surgeon case volume

Objective:

The Consultant Outcomes Publication has made it mandatory to submit surgeon-level data on radical cystectomy (RC) practice in England. The current analysis describes contemporary surgical practice and compares this by surgeon and centre case volume.

Materials and methods:

Between 1 January 2014 and 31 December 2015, data on 3742 RCs performed by 161 surgeons over 84 centres were recorded on the British Association of Urological Surgeons audit and data platform. Centre case volumes were grouped as high (> 60), medium (30–60) and low (< 30), while surgeon case volumes were grouped as high (> 30), medium (8–30) and low (< 8). All data averages were for the combined 2-year period.

Results:

The median number of RCs performed was 16/surgeon and 31/centre; 45.4% of cases were performed for muscle-invasive transitional cell carcinoma (TCC). The commonest performed urinary diversion was ileal conduit (85.2%), followed by orthotopic bladder substitution (5.7%). Open radical cystectomy (ORC) was performed in 67.8%, robotically-assisted cystectomy (RARC) in 20.6% and laparoscopic cystectomy (LRC) in 9.1% of cases. RARC was more likely to be performed by high-volume surgeons and centres. The majority of patients underwent a lymph node dissection (LND), with rates varying from 79.5% to 90.3%. Reported rates of high-grade complication were generally low across all groups, suggesting under-reporting. There was a trend towards higher reported transfusion rates as centre volumes decreased. The median length of stay (LOS) was 7–9 days for minimally invasive approaches compared to open surgery, which was 11–12 days. Mortality rates were low across all groups.

Conclusions:

Compliance with the data registry is high. ORC remains the most common approach. High-case volume surgeons and centres more commonly offer RARC. The majority of patients undergo LND. There is a trend towards higher reported rates of transfusion as centre volume decreases. LOS is shorter in RARC and LRC in comparison to ORC, but is otherwise similar across centres and surgeons.

Level of evidence:

2b

Can Renal and Bladder Ultrasound Replace Computerized Tomography Urogram in Patients Investigated for Microscopic Hematuria?

Purpose

Computerized tomography urogram is recommended when investigating patients with hematuria. We determined the incidence of urinary tract cancer and compared the diagnostic accuracy of computerized tomography urogram to that of renal and bladder ultrasound for identifying urinary tract cancer.

Materials and Methods

The DETECT (Detecting Bladder Cancer Using the UroMark Test) I study is a prospective observational study recruiting patients 18 years old or older following presentation with macroscopic or microscopic hematuria at a total of 40 hospitals. All patients underwent cystoscopy and upper tract imaging comprising computerized tomography urogram and/or renal and bladder ultrasound.

Results

A total of 3,556 patients with a median age of 68 years were recruited in this study, of whom 2,166 underwent renal and bladder ultrasound, and 1,692 underwent computerized tomography urogram in addition to cystoscopy. The incidence of bladder, renal and upper tract urothelial cancer was 11.0%, 1.4% and 0.8%, respectively, in macroscopic hematuria cases. Patients with microscopic hematuria had a 2.7%, 0.4% and 0% incidence of bladder, renal and upper tract urothelial cancer, respectively. The sensitivity and negative predictive value of renal and bladder ultrasound to detect renal cancer were 85.7% and 99.9% but they were 14.3% and 99.7%, respectively, to detect upper tract urothelial cancer. Renal and bladder ultrasound was poor at identifying renal calculi. Renal and bladder ultrasound sensitivity was lower than that of computerized tomography urogram to detect bladder cancer (each less than 85%). Cystoscopy had 98.3% specificity and 83.9% positive predictive value.

Conclusions

Computerized tomography urogram can be safely replaced by renal and bladder ultrasound in patients who have microscopic hematuria. The incidence of upper tract urothelial cancer is 0.8% in patients with macroscopic hematuria and computerized tomography urogram is recommended. Patients with suspected renal calculi require noncontrast renal tract computerized tomography. Imaging cannot replace cystoscopy to diagnose bladder cancer.

Radical cystectomy: Analysis of trends in UK practice 2004–2012, from the British Association of Urological Surgeons’ (BAUS) Section of Oncology Dataset

Objective:

To analyse the British Association of Urological Surgeons’ (BAUS) radical cystectomy (RC) dataset, to examine the trends in patient selection, use of neoadjuvant chemotherapy (NAC) and operative technique.

Methods:

Data for RC were entered into a database voluntarily, by operating surgeons. A comparison was made to the Hospital Episode Statistics (HES) data, to estimate the proportion of cases captured by the dataset.

