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Brookman-May SD, Kamat AM, May M. Re: Achieving Benchmarks for National Quality Indicators Reduces Recurrence and Progression in Non-muscle-invasive Bladder Cancer. Eur Urol 2024:S0302-2838(24)02553-3. [PMID: 39164169 DOI: 10.1016/j.eururo.2024.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 08/08/2024] [Indexed: 08/22/2024]
Affiliation(s)
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthias May
- Department of Urology, St. Elisabeth Hospital Straubing, Brothers of Mercy Hospital, Straubing, Germany
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Sankin A, Dave P, Cherrill LR, Boucher RH, Zeegers MP, Cheng KK, James ND, Agalliu I, Bryan RT. Low-grade Urothelial Carcinoma Recurs at a Tempo that Naturally Accelerates Over Time. Urology 2024:S0090-4295(24)00572-7. [PMID: 39029806 DOI: 10.1016/j.urology.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/04/2024] [Accepted: 07/09/2024] [Indexed: 07/21/2024]
Abstract
OBJECTIVE To investigate the cadence of recurrence in patients with low grade intermediate-risk non-muscle invasive bladder cancer (LG IR-NMIBC) based on clinical determinants. We aim to describe patterns in rates of recurrence to better inform surveillance regimens for this chronic, burdensome, and costly disease. METHODS Using baseline and follow-up data from participants in the West Midlands' (United Kingdom, UK) Bladder Cancer Prognosis Programme (BCPP), we assessed overall recurrence rate and recurrence-free intervals throughout the follow-up period for IR-NMIBC participants. Recurrence-free intervals were calculated using the Kaplan-Meier method. RESULTS We identified 379 patients with G1/G2 pTa tumors classified as intermediate risk. Median age was 70 and 284/379 (75%) were male. The median follow-up time was 4.2 years (95% CI: 3.9-4.8). After 5 years of follow-up, 53% of patients had at least one recurrence. One-year recurrence-free survival (RFS) was 75% and 4-year RFS was 50%. The median time to or between 1st, 2nd, 3rd, 4th, and 5th sequential recurrences was 49, 19, 12, 14, and 10 months, respectively. CONCLUSION Over half of patients with IR-NMIBC are destined to recur. Our data suggest that a subset of patients experience acceleration of recurrence over time and that this acceleration may serve as a potential kinetic biomarker for these individuals that could inform surveillance intervals and future treatment strategies.
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Affiliation(s)
- Alex Sankin
- Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY.
| | - Priya Dave
- Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - Louise-Rae Cherrill
- Cancer Research United Kingdom Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, England, UK
| | - Rebecca H Boucher
- Cancer Research United Kingdom Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, England, UK
| | - Maurice P Zeegers
- Maastricht University, Schools of NUTRIM and CAPHRI, Department of Epidemiology, Maastricht, the Netherlands
| | - K K Cheng
- Institute of Applied Health Research, University of Birmingham, Birmingham, England, UK
| | | | - Ilir Agalliu
- Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Richard T Bryan
- Bladder Cancer Research Centre, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, England, UK
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Oedorf K, Haug ES, Liedberg F, Järvinen R, Gudjonsson S, Boström PJ, Jerlström T, Gudbrandsdottir G, Jensen JB, Lam GW. Perioperative management of upper tract urothelial carcinoma in the Nordic countries. BMC Urol 2024; 24:132. [PMID: 38914985 PMCID: PMC11197368 DOI: 10.1186/s12894-024-01515-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 06/10/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Upper tract urothelial carcinoma (UTUC) is a rare malignancy, with typically only few new cases annually per urological department. Adherence to European association of urology (EAU) guidelines on UTUC in the Nordic countries is unknown. The objective of this survey was to examine the implementation of EAU guidelines, the perioperative management and organization of the treatment of UTUC in the Nordic countries. METHODS The electronic survey was distributed to 93 hospitals in the Nordic countries performing radical nephroureterectomy (NU). The survey consisted of 57 main questions and data was collected between December 1st, 2021 and April 23rd, 2022. RESULTS Overall response rate was 47/93 (67%) with a completion rate of 98%. Five out of the 6 examined subjects on diagnostic practice are applied by ≥ 72% of the participating centers. NU as treatment for high-risk UTUC is performed by 37/47 (79%), and 91% include a bladder cuff excision. CONCLUSIONS Adherence to EAU guidelines is high on diagnostic practice in the Nordic countries, whereas disease management is less coherent.
