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Musat MG, Kwon CS, Masters E, Sikirica S, Pijush DB, Forsythe A. Treatment Outcomes of High-Risk Non-Muscle Invasive Bladder Cancer (HR-NMIBC) in Real-World Evidence (RWE) Studies: Systematic Literature Review (SLR). Clinicoecon Outcomes Res 2022; 14:35-48. [PMID: 35046678 PMCID: PMC8759992 DOI: 10.2147/ceor.s341896] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/18/2021] [Indexed: 12/30/2022]
Abstract
Background To date, there has been limited synthesis of RWE studies in high-risk non-muscle invasive bladder cancer (HR-NMIBC). The objective of this research was to conduct a systematic review of published real-world evidence to better understand the real-world burden and treatment patterns in HR-NMIBC. Methods An SLR was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with the scope defined by the Population, Intervention Comparators, Outcomes, and Study design (PICOS) criteria. EMBASE, MEDLINE, and Cochrane databases (Jan 2015–Jul 2020) were searched, and relevant congress abstracts (Jan 2018–Jul 2020) identified. The final analysis only included studies that enrolled ≥100 patients with HR-NMIBC from the US, Europe, Canada, and Australia. Results The SLR identified 634 RWE publications in NMIBC, of which 160 studies reported data in HR-NMIBC. The average age of patients in the studies was 71 years, and 79% were males. The rates of BCG intravesical instillations ranged from 3% to 86% (29–95% for induction and 8–83% for maintenance treatment). Five-year outcomes were 17–89% recurrence-free survival (longest survival in patients completing BCG maintenance), 58–89% progression-free survival, 71–96% cancer-specific survival (lowest survival in BCG-unresponsive patients), and 28–90% overall survival (lowest survival in patients who did not receive BCG or instillation therapy). Conclusion BCG treatment rates and survival outcomes in patients with HR-NMIBC vary in the real world, with better survival seen in patients completing maintenance BCG, responding to treatment, and not progressing to muscle-invasive disease. There is a need to better understand the factors associated with BCG use and discontinuation and for an effective treatment that improves outcomes in HR-NMIBC. Generalization of these results is limited by variations in data collection, reporting, and methodologies used across RWE studies.
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Affiliation(s)
- Mihaela Georgiana Musat
- Evidence Generation, Purple Squirrel Economics, a Wholly Owned Subsidiary of Cytel, Inc., Waltham, MA, USA
| | - Christina Soeun Kwon
- Evidence Generation, Purple Squirrel Economics, a Wholly Owned Subsidiary of Cytel, Inc., Waltham, MA, USA
| | | | - Slaven Sikirica
- Global Health Economics and Outcomes Research, Pfizer, New York, NY, USA
| | - Debduth B Pijush
- Global Health Economics and Outcomes Research, Pfizer, New York, NY, USA
| | - Anna Forsythe
- Value and Access, Purple Squirrel Economics, a Wholly Owned Subsidiary of Cytel, Inc., Waltham, MA, USA
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Damrauer JS, Roell KR, Smith MA, Sun X, Kirk EL, Hoadley KA, Benefield HC, Iyer G, Solit DB, Milowsky MI, Kim WY, Nielsen ME, Wobker SE, Dalbagni G, Al-Ahmadie HA, Olshan AF, Bochner BH, Furberg H, Troester MA, Pietzak EJ. Identification of a Novel Inflamed Tumor Microenvironment Signature as a Predictive Biomarker of Bacillus Calmette-Guérin Immunotherapy in Non-Muscle-Invasive Bladder Cancer. Clin Cancer Res 2021; 27:4599-4609. [PMID: 34117034 PMCID: PMC8416390 DOI: 10.1158/1078-0432.ccr-21-0205] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/24/2021] [Accepted: 06/10/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Improved risk stratification and predictive biomarkers of treatment response are needed for non-muscle-invasive bladder cancer (NMIBC). Here we assessed the clinical utility of targeted RNA and DNA molecular profiling in NMIBC. EXPERIMENTAL DESIGN Gene expression in NMIBC samples was profiled by NanoString nCounter, an RNA quantification platform, from two independent cohorts (n = 28, n = 50); targeted panel sequencing was performed in a subgroup (n = 50). Gene signatures were externally validated using two RNA sequencing datasets of NMIBC tumors (n = 438, n = 73). Established molecular subtype classifiers and novel gene expression signatures were assessed for associations with clinicopathologic characteristics, somatic tumor mutations, and treatment outcomes. RESULTS Molecular subtypes distinguished between low-grade Ta tumors with FGFR3 mutations and overexpression (UROMOL-class 1) and tumors with more aggressive clinicopathologic characteristics (UROMOL-classes 2 and 3), which were significantly enriched with TERT promoter mutations. However, UROMOL subclasses were not associated with recurrence after bacillus Calmette-Guérin (BCG) immunotherapy in two independent cohorts. In contrast, a novel expression signature of an inflamed tumor microenvironment (TME) was associated with improved recurrence-free survival after BCG. Expression of immune checkpoint genes (PD-L1/PD-1/CTLA-4) was associated with an inflamed TME, but not with higher recurrence rates after BCG. FGFR3 mutations and overexpression were both associated with low immune signatures. CONCLUSIONS Assessment of the immune TME, rather than molecular subtypes, is a promising predictive biomarker of BCG response. Modulating the TME in an immunologically "cold" tumor warrants further investigation. Integrated transcriptomic and exome sequencing should improve treatment selection in NMIBC.
