Risk-specific intensity of surveillance practices in non-muscle-invasive bladder cancer: Results from the BCAN/SUO/AUA/LUGPA electronic survey

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Background: The ideal surveillance regimen for patients with non-muscle-invasive bladder cancer (NMIBC) is uncertain. Given different grade- and stage-specific risks of recurrence and progression, there is some question whether it might be acceptable to pursue less intensive surveillance practices for patients with lower risk disease, and there is a paucity of data on current patterns of care in this area of practice.

Methods: An electronic survey was developed by the Bladder Cancer Advocacy Network (BCAN) to elicit self-reported practices of cystoscopy, cytology, and radiographic testing in the setting of surveillance for patients with a history of NMIBC. The survey was circulated to urologists via the AUA, SUO and LUGPA distribution lists. 512 respondents completed the survey.

Results: Among respondents, 66% report performing cystoscopy every 3 months on all patients for at least the first two years following diagnosis of NMIBC. The remaining 33% report performing surveillance cystoscopy less frequently, 95% of whom report doing so in the setting of low grade pathology. Similarly, 51% report using cytology with every cystoscopy, 23% do so for all high grade cases, and 30% report not using cytology with every cystoscopy. In the absence of recurrence for patients with an initial high grade diagnosis, upper tract reimaging is performed annually in 48%, biannually in 37% and never in 3%. The corresponding figures for patients with an index diagnosis of low grade disease are 14%, 37% and 28%, respectively. In the event of a recurrence in the bladder, 80% of respondents report reimaging the upper tracts for patients with high grade disease, versus 45% in the event of a low grade recurrence.

Conclusions: A substantial number of urologists responding to a survey report using relatively less intensive surveillance practices in patients with lower risk NMIBC. These results suggest a lack of consensus on the ideal intensity of evaluation in this setting, and provide a basis for prospective studies to validate the safest and most cost-effective strategies for surveillance.

No significant financial relationships to disclose.

Patterns of utilization of urine-based markers in non-muscle-invasive bladder cancer: Results from the BCAN/SUO/AUA/LUGPA electronic survey

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Background: In addition to cytologic evaluation, there are currently four urine-based tests approved by the FDA for bladder cancer detection. At this point, the Guidelines panels from the AUA and EAU do not make specific recommendations about the ideal role of these tests. Furthermore, there is a paucity of data on current patterns of care in this area of practice.

Methods: An electronic survey was developed by the Bladder Cancer Advocacy Network (BCAN) to elicit self-reported practices of the use of cytology and urine-based markers in the settings of general use, surveillance, and assessment of response after intravesical therapy for patients with NMIBC. The survey was circulated to urologists via the AUA, SUO and LUGPA distribution lists. 512 respondents completed the survey.

Results: Among all respondents, 93% report sending cytology routinely (25% via barbotage) in general use. In contrast, 37% report using NMP22 in this setting, 54% report using FISH, and 32% (45% of SUO respondents vs. 31% of AUA respondents, p=0.04) responded that there is “no role for urine-based markers in this setting.” Similar proportions were reported in the specific settings of routine surveillance and post-BCG assessment. When presented with the vignette of a positive marker test and negative cytology and cystoscopy, 36% chose to proceed to the OR for biopsy, 37% chose to repeat cystoscopy and cytology in 3 months, 21% chose “no role for markers in this setting” and 13% chose “other.”

Conclusions: In the absence of more specific guidance, the results of this survey suggest considerable variation in the use and interpretation of urine-based markers in NMIBC. FISH is the marker reported to be used most commonly in multiple settings, however 31-45% of respondents report “no role” for any of the tests in their practice. Greater than one out of three respondents reported taking patients for biopsy under anesthesia in the setting of an isolated positive marker. These preliminary data underscore the need for prospective studies to validate the optimal role of urine-based markers in the setting of NMIBC.

No significant financial relationships to disclose.

Reported patterns of utilization of intravesical therapy in non-muscle-invasive bladder cancer: Results from the BCAN/SUO/AUA/LUGPA electronic survey

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Background: Guidelines recommend intravesical chemotherapy and immunotherapy in the management of non-muscle-invasive bladder cancer (NMIBC) to reduce the risks of recurrence and potentially progression. Nevertheless, recent claims-based analyses have suggested exceedingly low rates of utilization of some of these therapies in practice. In general, there is a paucity of data to inform our understanding of current patterns of care.

Methods: An electronic survey was developed by the Bladder Cancer Advocacy Network (BCAN) to elicit self-reported practices of utilization of intravesical chemo- and immuno-therapy for patients with NMIBC. The survey was circulated to urologists via the AUA, SUO and LUGPA distribution lists. 512 respondents completed the survey.

Results: Overall, 63% of respondents reported routine administration of perioperative mitomycin-c (MMC) after TURBT [80% of SUO respondents vs. 55% of AUA/LUGPA respondents (p<0.001)]. Whereas 5% of respondents reported routine induction therapy with all new low-grade (LG) diagnoses, 99% reported routinely doing so in new high-grade (HG) cases; most commonly with single- agent BCG (94%; vs. 9% BCG/IFN and 5% MMC). Reported induction therapy was higher in the setting of high-volume (77%) or frequently recurrent LG (44%) disease. 89% reported routinely using maintenance therapy for HG, vs. 29% for LG. Reduced strength BCG was most commonly endorsed only in the settings of poor tolerance of full strength (84%) or maintenance (11%), with only 3% endorsing routine use. Routine post-BCG biopsy, even with normal cystoscopy, was endorsed by 28% of respondents, and 64% of respondents used urine-based markers to assess response to intravesical therapy.

