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Wissing MD, O’Flaherty A, Dragomir A, Tanguay S, Kassouf W, Aprikian AG. Chronic prednisone, metformin, and nonsteroidal anti-inflammatory drug use and clinical outcome in a cohort of bladder cancer patients undergoing radical cystectomy in Québec, Canada. BMC Urol 2023; 23:119. [PMID: 37452329 PMCID: PMC10349444 DOI: 10.1186/s12894-023-01287-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Studies have suggested a positive association between bladder cancer (BC) outcome and comedication use, including nonsteroidal anti-inflammatory drugs (NSAID), metformin, and prednisone use. To validate these associations, we evaluated whether these medications were associated with clinical outcome in a Canadian cohort of BC patients. METHODS This is a retrospective cohort study on BC patients undergoing radical cystectomy (RC) in Québec province in 2000-2015, as registered in the provincial health administration databases. Medication use was considered chronic when prescribed for ≥ 1 year. Overall (OS), disease-specific (DSS) and recurrence-free (RFS) survival were compared using multivariable Cox proportional hazards models. Covariates included age, Charlson's comorbidity index, region of residence, year of RC, distance to hospital, hospital type, hospital and surgeon annual RC volume, neoadjuvant chemotherapy use, and type of bladder diversion, as well as mutual adjustment for concomitant comedication use (statins, NSAIDs, metformin, and prednisone). RESULTS Of 3742 patients included, 293, 420, and 1503 patients chronically used prednisone, metformin, and NSAIDs before surgery, respectively. In multivariable analyses, preoperative prednisone use was associated with improved OS (HR 0.67, 95%CI 0.55-0.82), DSS (HR 0.58, 95%CI 0.45-0.76), and RFS (HR 0.61, 95%CI 0.47-0.78). Patients who chronically used metformin preoperatively had a worse OS (HR 1.29, 95%CI 1.07-1.55), DSS (HR 1.38, 95%CI 1.10-1.72), and RFS (HR 1.41, 95%CI 1.13-1.74). Preoperative, chronic NSAID use was not significantly associated with all clinical outcomes, with adjusted HRs for OS, DSS, and RFS of 1.10 (95%CI 0.95-1.27), 1.24 (95%CI 1.03-1.48), and 1.22 (95%CI 1.03-1.45), respectively. Directionality of findings was similar when stratifying by comedication use in the year following surgery. Results were similar after propensity-score matching too. CONCLUSIONS In our Canadian cohort of BC undergoing RC, chronic prednisone use was associated with improved clinical outcomes, while metformin and NSAID were not.
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Affiliation(s)
- Michel D. Wissing
- Division of Urology, Department of Surgery, McGill University Health Center – Research Institute, 1001 Boulevard Decarie, D02.8100, Montreal, Québec H4A 3J1 Canada
- Department of Oncology, McGill University, 5100 Maisonneuve Blvd West, Suite 720, Montreal, Québec H4A 3T2 Canada
| | - Ana O’Flaherty
- Division of Urology, Department of Surgery, McGill University Health Center – Research Institute, 1001 Boulevard Decarie, D02.8100, Montreal, Québec H4A 3J1 Canada
| | - Alice Dragomir
- Division of Urology, Department of Surgery, McGill University Health Center – Research Institute, 1001 Boulevard Decarie, D02.8100, Montreal, Québec H4A 3J1 Canada
| | - Simon Tanguay
- Division of Urology, Department of Surgery, McGill University Health Center – Research Institute, 1001 Boulevard Decarie, D02.8100, Montreal, Québec H4A 3J1 Canada
| | - Wassim Kassouf
- Division of Urology, Department of Surgery, McGill University Health Center – Research Institute, 1001 Boulevard Decarie, D02.8100, Montreal, Québec H4A 3J1 Canada
| | - Armen G. Aprikian
- Division of Urology, Department of Surgery, McGill University Health Center – Research Institute, 1001 Boulevard Decarie, D02.8100, Montreal, Québec H4A 3J1 Canada
- Department of Oncology, McGill University, 5100 Maisonneuve Blvd West, Suite 720, Montreal, Québec H4A 3T2 Canada
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Maibom SL, Joensen UN, Poulsen AM, Kehlet H, Brasso K, Røder MA. Short-term morbidity and mortality following radical cystectomy: a systematic review. BMJ Open 2021; 11:e043266. [PMID: 33853799 PMCID: PMC8054090 DOI: 10.1136/bmjopen-2020-043266] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To study short-term (<90 days) morbidity and mortality following radical cystectomy (RC) for bladder cancer and identify modifiable risk factors associated with these. DESIGN Systematic review. METHODS The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE were searched for relevant papers on 11 June 2019 and rerun on 27 May 2020. Studies reporting complications, reoperations, length of stay and mortality within 90 days were included. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine and the quality of evidence was assessed using the Newcastle-Ottawa Scale. RESULTS The search retrieved 1957 articles. Sixty-six articles were included. The quality of evidence was poor to good. Most studies were retrospective, and no randomised clinical trials were identified. Of included studies a median of 6 Martin criteria for reporting complications after surgery were fulfilled. The Clavien-Dindo classification for grading complications was most frequently used. The weighted overall complication rate after RC was 34.9% (range 28.8-68.8) for in-house complications, 39.0% (range 27.3-80.0) for 30-day complications and 58.5% (range 36.1-80.5) for 90-day complications. The most common types of complications reported were gastrointestinal (29.0%) and infectious (26.4%). The weighted mortality rate was 2.4% (range 0.9-4.7) for in-house mortality, 2.1% (0.0-3.7) for 30-day mortality and 4.7% (range 0.0-7.0) for 90-day mortality. Age and comorbidity were identified as the best predictors for complications following RC. CONCLUSION Short-term morbidity and mortality are high following RC. Reporting of complications is heterogeneous and the quality of evidence is generally low. There is a continuous need for randomised studies to address any intervention that can reduce morbidity and mortality following RC. PROSPERO REGISTRATION NUMBER 104937.
