Neoadjuvant gemcitabine and carboplatin followed by immediate cystectomy may be associated with a survival benefit in patients with clinical T2 bladder cancer

The role of histological subtype and chemotherapy on prognosis of ureteral cancer

OBJECTIVE

To date, there have been few studies examining the prognostic implications of histological subtypes in ureteral cancer. And chemotherapy plays a crucial role in the treatment of ureteral cancer, while many factors influence the efficacy of chemotherapy. This study aimed to utilize the Surveillance, Epidemiology and End Results database to assess the impact of histological type on ureteral cancer prognostic outcomes and discovered how histological type and T-stage influence the efficacy of chemotherapy.

METHODS

Based on Surveillance, Epidemiology, and End Results Program, we reviewed 8915 records of patients with primary ureteral cancer from 18 centers between 2000 and 2018. We focused on the overall survival and cancer-specific survival of the records and used Kaplan‒Meier method to calculate survival curves.

RESULTS

In the comparison of prognostic outcomes, atypical subtypes exhibited a less favorable prognosis compared to typical ureteral carcinoma. Notably, patients diagnosed with papillary urothelial carcinoma demonstrated the most favorable overall survival (p = 0.005). Statistically significant benefits were observed in the prognosis of patients with non-papillary urothelial carcinoma who received chemotherapy (HR = 0.860, 95% CI 0.764-0.966, p = 0.011), while chemotherapy did not yield a statistically significant effect on the prognosis of patients with papillary urothelial carcinoma (HR = 1.055, 95% CI 0.906-1.228, p = 0.493). Chemotherapy had an adverse impact on the prognosis of patients with T1 ureteral cancer (HR = 1.235, 95% CI 1.016-1.502, p = 0.034), whereas it exhibited a positive prognostic effect for T3/T4 cases (HR = 0.739, 95% CI 0.654-0.835, p < 0.001).

CONCLUSIONS

Histological type affects the prognosis of ureteral cancer. And evaluation of cancer histological type and T stage in ureteral cancer patients prior to chemotherapy is mandatory.

Multicenter evaluation of neoadjuvant and induction gemcitabine-carboplatin versus gemcitabine-cisplatin followed by radical cystectomy for muscle-invasive bladder cancer

PURPOSE

Cisplatin-based chemotherapy followed by radical cystectomy (RC) is recommended in patients with muscle-invasive bladder cancer (MIBC). However, up to 50% of patients are cisplatin ineligible. The aim of this study was to compare clinical outcomes after ≥ 3 cycles of preoperative gemcitabine-carboplatin (gem-carbo) versus gemcitabine-cisplatin (gem-cis).

METHODS

We identified 1865 patients treated at 19 centers between 2000 and 2013. Patients were included if they had received ≥ 3 cycles of neoadjuvant (cT2-4aN0M0) or induction (cTanyN + M0) gem-carbo or gem-cis followed by RC.

RESULTS

We included 747 patients treated with gem-carbo (n = 147) or gem-cis (n = 600). Patients treated with gem-carbo had a higher Charlson Comorbidity Index (p = 0.016) and more clinically node-positive disease (32% versus 20%; p = 0.013). The complete pathological response (pCR; ypT0N0) rate did not significantly differ between gem-carbo and gem-cis (20.7% versus 22.1%; p = 0.73). Chemotherapeutic regimen was not significantly associated with pCR (OR 0.99 [95%CI 0.61-1.59]; p = 0.96), overall survival (OS) (HR 1.20 [95%CI 0.85-1.67]; p = 0.31), or cancer-specific survival (CSS) (HR 1.35 [95%CI 0.93-1.96]; p = 0.11). Median OS of patients treated with gem-carbo and gem-cis was 28.6 months (95%CI 18.1-39.1) and 45.1 months (95%CI 32.7-57.6) (p = 0.18), respectively. Median CSS of patients treated with gem-carbo and gem-cis was 28.8 months (95%CI 9.8-47.8) and 71.0 months (95%CI median not reached) (p = 0.02), respectively. Subanalyses of the neoadjuvant and induction setting did not show significant survival differences.