Conclusions: Urologists report grade-specific patterns of utilization of intravesical therapy for NMIBC, at rates higher than suggested in some claims-based analyses. Variation exists in post-treatment followup practices. Further study is needed to rectify these self-reported patterns of care with results from claims-based analyses.

No significant financial relationships to disclose.

Effects of oestrogen and progestogen on serum levels of alpha(2)-macroglobulin, transferrin, albumin, and IgG

The levels of four serum proteins, assayed by a radial immunodiffusion technique, have been measured in healthy women who had been given either the oestrogen or progestogen component of a combined oral contraceptive preparation for three weeks. Raised alpha(2)-macroglobulin and transferrin levels were found after oestrogen treatment but albumin and IgG did not significantly alter. In the progestogen-treated group all four proteins remained unchanged. The four proteins have also been assayed at frequent intervals during the normal menstrual cycle. No evidence of cyclical variation was found.

Cyclobutane pyrimidine dimers are photosensitised by carprofen plus UVA in human HaCaT cells

Every year in the UK about 75,000 cases of non-melanoma skin cancer (NMSC) are registered, and about 9500 people are diagnosed with cutaneous melanoma (CM). The main risk factor for these cancers is exposure to sunlight. The effects of light on skin are wavelength dependent, with wavelengths in the UVB waveband (280-315 nm) being the most carcinogenic. UVB is directly absorbed by DNA, producing dimeric pyrimidine photoproducts including cyclobutane pyrimidine dimers (CPD) and pyrimidine (6-4) pyrimodone photoproducts (6-4PP). However UVA (315-400 nm) can also produce CPD, induce skin tumours in mice, and has been shown to be mutagenic in cell culture. Although the precise role of UVA in human skin cancer remains to be elucidated, it comprises the major portion of solar UV radiation, transmits through window glass and can be delivered in high doses from tanning lamps. Non-steroidal anti-inflammatory drugs (NSAIDs), in particular the 2-aryl propionic acid derivatives, are a well-documented group of photosensitising chemicals producing clinical phototoxic and photoallergic reactions. We have used carprofen, a model compound from this group to see if it could amplify the effects of UVA and contribute to the formation of CPD by UVA. Preliminary work has shown that carprofen combined with low doses of UVA (lambda(max): 365 nm; 5 J/cm(2)) can produce both strand breaks (SB) and CPD in human skin or blood cells. CPD were detected indirectly by both an immunofluorescence method and as T4 endonuclease V sensitive sites in the comet assay. These findings show that compounds other than fluoroquinolones and psoralen derivatives may contribute to CPD formation in skin cells in combination with UVA.

European S3-guidelines on the systemic treatment of psoriasis vulgaris

Of the 131 studies on monotherapy or combination therapy assessed, 56 studies on the different forms of phototherapy fulfilled the criteria for inclusion in the guidelines. Approximately three-quarters of all patients treated with phototherapy attained at least a PASI 75 response after 4 to 6 weeks, and clearance was frequently achieved (levels of evidence 2 and 3). Phototherapy represents a safe and very effective treatment option for moderate to severe forms of psoriasis vulgaris. The onset of clinical effects occurs within 2 weeks. Of the unwanted side effects, UV erythema from overexposure is by far the most common and is observed frequently. With repeated or long-term use, the consequences of high, cumulative UV doses (such as premature aging of the skin) must be taken into consideration. In addition, carcinogenic risk is associated with oral PUVA and is probable for local PUVA and UVB. The practicability of the therapy is limited by spatial, financial, human, and time constraints on the part of the physician, as well as by the amount of time required by the patient. From the perspective of the cost-bearing institution, phototherapy has a good cost-benefit ratio. However, the potentially significant costs for, and time required of, the patient must be considered.

Delayed ultraviolet erythema not suppressed by oral prednisolone: a randomized crossover study

BACKGROUND

The anti-inflammatory potency of topical dermatological corticosteroids in suppressing ultraviolet (UV) erythema is routinely measured. No such model exists to assess the potency of systemically administered steroids.

OBJECTIVE

To determine whether or not suppression of delayed UV erythema by a systemic corticosteroid could provide a useful model for assessing the anti-inflammatory potency of systemic corticosteroids.

METHODS

We conducted a randomized, placebo-controlled, patient and assessor blinded, crossover study of oral prednisolone effects on the delayed UV-induced erythemal response in normal subjects. Six healthy volunteers were phototested with a xenon arc monochromator and then dosed with 30 mg of oral prednisolone or matching placebo daily for 4 days. Repeat phototesting was performed on the 4th day of dosing. The minimal erythema dose (MED) was assessed immediately after test UV doses were administered and 24 h later. After a 2-week washout period, the dosing and testing were repeated in a crossover fashion.

RESULTS

A suppression index (SI) [1/(baseline MED value divided by on prednisolone/placebo value)] allowed comparison of the degree of suppression on and off prednisolone. Oral prednisolone did not significantly suppress the threshold UV erythema response (MED). We may have missed small effects in this study and possibly a larger dose or a longer duration of corticosteroid would have had an effect. Possibly, assessment of corticosteroid potency in suppressing established UV erythema rather than on the development of threshold erythema would have yielded different results.

CONCLUSION

The threshold UV erythema suppression model assessed in this study could not distinguish between oral prednisolone and placebo. This UV-erythema suppression test system is not promising as a model to test the anti-inflammatory potency of systemic steroids.