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Affiliation(s)
- Sophia Liff Maibom
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Ulla Nordström Joensen
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Alicia Martin Poulsen
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
- Section for Surgical Pathophysiology, The Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Andreas Røder
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
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The Use of 5-Alpha Reductase Inhibitors and Alpha-1 Blockers Does Not Improve Clinical Outcome in Male Patients Undergoing Radical Cystectomy for Bladder Cancer in Quebec, Canada. Clin Genitourin Cancer 2021; 19:371-371.e9. [PMID: 33676834 DOI: 10.1016/j.clgc.2021.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/30/2021] [Accepted: 01/31/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Existing literature suggests that bladder cancer (BC) outcome may be improved when patients use 5α-reductase inhibitors and/or α1-blockers, but such a conclusion may be subject to publication bias. We evaluated whether preoperative use of 5α-reductase inhibitors or α1-blockers was associated with improved clinical outcomes in a cohort of patients with BC undergoing radical cystectomy (RC). PATIENTS AND METHODS Using provincial health administrative databases, we retrospectively identified male BC patients undergoing RC in Quebec province between 2000 and 2015, and we collected data from 2 years before RC until December 2016 or death. Survival analyses were conducted using Kaplan-Meier curves, log-rank tests, propensity score matching, and uni- and multivariable Cox proportional hazards models. Covariates included age, Charlson's comorbidity index, region of residence, year of RC, distance to hospital, hospital type, annual RC volume of each hospital and surgeon, neoadjuvant chemotherapy use, and type of bladder diversion. RESULTS Of the 2822 patients included, 284 patients used 5α-reductase inhibitors and 1001 patients used α1-blockers prior to surgery. Median follow-up time was 7.7 years. Patients who used 5α-reductase inhibitors or α1-blockers were generally older, had more comorbidities, and were treated more recently in academic centers. Overall, bladder cancer-specific and recurrence-free survival did not differ significantly between those using 5α-reductase inhibitors prior to surgery and controls who never used 5α-reductase inhibitors. Adjusted hazard ratios were 1.03 (95% confidence interval [CI], 0.88-1.21) for overall survival, 1.12 (95% CI, 0.92-1.36) for bladder cancer-specific survival, and 1.19 (95% CI, 0.99-1.42) for recurrence-free survival. The aforementioned outcomes were significantly worse in patients who used α1-blockers prior to surgery compared to controls, with respective adjusted hazard ratios of 1.15 (95% CI, 1.04-1.27), 1.19 (95% CI, 1.05-1.35), and 1.18 (95% CI, 1.05-1.33). CONCLUSION Preoperative use of 5α-reductase inhibitors and α1-blockers did not improve clinical outcome in our cohort of male patients undergoing radical cystectomy for bladder cancer.
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Impact of hospital and surgeon volumes on short-term and long-term outcomes of radical cystectomy. Curr Opin Urol 2020; 30:701-710. [PMID: 32732625 DOI: 10.1097/mou.0000000000000805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW There is heightened awareness and trends towards centralizing high-risk, complex surgeries such as radical cystectomy to minimize complications and improve survival. However, after nearly a decade of mandated and/or passive centralization of care, debate regarding its benefits and harms continues. RECENT FINDINGS During the past decade, mandated and passive centralization has led to an increase in radical cystectomies performed in high-volume hospitals (HVHs) and, perhaps by high-volume surgeons (HVS), in addition to efforts to increase the uptake of multidisciplinary strategies in the management of radical cystectomy patients. Consequently, 30 and 90-day mortality rates and overall survival have improved, and major complications and transfusion rates have decreased. Factors impacting surgical quality, such as negative surgical margin(s), pelvic lymphadenectomy and/or lymph node yield rates have increased. However, current studies have not demonstrated a coadditive impact of centralization on oncological outcomes (i.e. cancer-specific and recurrence-free survival). The benefits of centralization on oncologic survival of radical cystectomy remain unclear given the varied definitions of HVHs and HVSs across studies. In fact, centralization of radical cystectomy could lead to an increase in patient load in HVHs and for HVSs, thereby leading to longer surgery waiting times, a factor that is important in the management of muscle-invasive bladder cancer. SUMMARY The benefits of centralization of radical cystectomy with multidisciplinary management are shown increasingly and convincingly. More studies are necessary to prospectively test the benefits, risks and harms of centralization.