CONCLUSION

Our results show that a subset of cisplatin-ineligible patients with MIBC achieve pCR on gem-carbo and that survival outcomes seem comparable to gem-cis provided patients are able to receive ≥ 3 cycles and undergo RC.

Management of Bladder Cancer Patients with Clinical Evidence of Lymph Node Invasion (cN+)

The purpose of this review is to present the current knowledge about the diagnostic and treatment options for bladder cancer (BCa) patients with clinically positive lymph nodes (cN+). This review shows compaction of CT and MRI performance in preoperative prediction of lymph node invasion (LNI) in BCa patients, along with other diagnostic methods. Most scientific societies do not distinguish cN+ patients in their guidelines; recommendations concern muscle-invasive bladder cancer (MIBC) and differ between associations. The curative treatment that provides the best long-term survival in cN+ patients is a multimodal approach, with a combination of neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) with extended pelvic lymph node dissection (ePLND). The role of adjuvant chemotherapy (AC) remains uncertain; however, emerging evidence indicates comparable outcomes to NAC. Therefore, in cN+ patients who have not received NAC, AC should be implemented. The response to ChT is a crucial prognostic factor for cN+ patients. Recent studies demonstrated the growing importance of immunotherapy, especially in ChT-ineligible patients. Moreover, immunotherapy can be suitable as adjuvant therapy in selected cases. In cN+ patients, the extended template of PLND should be utilized, with the total resected node count being less important than the template. This review is intended to draw special attention to cN+ BCa patients, as the oncological outcomes are significantly worse for this group.

Treatment of muscle-invasive and advanced bladder cancer in 2020

Bladder cancer accounts for nearly 170,000 deaths worldwide annually. For over 4 decades, the systemic management of muscle-invasive and advanced bladder cancer has primarily consisted of platinum-based chemotherapy. Over the past 10 years, innovations in sequencing technologies have led to rapid genomic characterization of bladder cancer, deepening our understanding of bladder cancer pathogenesis and exposing potential therapeutic vulnerabilities. On the basis of its high mutational burden, immune checkpoint inhibitors were investigated in advanced bladder cancer, revealing durable responses in a subset of patients. These agents are now approved for several indications and highlight the changing treatment landscape of advanced bladder cancer. In addition, commonly expressed molecular targets were leveraged to develop targeted therapies, such as fibroblast growth factor receptor inhibitors and antibody-drug conjugates. The molecular characterization of bladder cancer and the development of novel therapies also have stimulated investigations into optimizing treatment approaches for muscle-invasive bladder cancer. Herein, the authors review the history of muscle-invasive and advanced bladder cancer management, highlight the important molecular characteristics of bladder cancer, describe the major advances in treatment, and offer future directions for therapeutic development.

Neoadjuvant therapy for muscle-invasive bladder cancer

INTRODUCTION

Muscle-invasive bladder cancer (MIBC) is generally a highly aggressive malignancy with early and mostly distant recurrences. Cisplatin-based combinations have been established as neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) providing overall survival as well as disease-free survival benefit. Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of metastatic urothelial carcinoma and are being tested in the neoadjuvant setting as well.

AREAS COVERED

This review covers the existing guidelines for the management of MIBC. It summarizes the use of different NAC regimens. It also discusses the published literature of ICIs in this setting and explores future perspectives.

EXPERT OPINION

Cisplatin-based NAC is the standard of care in MIBC prior to RC. Cisplatin-ineligible MIBC patients have not demonstrated to clearly benefit from a chemotherapy regimen and proceed directly to RC, although novel agents have been evaluated in this setting. Pembrolizumab and atezolizumab as monotherapy have shown feasibility and promising pathologic response rates. The combination of cisplatin-based chemotherapy with ICIs and chemotherapy-free ICI alone approaches are being investigated in randomized trials. Molecular subclassification and development of predictive biomarkers in MIBC will further help to identify optimal treatment strategies in these patients.