Results:

From 2004 to 2012, data was collected on 5321 patients undergoing RC. This constituted 37.1% of all HES RC cases during the corresponding time period. Notable trends were: An increasing use of NAC, the introduction of minimally-invasive surgery (23.5% in 2012), a dramatic reduction in blood transfusion rates and the increasing yields from lymph node dissection. The ileal conduit urinary diversion predominated as the urinary diversion of choice (80% of cases).

Conclusions:

This analysis of a large multi-centre dataset provides insight into RC practice in the UK, over 8 years. The major weaknesses of the study were that only one-third of cases were recorded and that outcome data was very limited. Mandatory publication of outcome data from 2016 should increase the recording of cases and provide material for a more complete analysis.

Laparoscopic ureteral reimplantation: prospective evaluation of medium-term results and current developments

OBJECTIVE

Laparoscopic ureteral reimplantation is a feasible method for treating ureteral pathology with good preliminary results in the literature. In this study, we review our medium-term results for laparoscopic ureteral reimplantation and discuss current developments of this procedure.

MATERIALS AND METHODS

Twenty-four laparoscopic ureteral reimplantations were performed between August 2003 and December 2008 for ureteral strictures or ureteral injuries. The mean age was 53.5 years (8 men, 16 women). Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Ten patients underwent vesicopsoas-hitch, nine patients had a vesicopsoas-hitch combined with Boari-flap, and five had Lich-Gregoir extravesical ureteral reimplantations. Success was defined as relief of obstruction on postoperative imaging studies, as well as symptomatic relief.

RESULTS

Laparoscopic ureteral reimplantations were successfully performed in all patients. The mean operative time was 215 min (131-351). Mean estimated blood loss was 283 ml (50-550). One patient had an intraoperative bowel injury which was managed laparoscopically during the same procedure. There were two postoperative complications; two prolonged ileus and one deep venous thrombosis (DVT). Mean hospital stay was 8.7 days. Average time to return to normal activity was 2.6 weeks. Postoperative radiological imaging studies showed good drainage, without hydronephrosis, in 23 patients (success rate 95.8 %) at a median follow up interval of 35 months.

CONCLUSIONS

Laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that this procedure will become an established treatment option.

Prevention and management of ureteral injuries occurring during laparoscopic radical prostatectomy: the Heilbronn experience and a review of the literature

OBJECTIVES

There is a small risk of ureteral injury during laparoscopic radical prostatectomy (LRP). It is important to recognise and repair such ureteral injuries immediately. Laparoscopic reconstructive surgery has proven to be feasible for the treatment of ureteral injury. We report our experience of ureteral injuries during LRP including the incidence, mechanism of injury, management, prevention and outcome.

MATERIALS AND METHODS

During a 9-year period, 2,164 LRP's were performed at our clinic. Three cases were complicated by lower ureteral injuries including two complete and one partial transection. The complete transections occurred during posterior dissection of the bladder neck and seminal vesicles, and the partial transection during an extended lymph node dissection. All were recognised and managed intraoperatively. We performed Lich-Gregoir (LG) extravesical ureteral reimplantation for complete transections, and primary repair for the partial ureteral transection.

RESULTS

Overall, the incidence of ureteral injuries was 0.13%. Laparoscopic reconstructive surgery was performed successfully in all cases without complication. This added 71, 46 and 59 min, respectively, to LRP operative time. The postoperative course was uneventful in all patients. Hospital stay was 8 days. After 30, 17 and 14 months of follow-up, intravenous urography (IVU) demonstrated good drainage.

CONCLUSION

Recognition and repair of ureteral injuries during LRP requires a high index of suspicion, and expertise in laparoscopic technique. Laparoscopic reimplantation or primary repair of these injuries during LRP is, in experienced hands, a safe, feasible and minimally invasive procedure with the benefits of laparoscopic surgery maintained for the patient.

Laparoscopic radical prostatectomy in clinical T1a and T1b prostate cancer: oncologic and functional outcomes--a matched-pair analysis

OBJECTIVES

To evaluate the effect of previous transurethral resection of the prostate (TURP) on surgical, functional, and oncologic outcomes after laparoscopic radical prostatectomy.

