Real World Multi-Institutional Outcomes of Bladder Carbogen and Nicotinamide (BCON) in Muscle-Invasive Bladder Cancer (MIBC)

PURPOSE/OBJECTIVE(S)

Bladder carbogen and nicotinamide (BCON), combined with radiotherapy, is a standard of care in the bladder-preserving treatment of muscle-invasive bladder cancer (MIBC). UK national guidelines recommend neoadjuvant chemotherapy (NAC) before bladder preservation. However, patients did not receive NAC in the definitive phase III BCON trial. This study assessed tolerability and real-world outcomes of BCON alone or with NAC (NAC-BCON).

MATERIALS/METHODS

With institutional approval, demographics and clinical information were obtained for a retrospective cohort study of BCON patients (2017-2021) across 3 UK centers. Clinician-reported toxicity was assessed using RTOG grading during radiotherapy, 6 weeks and 12 months after. Cross-sectional imaging and cystoscopy determined local control, metastasis-free survival (MFS), and cancer-specific survival (CSS). Subgroup differences were compared using T and χ2 tests. Survival was analyzed by Kaplan-Meier, log-rank, and multivariate Cox proportional hazard regression. Statistical analysis was conducted using R version 4.2.1 (R Core Team (2022)).

RESULTS

A total of 317 patients were treated with BCON; 75 (24%) received NAC-BCON. Median follow-up was 29 months (4-63m). Patient characteristics are shown in Table 1. NAC-BCON patients were younger (median 72 vs 78 years, p<0.05), with better PS (p<0.05) and ACE-27 (p<0.05), with no statistical difference in T-staging and histopathology. 298 (94%) completed BCON, whilst 59/75 (79%) completed ≥3 cycles of NAC. There was no significant increased grade 3 acute or late bowel or bladder toxicity with NAC. 3-month cystoscopy post radiotherapy demonstrated complete response in 282/317 (89%). 121 (38%) developed metastases, and 112 (35%) died of MIBC. 5-year BCON MFS was 62% and 49% for NAC-BCON (HR 0.69, 95% CI 0.98- 2.51, p = 0.064); 5-year BCON CSS was 55% and 52% for NAC-BCON (HR 0.83, 95% CI 0.79-1.83, p = 0.39). This remained after adjusting for clinical factors in a multivariate Cox model for both MFS (p = 0.22) and CSS (p = 0.37).

CONCLUSION

Our real-world data compares favorably to published BCON 5-year relapse-free survival (41%) and OS (49%). NAC-BCON has no increased toxicity with comparable treatment completion rates to BCON alone. No significant improvement in survival outcomes was seen with NAC, possibly due to small numbers and patient selection in a non-randomized cohort. Further analysis is planned with additional center input.

Translation of Prognostic and Pharmacodynamic Biomarkers from Trial to Non-trial Patients with Metastatic Castration-resistant Prostate Cancer Treated with Docetaxel

AIMS

We conducted a pooled analysis of four randomised controlled trials and a non-trial retrospective dataset to study the changes in serum prostate-specific antigen (PSA) concentrations during treatment and its impact on survival in men treated with docetaxel for metastatic castration-resistant prostate cancer. We also compared the outcomes and pre-treatment prognostic factors between trial and non-trial patients.

MATERIALS AND METHODS

Data were obtained from four randomised controlled trials and a non-trial cohort from a tertiary cancer centre. The PSA kinetics covariates chosen were absolute value (PSAT), best percentage change (BPCH) and tumour growth rate (K). The association between the covariates collected and overall survival was assessed within a Cox proportional hazards model. How well a covariate captured the difference between trial and non-trial patients was assessed by reporting on models with or without trial status as a covariate.

RESULTS

We reviewed individual datasets of 2282 patients. The median overall survival for trial patients was 20.4 (95% confidence interval 19.6-22.2) months and for the non-trial cohort was 12.4 (10.7-14.7) months (P < 0.001). Of the pre-treatment factors, we found that only lactate dehydrogenase fully captured the difference in prognosis between the trial and non-trial cohorts. All PSA kinetic metrics appeared to be prognostic in both the trial and non-trial patients. However, the effect size was reduced in non-trial versus trial patients (interaction P < 0.001). Of the time-dependent covariates, we found that BPCH best captured the difference between trial and non-trial patient prognosis.

CONCLUSIONS

The analysis presented here highlights how data from open-source trial databases can be combined with emerging clinical practice databases to assess differences between trial versus non-trial patients for particular treatments. These results highlight the importance of developing prognostic models using both pre-treatment and time-dependent biomarkers of new treatments.

A practical approach to bladder preservation with hypofractionated radiotherapy for localised muscle-invasive bladder cancer

Bladder preservation with trimodality treatment (TMT) is an alternative strategy to radical cystectomy (RC) for the management of localised muscle invasive bladder cancer (MIBC). TMT comprises of transurethral resection of the bladder tumour (TURBT) followed by radiotherapy with concurrent radiosensitisation. TMT studies have shown neo-adjuvant chemotherapy with cisplatin-based regimens is often given to further improve survival outcomes. A hypofractionated radiotherapy regimen is preferable due to its non-inferiority in local control and late toxicities. Radiosensitisation can comprise concurrent chemotherapy (with gemcitabine, cisplatin or combination fluorouracil and mitomycin), CON (carbogen and nicotinomide) or hyperthermic treatment. Radiotherapy techniques are continuously improving and becoming more personalised. As the bladder is a mobile structure subject to volumetric changes from filling, an adaptive approach can optimise bladder coverage and reduce dose to normal tissue. Adaptive radiotherapy (ART) is an evolving field that aims to overcome this. Improved knowledge of tumour biology and advances in imaging techniques aims to further optimise and personalise treatment.

A systematic review and meta-analysis of cancer patients affected by a novel coronavirus

BACKGROUND

Cancer patients with COVID-19 disease have been reported to have double the case fatality rate of the general population.

MATERIALS AND METHODS

A systematic search of PubMed/MEDLINE, Embase, Cochrane Central, Google Scholar, and MedRxiv was done for studies on cancer patients with COVID-19. Pooled proportions were calculated for categorical variables. Odds ratio and forest plots were constructed for both primary and secondary outcomes. The random-effects model was used to account for heterogeneity between studies.

RESULTS

This systematic review of 31 studies and meta-analysis of 181,323 patients from 26 studies involving 23,736 cancer patients is the largest meta-analysis to the best of our knowledge assessing outcomes in cancer patients affected by COVID-19. Our meta-analysis shows that cancer patients with COVID-19 have a higher likelihood of death (odds ratio, OR 2.54), which was largely driven by mortality among patients in China. Cancer patients were more likely to be intubated, although ICU admission rates were not statistically significant. Among cancer subtypes, the mortality was highest in hematological malignancies (OR 2.43) followed by lung cancer (OR 1.8). There was no association between receipt of a particular type of oncologic therapy and mortality. Our study showed that cancer patients affected by COVID-19 are a decade older than the normal population and have a higher proportion of co-morbidities. There was insufficient data to assess the association of COVID-directed therapy and survival outcomes in cancer patients. Despite the heterogeneity of studies and inconsistencies in reported variables and outcomes, these data could guide clinical practice and oncologic care during this unprecedented global health pandemic.

CONCLUSION

Cancer patients with COVID-19 disease are at increased risk of mortality and morbidity. A more nuanced understanding of the interaction between cancer-directed therapies and COVID-19-directed therapies is needed. This will require uniform prospective recording of data, possibly in multi-institutional registry databases.