The Utility and Efficacy of Laparoscopic Radical Cystectomy in Patients with Muscle-Invasive Bladder Cancer at a Single Institution

BACKGROUND

The aim of this study was to compare the surgical and oncological outcomes and complications of laparoscopic radical cystectomy (LRC) to those of open radical cystectomy (ORC) in patients with muscle-invasive bladder cancer (MIBC).

METHODS

Our study focused on patients with histologically confirmed stage T2-T4a urothelial carcinoma of the bladder without distant metastases, who underwent LRC (LRC group) or ORC (ORC group). The primary endpoints in this study were the overall survival (OS) and recurrence-free survival (RFS) rates.

RESULTS

In this study, 59 patients, 17 underwent LRC and 42 underwent ORC, were enrolled. The 2-year OS rate was 100% in the LRC group and 88.0% in the ORC group (p = 0.85). The 2-year RFS rate was 63.5% in the LRC group and 69.5% in the ORC group (p = 0.321). On multivariate analysis, the histological type, positive lymph node, and positive resection margin were significantly associated with the OS rates.

CONCLUSIONS

This study suggested that LRC may achieve similar oncological outcomes and fewer perioperative complications and less blood loss compared to ORC. Therefore, LRC should be considered as one of the treatment options for patients with MIBC.

The utilization status of neoadjuvant chemotherapy in muscle-invasive bladder cancer: a systematic review and meta-analysis

INTRODUCTION

To give a comprehensive depiction of the utilization status of neoadjuvant chemotherapy (NAC) in muscle invasive bladder cancer (MIBC) worldwide.

EVIDENCE ACQUISITION

Potential relevant research papers of Pubmed, Embase, Web of Science, and the Cochrane Library were reviewed to identify eligible studies. Primary outcomes of this meta-analysis were utilization rate of NAC and its utility distribution in different genders, races, ages, countries and temporal trends. The utilization rates of NAC were calculated as 'Proportion (s)' with 95% confidence intervals (CIs) and pooled estimates were calculated by using a random-effect model.

EVIDENCE SYNTHESIS

A total of thirteen studies and 35,738 patients were included. The total proportion of NAC applied in MIBC populations prior to radical cystectomy (RC) was 17.2% (95% CI: 12.5-21.9%, I²=99.7%). The comparative analyses showed there were no significant differences existing in different genders or races on NAC utilization rates. In terms of age distribution, <60 age group conferred higher utilization rate of NAC than the older (OR=1.919, 95% CI: 1.671-2.202, P=0.0001). As for regional distribution, our meta-analysis showed that Japan (Proportion: 44.0%, 95% CI: 6.5-81.5%, I²=99.6%) and Sweden (37.9%, 95% CI: 34.9-40.8%) were the top two leading countries which contributed to the most frequent application of NAC. In respect of pathologic responses after NAC, complete, partial and down-staged pathologic responses were achieved in 16.6% (95% CI: 7.4-25.9%, I²=89.7%), 14.6% (95% CI: 0.8-28.5%, I²=89.7%) and 45.0% (95% CI: 17.8-72.2%, I²=98.8%) patients, respectively.

CONCLUSIONS

The present study shows the low utilization rate of NAC in MIBC patients. Standardization of the treatment modality of MIBC and promotion of guidelines might be necessary to expedite the adoption of NAC in near future.

Utility of robot-assisted radical cystectomy with intracorporeal urinary diversion for muscle-invasive bladder cancer

Radical cystectomy remains the gold standard for treatment of muscle‐invasive bladder cancer. Robot‐assisted radical cystectomy has technical advantages over laparoscopic radical cystectomy and has emerged as an alternative to open radical cystectomy. Despite the advancements in robotic surgery, experience with total intracorporeal reconstruction of urinary diversion remains limited. Most surgeons have carried out the hybrid approach of robot‐assisted radical cystectomy and extracorporeal reconstruction of urinary diversion, as intracorporeal reconstruction of urinary diversion remains technically challenging. However, intracorporeal reconstruction of urinary diversion might potentially proffer additional benefits, such as decreased fluid loss, reduction in estimated blood loss and a quicker return of bowel function. The adoption of intracorporeal ileal neobladder reconstruction has hitherto been limited to high‐volume academic institutions. In the present review, we compare the totally intracorporeal robot‐assisted radical cystectomy approach with open radical cystectomy and robot‐assisted radical cystectomy + extracorporeal reconstruction of urinary diversion in muscle‐invasive bladder cancer patients.