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Affiliation(s)
- Kimie Oedorf
- Department of Urology, Herlev and Gentofte Hospital, Copenhagen, Denmark.
| | | | - Fredrik Liedberg
- Department of Urology, Skaanes Universitetssjukhus, Malmö, Sweden
| | - Riikka Järvinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sigurdur Gudjonsson
- Faculty of Medicine, Department of Urology, University of Iceland, Landspitali University Hospital, Reykjavik, Iceland
| | - Peter J Boström
- Department of Urology, Turku University Hospital, University of Turku, Turku, Finland
| | - Tomas Jerlström
- Department of Urology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | | | - Gitte Wrist Lam
- Department of Urology, Herlev and Gentofte Hospital, Copenhagen, Denmark
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Heer R, Tan WS, Gravestock P, Vadiveloo T, Lewis R, Penegar S, Vale L, MacLennan G, Hall E. Reply to Arnulf Stenzl, Morgan Rouprêt, J. Alfred Witjes, Paolo Gontero. High-quality Transurethral Resection of Bladder Tumour Needs Additional Forms of Tumour Delineation. Eur Urol 2023;83:193-4. Eur Urol 2024; 85:309-312. [PMID: 37330372 DOI: 10.1016/j.eururo.2023.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 05/30/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Rakesh Heer
- Division of Surgery, Imperial College London, London, UK.
| | | | - Paul Gravestock
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Thenmalar Vadiveloo
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | | | | | - Luke Vale
- Newcastle University, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Emma Hall
- The Institute of Cancer Research, London, UK
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Kikuchi E, Ng CF, Kitamura H, Ku JH, Lee LS, Lin TP, Ng JYS, Nishiyama H, Poon DMC, Kanesvaran R, Seo HK, Spiteri C, Tan EM, Tsai YS, Tran B. Controversies in terminology associated with management of BCG-unresponsive NMIBC in Asia-Pacific. Int J Urol 2024; 31:32-38. [PMID: 37795933 DOI: 10.1111/iju.15298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/06/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES Examine the understanding of terminologies and management patterns of bacillus Calmette-Guérin (BCG)-unresponsive nonmuscle invasive bladder cancer (NMIBC) in six territories in Asia-Pacific. METHODS This study involved two phases: (1) a survey with 32 urologists and 7 medical oncologists (MOs) and (2) a factorial experiment and in-depth interviews with 23 urologists and 2 MOs. All clinicians had ≥8 years' experience managing NMIBC patients in Australia, Hong Kong, Japan, South Korea, Singapore, and Taiwan. Data from Phase 1 were summarized using descriptive statistics; content and thematic analyses applied in Phase 2. RESULTS In phase 1, 35% of clinicians defined BCG-unresponsive as BCG-refractory, -relapse and -resistant, 6% defined it as BCG-refractory and -relapse; 22% classified BCG-failure as BCG-refractory, -relapse, -resistant, and when muscle-invasive bladder cancer is detected. If eligible and willing, 50% (interquartile range [IQR], 50%-80%) of BCG-unresponsive patients would undergo radical cystectomy (RC), and 50% (IQR 20%-50%) of RC-eligible patients would receive bladder-sparing treatment or surveillance. In phase 2, we found that 32%, 88%, and 48% of clinicians, respectively, used "BCG-unresponsive," "BCG-refractory," and "BCG-relapse" in clinical practice but with no consistent interpretation of the terms. Compared with EAU definitions, 8%-60% of clinicians appropriately classified 9 tumor types that are persistent or recurrent after adequate BCG. Fifty percent of clinicians mentioned a lack of bladder-preserving treatment that outperforms RC in quality of life as a reason to retreat BCG-unresponsive patients with BCG. CONCLUSIONS Our study revealed varied understanding and application of BCG-unresponsive terminologies in practice. There is a need for a uniform and simple definition of BCG-unresponsive disease in Asia-Pacific.
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Affiliation(s)
- Eiji Kikuchi
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Chi-Fai Ng
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | - Ja Hyeon Ku
- Department of Urology, Seoul National University, Seoul, South Korea
| | - Lui Shiong Lee
- Department of Urology, Seng Kang General Hospital, Singapore, Singapore
| | - Tzu-Ping Lin
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Junice Yi Siu Ng
- Health Economics and Outcomes Research, IQVIA Asia-Pacific, Singapore, Singapore
| | | | - Darren Ming-Chun Poon
- Comprehensive Oncology Center, Hong Kong Sanatorium & Hospital, Hong Kong, Hong Kong
| | - Ravindran Kanesvaran
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Ho Kyung Seo
- Department of Urology, National Cancer Center, Goyang-si, South Korea
| | - Carmel Spiteri
- Market Access Asia Pacific, MSD Macquarie Park, NSW, Macquarie Park, Australia
| | - Ee Min Tan
- Health Economics and Outcomes Research, IQVIA Asia-Pacific, Singapore, Singapore
| | - Yuh-Shyan Tsai
- Department of Urology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ben Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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Ku JH, Lee LS, Lin TP, Kikuchi E, Kitamura H, Ng CF, Ng JYS, Poon DMC, Kanesvaran R, Seo HK, Spiteri C, Tan EM, Tran B, Tsai YS, Nishiyama H. Risk stratification and management of non-muscle-invasive bladder cancer: A physician survey in six Asia-Pacific territories. Int J Urol 2024; 31:64-71. [PMID: 37800879 DOI: 10.1111/iju.15309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/13/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVES Multiple clinical practice guidelines, conflicting evidence, and physician perceptions result in variations in risk stratification among patients with non-muscle-invasive bladder cancer (NMIBC). This study aims to describe the extent of this variation and its impact on management approaches in the Asia-Pacific region. METHODS We conducted a cross-sectional survey involving 32 urologists and seven medical oncologists with ≥8 years of experience managing early-stage bladder cancer patients across Australia, Hong Kong, Japan, South Korea, Singapore, and Taiwan. The physicians completed an anonymous questionnaire that assessed their risk stratification and respective management approaches, based on 19 NMIBC characteristics. For each NMIBC characteristic, they were required to select one risk group, and their most preferred management approach. RESULTS Our results demonstrated a higher consensus on risk classification versus management approaches. More than 50% of the respondents agreed on the risk classification of all NMIBC characteristics, but 42% or fewer chose the same treatment option as their preferred choice for all but two characteristics-existence of variant histology (55%) and persistent high-grade T1 disease on repeat resection (52%). Across territories, there was the greatest variation in preferred treatment options (i.e., no treatment, intravesical chemotherapy, or Bacillus Calmette-Guérin [BCG] treatment) for intermediate-risk patients and the highest consensus on the treatment of very high-risk patients, namely radical cystectomy. CONCLUSIONS Our study revealed considerable variation in risk stratification and management of NMIBC in the region. It is critical to develop practical algorithms to facilitate the recognition of NMIBC and standardize the treatment of NMIBC patients.