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Affiliation(s)
- Jeffrey S Damrauer
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Kyle R Roell
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Markia A Smith
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Xuezheng Sun
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Erin L Kirk
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Katherine A Hoadley
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Halei C Benefield
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gopakumar Iyer
- Department of Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - David B Solit
- Department of Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew I Milowsky
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - William Y Kim
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sara E Wobker
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Guido Dalbagni
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Urology, Weill Cornell Medicine, New York, New York
| | - Hikmat A Al-Ahmadie
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew F Olshan
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Bernard H Bochner
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Urology, Weill Cornell Medicine, New York, New York
| | - Helena Furberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa A Troester
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Medicine (Genitourinary Oncology Service), Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Eugene J Pietzak
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, New York.
- Department of Urology, Weill Cornell Medicine, New York, New York
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Klinger D, Hill BL, Barda N, Halperin E, Gofrit ON, Greenblatt CL, Rappoport N, Linial M, Bercovier H. Bladder Cancer Immunotherapy by BCG Is Associated with a Significantly Reduced Risk of Alzheimer's Disease and Parkinson's Disease. Vaccines (Basel) 2021; 9:vaccines9050491. [PMID: 34064775 PMCID: PMC8151667 DOI: 10.3390/vaccines9050491] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 12/16/2022] Open
Abstract
Bacillus Calmette–Guerin (BCG) is a live attenuated form of Mycobacterium bovis that was developed 100 years ago as a vaccine against tuberculosis (TB) and has been used ever since to vaccinate children globally. It has also been used as the first-line treatment in patients with nonmuscle invasive bladder cancer (NMIBC), through repeated intravesical applications. Numerous studies have shown that BCG induces off-target immune effects in various pathologies. Accumulating data argue for the critical role of the immune system in the course of neurodegenerative diseases such as Alzheimer’s disease (AD) and Parkinson’s disease (PD). In this study, we tested whether repeated exposure to BCG during the treatment of NMIBC is associated with the risk of developing AD and PD. We presented a multi-center retrospective cohort study with patient data collected between 2000 and 2019 that included 12,185 bladder cancer (BC) patients, of which 2301 BCG-treated patients met all inclusion criteria, with a follow-up of 3.5 to 7 years. We considered the diagnosis date of AD and nonvascular dementia cases for BC patients. The BC patients were partitioned into those who underwent a transurethral resection of the bladder tumor followed by BCG therapy, and a disjoint group that had not received such treatment. By applying Cox proportional hazards (PH) regression and competing for risk analyses, we found that BCG treatment was associated with a significantly reduced risk of developing AD, especially in the population aged 75 years or older. The older population (≥75 years, 1578 BCG treated, and 5147 controls) showed a hazard ratio (HR) of 0.726 (95% CI: 0.529–0.996; p-value = 0.0473). While in a hospital-based cohort, BCG treatment resulted in an HR of 0.416 (95% CI: 0.203–0.853; p-value = 0.017), indicating a 58% lower risk of developing AD. The risk of developing PD showed the same trend with a 28% reduction in BCG-treated patients, while no BCG beneficial effect was observed for other age-related events such as Type 2 diabetes (T2D) and stroke. We attributed BCG’s beneficial effect on neurodegenerative diseases to a possible activation of long-term nonspecific immune effects. We proposed a prospective study in elderly people for testing intradermic BCG inoculation as a potential protective agent against AD and PD.