Postoperative weight loss followed by radical cystectomy predicts poor prognosis in patients with muscle-invasive bladder cancer

We aimed to investigate the impact of postoperative weight loss following radical cystectomy (RC) on patients' prognoses. RC and urinary diversion were performed in 512 consecutive patients with muscle-invasive bladder cancer at our hospitals between May 1996 and July 2018. Demographic clinical information, pre- and postoperative serum albumin, hemoglobin, and weight were evaluated retrospectively at 1 month. We also evaluated the association of weight loss with complications and overall survival (OS) as estimated using the Kaplan-Meier method and compared using the log-rank test. Risk factors for poor OS were determined by Inverse Probability of Treatment Weighted (IPTW)-adjusted Cox regression analysis. In 385 patients who met the study search criteria, median postoperative weight loss from baseline at 1 week and 1 month was 1.1 (- 1.8%) and 3.2 (- 5.4%) kg, respectively. Patients with significant weight loss (defined as ≥ 7.5% at 1 month) had higher-grade complications within 1 month and had significantly shorter OS than those with weight loss of < 7.5%. Type of urinary diversion, loss of serum albumin, and loss of hemoglobin were not significantly associated with weight loss. IPTW-adjusted Cox regression analysis showed that such significant weight loss was an independent risk factor for poor OS. Weight loss followed by radical cystectomy was significantly associated with poor prognosis in patients with muscle-invasive bladder cancer.

Robotic cross-folded U-configuration intracorporeal ileal neobladder for muscle-invasive bladder cancer: Initial experience and functional outcomes

BACKGROUND

This study compared the surgical and urinary functional outcomes in patients with muscle-invasive bladder cancer (MIBC) who underwent robot-assisted radical cystectomy (RARC) followed by intracorporeal ileal neobladder reconstruction (ICNB) to those in patients who underwent minimum incision endoscopic radical cystectomy (MIE-RC) followed by extracorporeal ileal neobladder reconstruction (ECNB).

MATERIALS AND METHODS

This study reviewed the clinical records of 153 consecutive MIBC patients who underwent neoadjuvant chemotherapy followed by radical cystectomy and ileal neobladder reconstruction.

RESULTS

The operative time in the ICNB group was significantly longer than that in the ECNB group. The median estimated blood loss was significantly less in the ICNB group than in the ECNB group. The neobladder capacity gradually increased in both groups. The maximum neobladder pressure and urethral closure pressure gradually improved in both groups.

CONCLUSION

Our initial experience with ICNB was favourable, with acceptable surgical and urinary functional outcomes.

Asymptomatic recurrence detection and cost-effectiveness in urothelial carcinoma

For the management of muscle-invasive bladder cancer or upper tract urothelial carcinoma, the set guidelines recommend regular surveillance after radical cystectomy or radical nephroureterectomy. However, the prognostic benefit of regular oncological surveillance remains controversial in the absence of prospective studies although several retrospective studies with relatively large sample sizes have demonstrated the association between asymptomatic recurrence and better oncological outcomes. Seven out of eight studies reported that patients diagnosed with symptomatic recurrence showed significantly poorer prognosis in comparison to those diagnosed with asymptomatic recurrence. However, potential lead-time and length-time biases prevent the determination of any benefit of regular surveillance. In addition, an optimal surveillance protocol has yet to be established because conventional pathology-based protocols cannot identify the heterogenetic tumor biology of urothelial carcinoma, such as rapid- or slow-growing form of the disease. Several studies suggest that conventional pathology-based surveillance resulted in reduced cost-effectiveness. Recurrence risk-score stratified surveillance protocol including clinical and pathological factors may improve cost-effectiveness. The establishment of optimal risk stratification and surveillance strategies are required to improve the efficacy of regular oncological surveillance. Well-planned prospective studies are necessary to address the prognostic benefit of regular oncological surveillance and shared decision making.