METHODS

From a series of 2100 patients undergoing laparoscopic radical prostatectomy, we compared the intraoperative complications and functional and oncologic outcomes for 55 patients who had been diagnosed with prostate carcinoma on previous TURP (group 1), with those of 55 matched patients who had not undergone previous prostate surgery (group 2). The patients were match-paired for age, operating surgeon, procedure type (eg, nerve-sparing, lymph node dissection), anastamotic technique, pathologic stage, and Gleason score. The minimal duration of follow-up was 24 months.

RESULTS

Both groups were similar with respect to patient age and pathologic stage. Of those with Stage cT1a and cT1b, 83.6% had a clinically significant tumor, with a mean tumor volume of 1.7 cm(3) for those with Stage cT1a and 2.4 cm(3) for those with Stage cT1b. The positive surgical margin rate was 14.5% and 16.3% for groups 1 and 2, respectively. Biochemical recurrence developed in 12.7% and 11% of patients in groups 1 and 2, respectively. Neither outcome was significantly different between the 2 groups. The long-term continence rates were similar; however, previous TURP was associated with a lower continence rate (49.1%) at 3 months compared with 61.8% for group 2 (P = .01). A nerve-sparing technique was used in 54% of group 1 patients. No significant difference was found in the potency rates between the 2 groups at 12 months.

CONCLUSIONS

Laparoscopic radical prostatectomy after TURP is a challenging, but oncologically safe, procedure. The interval to total continence was delayed, but the potency rates remain unchanged.

Third-generation cryotherapy for prostate cancer in the UK: a prospective study of the early outcomes in primary and recurrent disease

OBJECTIVE

To present the early results of the use of third-generation cryotherapy in primary and recurrent prostate cancer at one UK centre.

PATIENTS AND METHODS

Over a 14-month period 51 patients underwent cryotherapy for prostate cancer. In 31 patients cryotherapy was used as the primary treatment and in 20 as a salvage treatment after radiotherapy or hormone ablation. Data were collected prospectively and the median follow-up was 9 months.

RESULTS

The prostate-specific antigen (PSA) level decreased to <0.5 ng/mL in 79% of patients undergoing primary treatment and in 67% of patients undergoing salvage treatment. A higher Gleason grade and PSA levels were associated with a poorer outcome. No patient developed a fistula, 4% developed urinary retention requiring transurethral prostatectomy and 4% had persistent incontinence. The rates of erectile dysfunction were high (86%). The median inpatient stay was 2 days.

CONCLUSION

Early results suggest that cryotherapy offers a safe alternative for primary and recurrent prostate cancer, particularly for older and less fit patients. Long-term data are required to assess the durability of response and the effect on survival.

Adhesion of lymphocytes to bladder cancer cells: the role of the alpha(E)beta(7) integrin

The alpha(E)beta(7)integrin (defined by CD103) is expressed by most intra-epithelial lymphocytes (IEL) but by fewer than 2% peripheral blood lymphocytes (PBL). An important ligand for this molecule is the epithelial cell adhesion molecule E-cadherin. Loss of E-cadherin is associated with increased invasion and metastasis in bladder cancer. This study examines the role of the alpha(E)beta(7)-E-cadherin interaction in lymphocyte targeting of bladder cancer cells. Lymphocytes were activated in vitro by mixed lymphocyte reaction (MLR) and CD103 was upregulated by treatment with transforming growth factor beta (TGFbeta). The CD103(+) lymphocytes were used in a flow cytometric adhesion assay with bladder cancer cell lines, differing in expression of E-cadherin and intercellular adhesion molecule-1 (ICAM-1). Antibody blockade was used to confirm the relative importance of CD103 and ICAM-1 to intercellular adhesion. Lymphocytes with upregulated CD103 compared to control lymphocytes showed enhanced adhesion to an E-cadherin expressing bladder cancer cell line ( P=0.0003). This increased adhesion could be abrogated by anti-CD103 adhesion blockade. For ICAM-1 expressing bladder cells, adhesion of lymphocytes could be markedly reduced using anti-ICAM-1 blockade. In conclusion, the upregulation of CD103 by lymphocytes increases adhesion to E-cadherin expressing bladder cancer targets. Loss of E-cadherin in bladder cancer progression may provide a mechanism both for increased invasion and effective immune evasion.

T cell adhesion and cytolysis of pancreatic cancer cells: a role for E-cadherin in immunotherapy?