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Affiliation(s)
- Danielle Klinger
- Department of Biological Chemistry, Institute of Life Sciences, The Hebrew University of Jerusalem, Jerusalem 91904, Israel;
| | - Brian L. Hill
- Department of Computer Science, University of California Los Angeles, Los Angeles, CA 90095-1596, USA; (B.L.H.); (E.H.)
| | - Noam Barda
- Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat-Gan 6578898, Israel;
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA 02115, USA
| | - Eran Halperin
- Department of Computer Science, University of California Los Angeles, Los Angeles, CA 90095-1596, USA; (B.L.H.); (E.H.)
| | - Ofer N. Gofrit
- Department of Urology, Hadassah University Hospital, Jerusalem 91904, Israel;
| | - Charles L. Greenblatt
- Department of Microbiology and Molecular Genetics, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 91904, Israel; (C.L.G.); (H.B.)
| | - Nadav Rappoport
- Department of Software and Information Systems Engineering, Faculty of Engineering Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel;
| | - Michal Linial
- Department of Biological Chemistry, Institute of Life Sciences, The Hebrew University of Jerusalem, Jerusalem 91904, Israel;
- Correspondence: ; Tel.: +972-54-882-0035
| | - Hervé Bercovier
- Department of Microbiology and Molecular Genetics, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 91904, Israel; (C.L.G.); (H.B.)
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Caputo JM, Moran G, Muller B, Keller AT, Li G, Anderson CB. The Management of Newly-Diagnosed Non-muscle Invasive Bladder Cancer in Veterans Integrated Services Network 02 of the Veterans Health Administration. Mil Med 2021; 185:276-281. [PMID: 31294791 DOI: 10.1093/milmed/usz166] [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: 03/12/2019] [Revised: 06/04/2019] [Accepted: 06/12/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Over 1,500 bladder cancers were diagnosed among US Veterans in 2010, the majority of which were non-muscle invasive bladder cancer (NMIBC). Little is known about NMIBC treatment within the Veterans Health Administration. The objective of the study was to assess the quality of care for Veterans with newly-diagnosed NMIBC within Veterans Integrated Service Network (VISN) 02. MATERIALS AND METHODS We used ICD-9 and ICD-10 codes to identify patients with newly-diagnosed bladder cancer from 1/2016-8/2017. We risk-stratified the patients into low, intermediate, and high-risk based on the 2016 American Urological Association Guidelines on NMIBC. Our primary objectives were percentages of transurethral resection of bladder tumors (TURBTs) with detrusor, repeat TURBT in high-risk and T1 disease, high-risk NMIBC treated with induction intravesical therapy (IVT), and responders treated with maintenance IVT. We performed logistic regression for association between distance to diagnosing hospital and receipt of induction IVT in high-risk patients. RESULTS There were 121 newly-diagnosed NMIBC patients; 16% low-risk, 28% intermediate-risk, and 56% high-risk. Detrusor was present in 80% of all initial TURBTs and 84% of high-risk patients. Repeat TURBT was performed in 56% of high-risk NMIBC and 60% of T1. Induction IVT was given to 66% of high-risk patients and maintenance IVT was given to 59% of responders. On multivariate logistic regression, distance to medical center was not associated with receipt of induction IVT (OR = 0.99, 95% CI [0.97,1.01], p = 0.52). CONCLUSIONS We observed high rates of sampling of detrusor in the first TURBT specimen, utilization of repeat TURBT, and administration of induction and maintenance intravesical BCG for high-risk patients among a regional cohort of US Veterans with NMIBC. While not a comparative study, our findings suggest high quality NMIBC care in VA VISN 02.