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Wissing MD, O’Flaherty A, Dragomir A, Tanguay S, Kassouf W, Aprikian AG. Statins are Associated with Reduced Overall and Cancer-Specific Mortality in Patients Undergoing Radical Cystectomy for Bladder Cancer. Bladder Cancer 2020. [DOI: 10.3233/blc-190254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Existing literature provides contrasting data on statin use and bladder cancer (BC) outcome. OBJECTIVE: We evaluated whether (chronic) statin use was associated with clinical outcomes in patients with BC undergoing radical cystectomy (RC). METHODS: Using provincial health administrative databases, we retrospectively identified BC patients undergoing RC in Quebec province in 2000-2015, and collected data from two years before RC until December 2016 or death. We compared patients who chronically used statins before RC to never statin users. Survival analyses were conducted using Kaplan-Meier curves, log-rank tests, and Cox proportional hazards models. Covariates in multivariable analyses were age, sex, Charlson’s comorbidity index, year of RC, distance to hospital, hospital type, hospital’s and surgeon’s annual RC volume, and neoadjuvant chemotherapy. RESULTS: Our cohort contained 1406 chronic and 1754 never statin users. Five-year overall, BC-specific and recurrence-free survival rates were 40.5% (95% confidence interval (95% CI) 37.8–43.2%), 52.8% (95% CI 49.8–55.7%), and 50.1% (95% CI 47.2–53.0%) for chronic statin users, versus 34.9% (95% CI 32.5–37.2%), 45.5% (95% CI 42.9–48.1%), and 43.4% (95% CI 40.9–45.9%) for never statin users (p≤0.001). In multivariable analyses, hazard ratios (HR) for death, BC-specific deaths and recurrences were 0.83 (95% CI 0.75–0.91), 0.81 (95% CI 0.72–0.91), and 0.83 (95% CI 0.74–0.93) for chronic statin users, respectively. Similar observations were made in patients with diabetes and/or cardiovascular comorbidities (p≤0.001). Clinical outcome was not improved in patients who started statins in the year following surgery compared to never statin users (p > 0.4). CONCLUSIONS: Chronic statin use is associated with improved clinical outcome in BC patients undergoing RC in Quebec.
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Affiliation(s)
- Michel D. Wissing
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
- Department of Oncology, McGill University, Montreal, QC, Canada
| | - Ana O’Flaherty
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Alice Dragomir
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Simon Tanguay
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
- Department of Oncology, McGill University, Montreal, QC, Canada
| | - Wassim Kassouf
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Armen G. Aprikian
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
- Department of Oncology, McGill University, Montreal, QC, Canada
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Wissing MD, Kassouf W, Tanguay S, Aprikian AG. The use of perioperative chemotherapy in patients undergoing radical cystectomy for bladder cancer in Quebec, Canada, 2000-2016. Can Urol Assoc J 2019; 14:E191-E201. [PMID: 31793860 DOI: 10.5489/cuaj.6094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Despite its proven benefit, studies have reported poor use of perioperative chemotherapy (POC) in bladder cancer patients undergoing radical cystectomy (RC). We evaluated POC use in Quebec between January 2000 and September 2016. METHODS Using provincial health administrative databases, data were retrospectively collected from patients from two years before RC until December 2016 or death. Logistic regression was used to identify variables predicting POC use. Survival analyses were conducted using Cox regression. Analyzed covariates were age, sex, comorbidities, year of RC, residence and hospital region, distance to hospital, hospital type and size, and hospital's and surgeon's RC volume. RESULTS A total of 790/4656 patients (17.0%) received POC. Neoadjuvant chemotherapy (NAC) use increased in recent years: 3.5% (2009), 11.2% (2012), and 20.7% (2015). POC use was increased in patients with recent surgery, a younger age, less comorbidities, residing closer to the hospital of surgery, and a high surgeon's RC volume (p<0.05). For patients treated between 2013 and 2016, a younger age (odds ratio [OR] 0.71; 95% confidence interval [CI] 0.64-0.80 per five years), shorter distance to the hospital (OR 0.88; 95% CI 0.77-0.99 per 50 km), surgery in an academic hospital (OR 1.86; 95% CI 1.06-3.29), and recent surgery (OR 1.34; 95% CI 1.14-1.58 per year) independently predicted NAC use. These NAC users had a significantly higher overall survival rate than patients without POC (hazard ratio 0.73; 95% CI 0.55-0.97). Limitations include missing data on pathological staging. CONCLUSIONS NAC/POC use increased in Quebec but was lower compared to most developed countries. Its use was lower in patients residing further from the hospital and in those treated in non-academic hospitals.