Pancreatic cancer is an aggressive and potent disease, which is largely resistant to conventional forms of treatment. However, the discovery of antigens associated with pancreatic cancer cells has recently suggested the possibility that immunotherapy might become a specific and effective therapeutic option. T cells within many epithelia, including those of the pancreas, are known to express the alphaEbeta7-integrin adhesion molecule, CD103. The only characterised ligand for CD103 is E-cadherin, an epithelial adhesion molecule which exhibits reduced expression in pancreatic cancer. In our study, CD103 was found to be expressed only by activated T cells following exposure to tumour necrosis factor beta 1, a factor produced by many cancer cells. Significantly, the expression of this integrin was restricted mainly to class I major histocompatibility complex-restricted CD8+ T cells. The human pancreatic cancer cell line Panc-1 was transfected with human E-cadherin in order to generate E-cadherin negative (wild type) and positive (transfected) sub-lines. Using a sensitive flow cytometric adhesion assay it was found that the expression of both CD103 (on T cells) and E-cadherin (on cancer cells) was essential for efficient adhesion of activated T cells to pancreatic cancer cells. This adhesion process was inhibited by the addition of antibodies specific for CD103, thereby demonstrating the importance of the CD103-->E-cadherin interaction for T-cell adhesion. Using a 51Cr-release cytotoxicity assay it was found that CD103 expressing T cells lysed E-cadherin expressing Panc-1 target cells following T cell receptor stimulation; addition of antibodies specific for CD103 significantly reduced this lysis. Furthermore, absence of either CD103 from the T cells or E-cadherin expression from the cancer cells resulted in a significant reduction in cancer cell lysis. Therefore, potentially antigenic pancreatic cancer cells could evade a local anti-cancer immune response in vivo as a consequence of their loss of E-cadherin expression; this phenotypic change may also favour metastasis by reducing homotypic adhesion between adjacent cancer cells. We conclude that effective immunotherapy is likely to require upregulation of E-cadherin expression by pancreatic cancer cells or the development of cytotoxic immune cells that are less dependent on this adhesion molecule for efficient effecter function.

Relationship between capitulum size and pre-dispersal seed predation by insect larvae in common Asteraceae

The evolution of a showy floral display as an advertisement to pollinators could simultaneously advertise the availability of resources to pre-dispersal seed-predators. The hypotheses tested here are that the incidence of seed predation by bud-infesting insect larvae in capitula of Asteraceae is positively related to (1) capitulum size among species, (2) capitulum size within species, (3) capitulum lifespan, and (4) the degree of flowering asynchrony on individual plants. Three populations of each of 20 common herbaceous species of Asteraceae from disturbed ground and grassland habitats were monitored for the presence of pre-dispersal, seed-eating insect larvae. Mean capitulum size (receptacle width) of each species was measured. In a sub-set of eight species, individual capitula were tagged to determine their flowering phenology and lifespan (from anthesis to seed shedding). From these data an index of flowering synchrony on individual plants was derived. Among species, the incidence of larval infestation increased with capitulum size. Small-flowered species such as Achillea millefolium were largely free of bud-infesting larvae, whilst large-flowered species such as Arctium minus were heavily infested. In three cases investigated in greater detail, bud infestation was found to increase with capitulum size within species, suggesting a potential for natural selection to favour smaller capitula. No relationship was found between infestation levels and either capitulum lifespan or degree of flowering synchrony, and there was no evidence that the relationship between capitulum size and infestation was confounded by correlations with these other features. The results support hypotheses 1 and 2, but not 3 and 4. It is suggested that the characteristic capitulum size of each species may represent a trade-off between the opposing selection pressures of pollinators and pre-dispersal seed predators.

Distribution of lymphocytes of the alpha(E)beta(7) phenotype and E-cadherin in normal human urothelium and bladder carcinomas