Emerging first line treatment options for bladder cancer: a review of phase II and III therapies in the pipeline

INTRODUCTION

The treatment of urothelial carcinoma (UC) had remained unchanged for several years until the recent FDA approval of immune checkpoint inhibitors (CPIs) in the salvage setting. Novel dual CPI-CPI and CPI-chemotherapy combinations are now being investigated aggressively as first line therapy for metastatic disease. Areas covered: We discuss the recent insights into the tumor biology of UC, which may impact the prognosis as well as assist in developing precision medicine. This is followed by an overview of existing treatment including conventional chemotherapy as well as the trials that led to the recent approval of PD-1 and PD-L1 inhibitors. Ongoing phase II and phase III trials developing PD-1/PD-L1 inhibitors, CTLA-4 inhibitors and VEGF inhibitors as first-line therapy are discussed. Expert opinion: The treatment paradigm for the first-line therapy of UC is expected to shift from conventional platinum-based combination chemotherapy towards novel therapy incorporating CPI immunotherapy. Finding the right combination of drugs in the appropriate disease setting and identifying the right patient population based on biomarkers are important questions to be answered. Another major challenge will be the financial burden associated with these new drugs.

Trends in neoadjuvant chemotherapy use and oncological outcomes for muscle-invasive bladder cancer in Japan: a multicenter study

OBJECTIVE

Despite benefits of neoadjuvant chemotherapy (NAC), the adoption of guideline recommendations for NAC use in patients with muscle-invasive bladder cancer (MIBC) has been slow. We aimed to evaluate temporal trends in NAC use and oncological outcomes in a representative cohort of patients with MIBC.

METHODS

We included 532 patients from 4 hospitals who underwent radical cystectomy (RC) for ≥ cT2 MIBC in 1996-2017. We retrospectively evaluated temporal changes in NAC use and progression-free and overall survival. Candidates for NAC were administered with either cisplatin- or carboplatin-based regimens. The impact of NAC on oncological outcomes was examined using multivariate Cox regression analysis with inverse probability of treatment weighting (IPTW) models.

RESULTS

Of 532 patients, 336 underwent NAC followed by RC (NAC group) and 196 underwent RC alone (Ctrl group). NAC use significantly increased from 10% (1996-2004) to 83% (2005-2016). The number of patients administered with cisplatin- and carboplatin-based regimens was 43 and 280, respectively. Oncological outcomes in the NAC group were significantly improved compared to those in the Ctrl group. Multivariable analysis with IPTW models revealed that NAC significantly improved oncological outcomes in patients with MIBC. A nomogram for 5-year overall survival predicted 16% improvement in patients undergoing NAC.

CONCLUSIONS

NAC use for MIBC increased after 2005. Platinum-based NAC for MIBC potentially improves oncological outcomes.

Oncological outcomes of neoadjuvant chemotherapy in patients with locally advanced upper tract urothelial carcinoma: a multicenter study

Objective

The clinical impact of neoadjuvant chemotherapy (NAC) on oncological outcomes in patients with locally advanced upper tract urothelial carcinoma (UTUC) remains unclear. We investigated the oncological outcomes of platinum-based NAC for locally advanced UTUC.

Results

Of 234 patients, 101 received NAC (NAC group) and 133 did not (Control [Ctrl] group). The regimens in the NAC group included gemcitabine and carboplatin (75%), and gemcitabine and cisplatin (21%). Pathological downstagings of the primary tumor and lymphovascular invasion were significantly improved in the NAC than in the Ctrl groups. NAC for locally advanced UTUC significantly prolonged recurrence-free and cancer-specific survival. Multivariate Cox regression analysis using an inverse probability of treatment weighted (IPTW) method showed that NAC was selected as an independent predictor for prolonged recurrence-free and cancer-specific survival. However, the influence of NAC on overall survival was not statistically significant.