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Affiliation(s)
- Michel D Wissing
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada.,Department of Oncology, McGill University, Montreal, QC, Canada
| | - Wassim Kassouf
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Simon Tanguay
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Armen G Aprikian
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada.,Department of Oncology, McGill University, Montreal, QC, Canada
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Organ-sparing procedures in GU cancer: part 3-organ-sparing procedures in urothelial cancer of upper tract, bladder and urethra. Int Urol Nephrol 2019; 51:1903-1911. [PMID: 31352580 DOI: 10.1007/s11255-019-02232-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The impact of radical surgery for urothelial carcinoma is significant on patient's quality of life. Organ-sparing surgery (OSS) can provide comparable oncological outcomes and with improved quality of life. In this review, we summarize the indications, techniques and outcomes of OSS for these tumors. METHODS PubMed® was searched for relevant articles. Keywords used were: for upper tract urothelial carcinoma (UTUC): endoscopic, ureteroscopic/percutaneous management, laser ablation; for urothelial bladder cancer: bladder preservation, trimodal therapy, muscle invasive bladder cancer (MIBC); for urethral cancer: urethra/penile-sparing, urethral carcinoma. RESULTS Kidney-sparing surgery is an option in patients with low-risk UTUC with better renal function preservation and comparable oncological control to radical nephroureterectomy. In select patients with MIBC, trimodal therapy has better quality of life and comparable oncological control to radical cystectomy. In distal male urethral cancer, penile conserving surgery is feasible and offers acceptable survival outcomes. In female urethral cancer, organ preservation can be achieved, in addition to OSS, through radiation. CONCLUSIONS In the appropriately selected patient, OSS in upper tract, bladder and urethral carcinoma has comparable oncological outcomes to radical surgery and with the additional benefit of improved quality of life.
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Minnella EM, Awasthi R, Bousquet-Dion G, Ferreira V, Austin B, Audi C, Tanguay S, Aprikian A, Carli F, Kassouf W. Multimodal Prehabilitation to Enhance Functional Capacity Following Radical Cystectomy: A Randomized Controlled Trial. Eur Urol Focus 2019; 7:132-138. [PMID: 31186173 DOI: 10.1016/j.euf.2019.05.016] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/16/2019] [Accepted: 05/31/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND In patients with bladder cancer, poor functional status has remarkable deleterious effects on postoperative outcome and prognosis. Conditioning intervention initiated before surgery has the potential to reduce functional decline attributable to surgery. Nonetheless, evidence is lacking in patients undergoing radical cystectomy. OBJECTIVE To determine whether a preoperative multimodal intervention (prehabilitation) is feasible and effective in radical cystectomy. DESIGN, SETTING, AND PARTICIPANTS This study, conducted at an academic tertiary health care institution, enrolled adult patients scheduled for radical cystectomy. From August 2013 to October 2017, 70 patients were randomized: 35 to multimodal prehabilitation (prehab group) and 35 to standard care (control group). INTERVENTION Multimodal prehabilitation was a preoperative conditioning intervention including aerobic and resistance exercise, diet therapy, and relaxation techniques. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary outcome was perioperative change in functional capacity, measured with the distance covered during a 6-min walk test (6MWD), assessed at baseline, before surgery, and at 4 and 8 wk after surgery. Data were compared using robust mixed linear models for repeated measures. RESULTS AND LIMITATIONS Preoperative change in 6MWD compared with baseline was not significantly different between groups (prehab group 40.8 [114.0] m vs control group 9.7 (108.4) m, p=0.250). However, at 4 wk after surgery, a significant difference in functional capacity was detected (6MWD, prehab group -15.4 [142.5] m vs control group -97.9 [123.8] m, p=0.014). No intervention-related adverse effects were reported. CONCLUSIONS Data suggested that multimodal prehabilitation resulted in faster functional recovery after radical cystectomy. PATIENT SUMMARY After major cancer surgery, people usually feel week and tired, and have less energy to perform activities of daily living. In this study, we showed that using the time before surgery to promote exercise and good nutrition could fasten recovery after the surgical removal of the bladder.
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Affiliation(s)
- Enrico Maria Minnella
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Rashami Awasthi
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Vanessa Ferreira
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | - Berson Austin
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christine Audi
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | - Simon Tanguay
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Armen Aprikian
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | - Wassim Kassouf
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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