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Affiliation(s)
- Joseph M Caputo
- Department of Urology, NewYork-Presbyterian/Columbia University Medical Center, 161 Fort Washington Avenue 11th Floor, New York, NY 10032.,James J. Peters Veterans Affairs Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468
| | - George Moran
- Department of Urology, NewYork-Presbyterian/Columbia University Medical Center, 161 Fort Washington Avenue 11th Floor, New York, NY 10032
| | - Benjamin Muller
- Department of Urology, NewYork-Presbyterian/Columbia University Medical Center, 161 Fort Washington Avenue 11th Floor, New York, NY 10032
| | - Alison T Keller
- James J. Peters Veterans Affairs Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468
| | - Gen Li
- Department of Biostatistics, Mailman School of Public Health, Columbia University, 722 West 168th St, New York, NY 10032
| | - Christopher B Anderson
- Department of Urology, NewYork-Presbyterian/Columbia University Medical Center, 161 Fort Washington Avenue 11th Floor, New York, NY 10032.,James J. Peters Veterans Affairs Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468
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Real World Outcomes of Patients with Bladder Cancer: Effectiveness Versus Efficacy of Modern Treatment Paradigms. Hematol Oncol Clin North Am 2021; 35:597-612. [PMID: 33958153 DOI: 10.1016/j.hoc.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Bladder cancer remains a common and insidious disease in the United States. There have been several advances in the understanding of the biology of bladder cancer, novel diagnostic tools, improvements in multidisciplinary care pathways, and new therapeutics for advanced disease over the past few decades. Clinical trials have demonstrated efficacy for new treatments in each disease state, but additional work is needed to advance the effectiveness of bladder cancer care. Real world data provide critical information regarding patterns of care, adverse events, and outcomes helping to bridge the efficacy versus effectiveness gap.
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Basile G, Pederzoli F, Bandini M, Raggi D, Gallina A, Salonia A, Briganti A, Montorsi F, Spiess PE, Necchi A. Intermediate- and high-risk nonmuscle invasive bladder cancer: Where do we stand? Urol Oncol 2021; 39:631-641. [PMID: 33766463 DOI: 10.1016/j.urolonc.2021.02.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/10/2021] [Accepted: 02/21/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The standard of care for intermediate- and high-risk non-muscle invasive bladder cancer (NMIBC) patients is transurethral resection of bladder tumor followed by intravesical adjuvant immunotherapy with Bacillus Calmette-Guerin (BCG). However, a non-negligible portion of patients is doomed to fail BCG-therapy and, consequently, undergo radical cystectomy as only treatment option available. In this context, effective options to improve tumor response, thus delaying or even avoiding radical cystectomy, are urgently needed. A narrative review of the literature was performed to summarize the rationale and the clinical outcomes regarding the use of immunotherapy and novel therapeutic perspectives both for BCG-treated and BCG-naïve NMIBC patients. RESULTS Several clinical trials are currently investigating immune checkpoint inhibitors and novel targeted approaches, including cancer vaccines, for NMIBC patients with BCG-naïve and BCG-unresponsive disease. Despite the lack of long-term safety data, novel therapeutic options, both by systemic and intravesical delivery, demonstrated a good tolerability, antitumor efficacy, and low rates of recurrence and/or progression to muscle-invasive disease. CONCLUSIONS Although clinical data available are mostly limited to phase I/II trials, novel targeted therapies have raised as an effective and reliable approach for patients failing BCG and for those who are therapy naïve. Phase III trials will be crucial in order to change the current clinical practice, after many years in which BCG was the only therapy available for intermediate- and high-risk NMIBC patients.
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Affiliation(s)
- Giuseppe Basile
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy.
| | - Filippo Pederzoli
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Bandini
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Daniele Raggi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Andrea Gallina
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Salonia
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Urological Research Institute (URI), Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Andrea Necchi
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