Materials and Methods

A total of 426 patients who underwent radical nephroureterectomy at five medical centers between January 1995 and April 2017 were examined retrospectively. Of the 426 patients, 234 were treated for a high-risk disease (stages cT3–4 or locally advanced [cN+] disease) with or without NAC. NAC regimens were selected based on eligibility of cisplatin. We retrospectively evaluated post-therapy pathological downstaging, lymphovascular invasion, and prognosis stratified by NAC use. Multivariate Cox regression analysis was performed for independent factors for prognosis.

Conclusions

Platinum-based NAC for locally advanced UTUC potentially improves oncological outcomes. Further prospective studies are needed to clarify the clinical benefit of NAC for locally advanced UTUC.

Risk-stratified surveillance and cost effectiveness of follow-up after radical cystectomy in patients with muscle-invasive bladder cancer

Background

The recurrence risk stratification and the cost effectiveness of oncological surveillance after radical cystectomy are not clear. We aimed to develop a risk stratification and a surveillance protocol with improved cost effectiveness after radical cystectomy.

Results

Of 581 enrolled patients, 175 experienced disease recurrences. The pathology-based protocol presented significant differences in recurrence-free survival between normal- and high-risk patients, but the medical expense was high, especially in normal-risk (≤pT2pN0) patients. Cox regression analysis identified six factors associated with recurrence-free survival. Risk score-based 5-year follow-up was significantly more cost effective than the pathology-based protocol.

Materials and Methods

We retrospectively evaluated 581 patients with radical cystectomy for muscle-invasive bladder cancer at 4 hospitals. Patients with routine oncological follow-up were stratified into normal- and high-risk groups by a pathology-based protocol utilizing pT, pN, lymphovascular invasion, and histology. Cost effectiveness of the pathology-based protocol was evaluated and a risk-score-based protocol was developed to optimize cost effectiveness. Risk-scores were calculated by summing risk factors independently associated with recurrence-free survival. Patients were stratified by low-, intermediate-, and high-risk score. Estimated cost per one recurrence detection by the pathology and by risk-scores were compared.

Conclusions

Risk-score-stratified surveillance protocol has potential to reduce over-evaluation after radical cystectomy without adverse effects on medical cost.

Preoperative chronic kidney disease predicts poor oncological outcomes after radical cystectomy in patients with muscle-invasive bladder cancer

OBJECTIVE

To evaluate the impact of preoperative chronic kidney disease (CKD) on oncologic outcomes in muscle-invasive bladder cancer patients who underwent radical cystectomy.

METHODS

A total of 581 patients who underwent radical cystectomy at four medical centers between January 1995 and February 2017 were examined retrospectively. We investigated oncologic outcomes, including progression-free, cancer-specific, and overall survival (PFS, CSS, and OS, respectively) stratified by preoperative CKD status (pre-CKD vs. non-CKD). We performed a Cox proportional hazards regression analysis using inverse probability of treatment weighting (IPTW) to evaluate the impact of preoperative CKD on prognosis and developed the prognostic factor-based risk stratification nomogram.

RESULTS

Of the 581 patients, 215 (37%) were diagnosed with CKD before radical cystectomy. Before the background adjustment, PFS, CSS, and OS after radical cystectomy were significantly lower in the pre-CKD group compared to the non-CKD group. Background-adjusted IPTW analysis showed that preoperative CKD was significantly associated with poor PFS, CSS, and OS after radical cystectomy. The nomogram for predicting 5-year PFS and OS probability showed significant correlation with actual PFS and OS (c-index = 0.73 and 0.77, respectively).

CONCLUSIONS

Muscle-invasive bladder cancer patients with preoperative CKD had a significantly lower survival probability than those without CKD.

The feasibility and effectiveness of robot-assisted radical cystectomy after neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer

Objectives

The aim of this study was to compare 29 muscle-invasive bladder cancer patients who received neoadjuvant chemotherapy (NAC) followed by immediate robot-assisted radical cystectomy (RARC) with those who underwent minimum-incision endoscopic RC (MIE-RC).