The primary aim of this work was to survey normal urothelium and transitional cell carcinoma (TCC) for the presence of T lymphocytes expressing the intraepithelial, CD103(+) phenotype. This antigen defines the alpha(E)beta(7)-integrin. The adhesive counter-receptor for alpha(E)beta(7) is E-cadherin, which is down-regulated during cancer progression. The secondary aim was to determine the pattern of distribution of CD103(+) lymphocytes in relation to E-cadherin expression in bladder cancer. Cryostat sections of normal bladder and TCC were treated with antibodies specific for human CD103, CD3, CD8 and E-cadherin. Visualization was performed by immunoperoxidase or alkaline phosphatase development with light and confocal microscopy. Dual staining and serial sections were used to assess the relationship between these antigens. Four samples of normal bladder and 26 TCC samples were assessed. Occasional T lymphocytes (CD3(+)) were seen in normal urothelium and lamina propria. In the urothelium the majority of these T lymphocytes (71%) were also CD8(+) and of these 68% expressed the CD103 marker. In the lamina propria 62% of the T lymphocytes were CD8(+) and 56% of these expressed the CD103 marker. In carcinomas significantly greater numbers of CD103(+) T lymphocytes were present in the surrounding stroma rather than infiltrating the carcinomas (P = 0.0006). Of those T lymphocytes infiltrating the tumours, 71% were CD8(+) and of these 58% expressed CD103. In the surrounding stroma 52% of lymphocytes were CD8(+) and 82% of this subset expressed CD103. Infiltration by CD103(+) lymphocytes was not related to the intensity of E-cadherin expression. T lymphocytes of the CD103(+) phenotype are present in normal urothelium where they may play a role in immunosurveillance. Rather than infiltrating into carcinomas, these cells predominate in the surrounding stroma which could suggest a failure of immune function.

Comparison of thyroid function in pregnant and non-pregnant Asian and western Caucasian women

BACKGROUND

Gestational thyrotoxicosis may be more prevalent in Asian women.

METHODS

We have measured thyroid function, ferritin and bone specific alkaline phosphatase (BALP) as peripheral markers of thyroid function and hCG in Asian and western Caucasian women in non-pregnant and early pregnancy.

RESULTS

TSH was lower in Asian women in non-pregnancy but not during normal pregnancy and this may reflect increased sensitivity of the thyroid gland to thyroid stimulation in the Asian population. No ethnic difference was found in FT3, FT4 or hCG but ferritin was lower and BALP higher in Asian women whether pregnant or not and this may be a reflection of iron balance and vitamin D status.

CONCLUSIONS

We found during normal pregnancy that dynamic patterns of change for thyroid hormones and hCG are not different in Asian and western Caucasian women. We have developed gestation related reference intervals, which are a pre-requisite to the study of ethnic differences in gestation thyrotoxicosis in pregnancy.

Exploring the value of shiatsu in palliative care day services

This qualitative study sought to evaluate the effects of shiatsu therapy on clients attending hospice day services. Eleven clients with advanced progressive disease received five therapy sessions each at weekly intervals. Data about the effects was collected through five unstructured interviews with each client. Four of these were conducted before, during, and shortly after the therapy regime, and the fifth was undertaken four weeks after treatment ended. All the interviews were tape-recorded, transcribed and subject to content analysis. The results of the analysis revealed significant improvements in energy levels, relaxation, confidence, symptom control, clarity of thought and mobility. These benefits were of variable duration - in some instances lasting a few hours but in others extending beyond the 5-week treatment regime. Action to ensure research trustworthiness included keeping research journals to provide an audit trail, conducting member checks and using peer debriefing. The study involved three overlapping cohorts of participants in a data collection period that took approximately 6 months.

Urethral recurrence after radical radiotherapy for bladder cancer

PURPOSE

Following cystectomy for bladder cancer, orthotopic reconstruction may result in a decreased risk of urethral recurrence compared to cutaneous diversion. We evaluate the rate of urethral recurrence after radical external beam radiotherapy.

MATERIALS AND METHODS

We reviewed the records of 214 men who had received radical radiotherapy at a single center from 1990 to 1995. Patients treated with chemotherapy were excluded from study.

RESULTS

A total of 214 men (median age 69 years, range 39 to 86) underwent radical radiotherapy for cure. Tumor stages were T1 in 7%, T2 in 41%, T3 in 42% and T4a in 10% of the patients. Median followup was 32 months (range 1 month to 8.4 years) and 5-year survival rate was 30%. Urethral recurrence developed in 7 (3.2%) cases and was detected within 18 months (median 10 months, range 3 months to 5 years) of followup in 5. In 2 of these 7 cases recurrence developed in the prostatic urethra, and when these 2 cases were excluded from analysis the recurrence rate decreased to 2.3%. A total of 64 men completed 5-year followup, with a 4.7% rate of urethral recurrence (3.1% excluding prostatic urethral recurrence). Multifocal disease, bladder neck involvement, prostatic disease and cis were possible risk factors for urethral recurrence.

CONCLUSIONS

The risk of urethral recurrence after radical radiotherapy for transitional cell carcinoma of the bladder is comparable with that reported after orthotopic reconstruction. It is not possible to exclude completely that men at higher risk were offered cystectomy, but the data are consistent with the suggestion that continued contact with urine may be protective.