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Williams SB, Howard LE, Foster ML, Klaassen Z, Sieluk J, De Hoedt AM, Freedland SJ. Estimated Costs and Long-term Outcomes of Patients With High-Risk Non-Muscle-Invasive Bladder Cancer Treated With Bacillus Calmette-Guérin in the Veterans Affairs Health System. JAMA Netw Open 2021; 4:e213800. [PMID: 33787908 PMCID: PMC8013821 DOI: 10.1001/jamanetworkopen.2021.3800] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Management of high-risk non-muscle-invasive bladder cancer (NMIBC) represents a clinical challenge due to high failure rates despite prior bacillus Calmette-Guérin (BCG) therapy. OBJECTIVE To describe real-world patient characteristics, long-term outcomes, and the economic burden in a population with high-risk NMIBC treated with BCG therapy. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study identified 412 patients with high-risk NMIBC from 63 139 patients diagnosed with bladder cancer who received at least 1 dose of BCG within Department of Veterans Affairs (VA) centers across the US from January 1, 2000, to December 31, 2015. Adequate induction BCG therapy was defined as at least 5 installations, and adequate maintenance BCG therapy was defined as at least 7 installations. Data were analyzed from January 2, 2020, to January 20, 2021. EXPOSURES Intravesical BCG therapy, including adequate induction BCG therapy, was defined as at least 5 intravesical instillations of BCG within 70 days from BCG therapy start date. Adequate maintenance BCG therapy was defined as at least 7 installations of BCG within 274 days of the start (the first instillation) of adequate induction BCG therapy (ie, adequate induction BCG plus some form of additional BCG). MAIN OUTCOMES AND MEASURES The Kaplan-Meier method was used to estimate outcomes, including event-free survival. All-cause expenditures were summarized as medians with corresponding interquartile ranges (IQRs) and adjusted to 2019 USD. RESULTS Of the 412 patients who met inclusion criteria, 335 (81%) were male and 77 (19%) were female, with a median age of 67 (IQR, 61-74) years. Follow-up was 2694 person-years. A total of 392 patients (95%) received adequate induction BCG therapy, and 152 (37%) received adequate BCG therapy. For all patients with high-risk NMIBC, the 10-year progression-free survival rate and disease-specific death rate were 78% and 92%, respectively. Patients with carcinoma in situ (Cis) had worse disease-free survival than those without Cis (hazard ratio [HR], 1.85; 95% CI, 1.34-2.56). Total median costs at 1 year were $29 459 (IQR, $14 991-$52 060); at 2 years, $55 267 (IQR, $28 667-$99 846); and at 5 years, $117 361 (IQR, $59 680-$211 298). Patients with progressive disease had significantly higher median 5-year costs ($232 729 [IQR, $151 321-$341 195] vs $94 879 [IQR, $52 498-$172 631]; P < .001), with outpatient care, pharmacy, and surgery-related costs contributing. CONCLUSIONS AND RELEVANCE Despite adequate induction BCG therapy, only 37% of patients received adequate BCG therapy. Patients with Cis had increased risk of progression, and progression regardless of Cis was associated with significantly increased costs relative to patients without progression. Extrapolating cost figures, regardless of progression, resulted in nationwide costs at 1 year of $373 million for patients diagnosed with high-risk NMIBC in 2019.
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Affiliation(s)
- Stephen B. Williams
- Division of Urology, Department of Surgery, University of Texas Medical Branch, Galveston
| | - Lauren E. Howard
- Durham Veterans Affairs Health Care System, Durham, North Carolina
- Biostatistics Shared Resource, Duke Cancer Institute, Durham, North Carolina
| | - Meagan L. Foster
- Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Zachary Klaassen
- Section of Urology, Department of Surgery, Augusta University, Medical College of Georgia, Augusta
| | | | | | - Stephen J. Freedland
- Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, California
- Center for Integrated Research on Cancer and Lifestyle, Cedars-Sinai Medical Center, Los Angeles, California
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Jeglinschi S, Schirmann A, Durand M, Sanchez S, Larré S, Léon P. Factors affecting guideline adherence in the initial treatment of non-muscle invasive bladder cancer: Retrospective study in a French peripheral hospital. Prog Urol 2019; 30:26-34. [PMID: 31813714 DOI: 10.1016/j.purol.2019.11.003] [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] [Revised: 09/10/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To assess whether the initial treatment of non-muscle invasive bladder cancer (NMIBC) was performed according to the guidelines, and to determine the reasons why initial treatment was not provided in nonadherence cases. MATERIALS AND METHODS We retrospectively reviewed all patients with NMIBC who underwent their first transurethral resection of bladder tumor (TURBT) at a peripheral hospital, between 2007 and 2016. The treatment offered to the patient was compared to the European Association of Urology guidelines according to risk stratification. For each patient who did not receive the treatment according to the guidelines, one of the following reasons was identified: poor patient compliance, poor patient general health status, urologist's decision, lack of resources. RESULTS One hundred fifty-nine patients were included with a mean age of 72.2 years at the time of NMIBC diagnosis. The low-risk patients were strictly treated according to the guidelines. Among the intermediate-risk patients, 14% received mitomycin C. Among the high-risk patients, 39% received intravesical Bacillus Calmette-Guerin. In the nonadherence cases (61%), the reasons were related to the patient in 44% of cases (poor compliance, 21%; poor patient general health status, 23%), urologist's decision in 54% of cases, and lack of resources in 2% of cases. Thirty-seven percent of the high-risk patients underwent re-resection. CONCLUSIONS Overall, adherence to NMIBC guidelines was low in all treatment types (intravesical therapy, re-resection, or cystectomy for very high-risk patients), but this finding was similar to that in previous studies. Reasons were mainly related to the urologist's decision or to the patient condition (poor compliance or poor general health status). LEVEL OF EVIDENCE 3.