Methods

We retrospectively reviewed the charts of 430 consecutive patients who underwent RC and bilateral pelvic node dissection (PLND) between May 1994 and July 2016. Our study focused on patients with MIBC who had histologically confirmed stage T2-T4aN0M0 urothelial carcinoma of the bladder and received NAC prior to surgery. Accordingly, 225 patients were included in this analysis, of whom, 29 underwent RARC (RARC group) and 196 underwent MIE-RC (MIE-RC group). The primary endpoints in this study were the positive surgical margin (PSM) rate and lymph node (LN) count.

Results

In the RARC group, 20 patients underwent RARC with intracorporeal urinary diversion and nine patients underwent RARC with extracorporeal urinary diversion. The median surgical duration for RC and bilateral PLND was 125 min in the RARC group and 98 min in the MIE-RC group (P < 0.001). The rate of PSM was 0% in the RARC group and 0.5% in the MIE-RC group. The median LN counts were 15 in the RARC group and 18 in the MIE-RC group. No intra-operative complication or mortality was associated with RARC or MIE-RP. All complications were grade 2 according to the Clavien-Dindo classification.

Conclusions

Our initial experience with NAC followed by RARC appears to be favorable, with acceptable operative and perioperative clinical outcomes when compared with those of MIE-RC.

Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline

PURPOSE

This multidisciplinary, evidence-based guideline for clinically non-metastatic muscle-invasive bladder cancer focuses on the evaluation, treatment and surveillance of muscle-invasive bladder cancer guided toward curative intent.

MATERIALS AND METHODS

A systematic review utilizing research from the Agency for Healthcare Research and Quality as well as additional supplementation by the authors and consultant methodologists was used to develop the guideline. Evidence-based statements were based on body of evidence strengths Grade A, B or C and were designated as Strong, Moderate and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions.

RESULTS

For the first time for any type of malignancy, the American Urological Association, American Society of Clinical Oncology, American Society for Radiation Oncology and Society of Urologic Oncology have formulated an evidence-based guideline based on a risk-stratified clinical framework for the management of muscle-invasive urothelial bladder cancer. This document is designed to be used in conjunction with the associated treatment algorithm.

CONCLUSIONS

The intensity and scope of care for muscle-invasive bladder cancer should focus on the patient, disease and treatment response characteristics. This guideline attempts to improve a clinician's ability to evaluate and treat each patient, but higher quality evidence in future trials will be essential to improve level of care for these patients.

Difference in toxicity reporting between patients and clinicians during systemic chemotherapy in patients with urothelial carcinoma

OBJECTIVES

To compare toxicity reporting between patients and clinicians in the case of systemic chemotherapy for urothelial carcinoma.

METHODS

Between June 2013 and March 2016, 100 urothelial carcinoma patients received two courses of chemotherapy of gemcitabine plus cisplatin or gemcitabine plus carboplatin, and they were prospectively enrolled in the present study. During chemotherapy, patients answered European Organization for the Research and Treatment of Cancer Quality-of-Life Questionnaire C30 quality-of-life questionnaires, including four toxicity-related symptoms (appetite loss, nausea, constipation and diarrhea). Clinicians evaluated adverse events using the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Differences of toxicity reporting were compared between patients and clinicians. Logistic regression analyses were carried out to investigate potential factors for underreporting by clinicians.

RESULTS

Toxicity underreporting was most frequently for diarrhea (44%), followed by appetite loss (39%), constipation (33%) and nausea (22%). In total, toxicity underreporting was observed in 72% of patients. Background-adjusted logistic regression analyses showed pretreatment quality-of-life items of global, symptomatic scores to be predictors for toxicity underreporting by clinicians. The limitations of the present study included its retrospective nature and small sample size.

CONCLUSIONS

Toxicity underreporting by clinicians is frequent in urothelial carcinoma patients receiving systemic chemotherapy. Pretreatment quality-of-life evaluation is essential not only for quality-of-life evaluation, but also to identify potential individuals at risk for toxicity underreporting.

Quality-of-life evaluation during platinum-based neoadjuvant chemotherapies for urothelial carcinoma

BACKGROUND

Although quality of life (QOL) is one of the most important considerations in patients treated with anticancer therapies, desirable regimens for neoadjuvant chemotherapy including QOL in locally advanced urothelial carcinoma remain unclear. The present study evaluated the influence of neoadjuvant platinum-based chemotherapy on QOL in patients with locally advanced urothelial carcinoma.

METHODS

Between June 2013 and March 2016, 83 urothelial carcinoma patients who received two courses of neoadjuvant chemotherapy were enrolled in this prospective observational study. Neoadjuvant regimens included gemcitabine + cisplatin (GCis) or gemcitabine + carboplatin (GCb) therapies. As a primary endpoint, we assessed QOL changes in each group before and after chemotherapy using the Quality of Life questionnaire on days 1, 3, and 15 of each cycle. Secondary endpoints included toxicity, safety, weight loss, renal function decline, and tumor responses.

RESULTS

QOL analyses were performed in 39 patients receiving GCis and in 44 patients receiving GCb. Appetite loss, role functioning, nausea/vomiting, physical, and fatigue deteriorated >10% from baseline in the GCis group but not in the GCb group. Constipation worsened, whereas scores for pain and emotional items improved in both groups. Objective response rates were 38.5 and 43.2% in the GCis and GCb groups, respectively.

CONCLUSIONS

Both GCis and GCb regimens were feasible in terms of QOL. The GCb regimen may be associated with a better QOL status especially in regard to gastrointestinal symptoms.

The safety and efficacy of gemcitabine for the treatment of bladder cancer

Bladder cancer is a common type of cancer with an estimated incidence of more than 70,000 patients and had a mortality of 16,000 patients in the US in 2015. In more than 70% of cases the disease is diagnosed at the non-muscle invasive stage. However, muscle invasive or metastatic stages need multimodal treatment strategies including surgical treatment and chemotherapy in a neoadjuvant, adjuvant or palliative setting. Gemcitabine is a pyrimidine antimetabolite that has shown efficacy when used systemically in bladder cancer with only mild toxicity compared to other chemotherapeutic agents. This article aims to summarize the results of clinical trials in monotherapeutic, combined or sequential treatment strategies, especially considering efficacy and safety of the different therapeutic regimes.

Differences in the recurrence pattern after neoadjuvant chemotherapy compared to surgery alone in patients with muscle-invasive bladder cancer

In patients with muscle-invasive bladder cancer (MIBC), neoadjuvant chemotherapy (NAC) confers a survival benefit compared to radical cystectomy (RC) alone. Recurrence is observed in many cases and is the most common cause of death in MIBC patients. However, the rate and pattern of recurrence after NAC in MIBC patients remain unclear. We retrospectively reviewed the charts of 348 consecutive patients who underwent RC and bilateral pelvic node dissection between May 1994 and July 2012. Our study focused on patients with MIBC who had histologically confirmed stage T2-T4a urothelial carcinoma of the bladder without lymph node or distant metastasis. Accordingly, 265 patients were included in this analysis, of whom 130 received NAC and 135 underwent RC alone. Propensity score matching was used to adjust for potential selection biases associated with treatment type. Recurrence was defined as local recurrence and distant metastasis, according to site. Propensity score matching analysis identified 130 matched pairs from the two groups. For the neoadjuvant gemcitabine and carboplatin (GCarbo) and RC alone groups, the 5-year overall survival rates were 89.2 and 51.4 %, respectively (P < 0.0001), and the recurrence-free survival rates were 85.4 and 57.0 %, respectively (P < 0.0001). However, the total number of local recurrences was markedly lower in the neoadjuvant GCarbo group than in the RC alone group. Neoadjuvant GCarbo was associated with improved oncological outcomes and a different recurrence pattern in MIBC patients compared to RC alone.