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Affiliation(s)
- S Jeglinschi
- Service d'urologie, CHU Nice, 06000 Nice, France; Service d'urologie, CHU Reims, 51100 Reims, France.
| | - A Schirmann
- Service d'urologie, CHU Reims, 51100 Reims, France
| | - M Durand
- Service d'urologie, CHU Nice, 06000 Nice, France
| | - S Sanchez
- Départment d'information médicale, centre hospitalier, 10000 Troyes, France
| | - S Larré
- Service d'urologie, CHU Reims, 51100 Reims, France
| | - P Léon
- Service d'urologie, CHU Reims, 51100 Reims, France; Service d'urologie, clinique Pasteur, 17200 Royan, France
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Golla V, Lenis AT, Faiena I, Chamie K. Intravesical Therapy for Non-muscle Invasive Bladder Cancer-Current and Future Options in the Age of Bacillus Calmette-Guerin Shortage. Rev Urol 2019; 21:145-153. [PMID: 32071562 PMCID: PMC7020281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Non-muscle invasive bladder cancer (NMIBC) is a common and burdensome malignancy. A substantial proportion of patients with intermediate- and high-risk disease will progress to invasive bladder cancer and are at a significant risk for metastasis and death. Bacillus Calmette-Guerin (BCG) therapy for selected cases has been the standard of care for nearly 40 years. Unfortunately, a world-wide shortage has made BCG challenging to obtain. Furthermore, recurrences and progressions do occur. With the US Food and Drug Administration creating a clear path to drug approval for novel treatments, many therapies have been tested, including intravesical cytotoxic chemotherapy, intravesical immunotherapy, systemic immunotherapy, and novel agents, such as gene therapy and targeted therapy. In this review, we highlight ongoing clinical trials.
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Affiliation(s)
- Vishnukamal Golla
- Department of Urology, The David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Andrew T Lenis
- Department of Urology, The David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Izak Faiena
- Department of Urology, The David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Karim Chamie
- Department of Urology, The David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
- Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA
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Ristau BT, Smaldone MC. Performance Measurement and Quality Improvement Initiatives for Bladder Cancer Care. Curr Urol Rep 2018; 19:100. [PMID: 30357590 DOI: 10.1007/s11934-018-0856-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Bladder cancer care is costly due to long surveillance periods for non-muscle-invasive bladder cancer (NMIBC) and comorbidities associated with the surgical treatment of muscle-invasive bladder cancer (MIBC). We reviewed current evidence-based practices and propose quality metrics for NMIBC and MIBC. RECENT FINDINGS For patients with NMIBC, we propose four categories of candidate quality metrics: (1) appropriate use of imaging, (2) re-staging transurethral resection of bladder tumor, (3) perioperative intravesical chemotherapy, and (4) induction and maintenance BCG in high-risk NMIBC. For patients with MIBC, we propose eight candidate quality measures: (1) neoadjuvant chemotherapy, (2) multidisciplinary consultation, (3) urinary diversion teaching, (4) appropriate perioperative antibiotics, (5) venous thromboembolic prophylaxis, (6) lymphadenectomy, (7) monitoring of complications, and (8) inclusion of enhanced recovery after surgery protocols. Marked variation in evidence-based practice exists among patients with bladder cancer and represents opportunity for quality improvement. Regional and national physician-led collaboratives may be the best vehicle to achieve quality improvement in bladder cancer.
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Affiliation(s)
- Benjamin T Ristau
- Urologic Oncology, Division of Urology, UConn Health, 263 Farmington Avenue, MC-8036, Farmington, CT, 06030, USA.
| | - Marc C Smaldone
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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11
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Gore JL, Wright JL. Can We Prevent Bladder Cancer Recurrences? Eur Urol 2018; 75:602-603. [PMID: 30337058 DOI: 10.1016/j.eururo.2018.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/01/2018] [Indexed: 02/02/2023]
Affiliation(s)
- John L Gore
- Department of Urology, University of Washington, Seattle, WA, USA.
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Patient Compliance With Maintenance Intravesical Therapy for Nonmuscle Invasive Bladder Cancer. Urology 2018; 118:107-113. [DOI: 10.1016/j.urology.2018.04.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 03/29/2018] [Accepted: 04/02/2018] [Indexed: 11/17/2022]
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13
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Lotan Y. Editorial Comment. Urology 2018; 118:111-112. [DOI: 10.1016/j.urology.2018.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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