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Affiliation(s)
- Ja Hyeon Ku
- Seoul National University, Seoul, South Korea
| | | | - Tzu-Ping Lin
- Taipei Veterans General Hospital, Taipei, Taiwan
| | - Eiji Kikuchi
- St Marianna University School of Medicine, Kawasaki, Japan
| | | | - Chi-Fai Ng
- The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | | | | | | | | | - Ee Min Tan
- IQVIA Asia-Pacific, Singapore, Singapore
| | - Ben Tran
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Levy JJ, Chan N, Marotti JD, Rodrigues NJ, Ismail AAO, Kerr DA, Gutmann EJ, Glass RE, Dodge CP, Suriawinata AA, Christensen B, Liu X, Vaickus LJ. Examining longitudinal markers of bladder cancer recurrence through a semiautonomous machine learning system for quantifying specimen atypia from urine cytology. Cancer Cytopathol 2023; 131:561-573. [PMID: 37358142 PMCID: PMC10527805 DOI: 10.1002/cncy.22725] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/31/2023] [Accepted: 04/20/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Urine cytology is generally considered the primary approach for screening for recurrence of bladder cancer. However, it is currently unclear how best to use cytological examinations for assessment and early detection of recurrence, beyond identifying a positive finding that requires more invasive methods to confirm recurrence and decide on therapeutic options. Because screening programs are frequent, and can be burdensome, finding quantitative means to reduce this burden for patients, cytopathologists, and urologists is an important endeavor and can improve both the efficiency and reliability of findings. Additionally, identifying ways to risk-stratify patients is crucial for improving quality of life while reducing the risk of future recurrence or progression of the cancer. METHODS In this study, a computational machine learning tool, AutoParis-X, was leveraged to extract imaging features from urine cytology examinations longitudinally to study the predictive potential of urine cytology for assessing recurrence risk. This study examined how the significance of imaging predictors changes over time before and after surgery to determine which predictors and time periods are most relevant for assessing recurrence risk. RESULTS Results indicate that imaging predictors extracted using AutoParis-X can predict recurrence as well or better than traditional cytological/histological assessments alone and that the predictiveness of these features is variable across time, with key differences in overall specimen atypia identified immediately before tumor recurrence. CONCLUSIONS Further research will clarify how computational methods can be effectively used in high-volume screening programs to improve recurrence detection and complement traditional modes of assessment.
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Affiliation(s)
- Joshua J. Levy
- Emerging Diagnostic and Investigative Technologies, Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766
- Department of Dermatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766
- Department of Epidemiology, Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
- Program in Quantitative Biomedical Sciences, Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
| | - Natt Chan
- Program in Quantitative Biomedical Sciences, Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
| | - Jonathan D. Marotti
- Emerging Diagnostic and Investigative Technologies, Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766
- Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
| | - Nathalie J. Rodrigues
- Emerging Diagnostic and Investigative Technologies, Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766
| | - A. Aziz O. Ismail
- Emerging Diagnostic and Investigative Technologies, Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766
- White River Junction VA Medical Center, White River Junction, VT, 05009
| | - Darcy A. Kerr
- Emerging Diagnostic and Investigative Technologies, Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766
- Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
| | - Edward J. Gutmann
- Emerging Diagnostic and Investigative Technologies, Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766
- Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
| | | | | | - Arief A. Suriawinata
- Emerging Diagnostic and Investigative Technologies, Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766
- Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
| | - Brock Christensen
- Department of Epidemiology, Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
- Department of Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
- Department of Community and Family Medicine, Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
| | - Xiaoying Liu
- Emerging Diagnostic and Investigative Technologies, Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766
- Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
| | - Louis J. Vaickus
- Emerging Diagnostic and Investigative Technologies, Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03766
- Dartmouth College Geisel School of Medicine, Hanover, NH, 03756
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Gallagher K, Bhatt N, Clement K, Zimmermann E, Khadhouri S, MacLennan S, Kulkarni M, Gaba F, Anbarasan T, Asif A, Light A, Ng A, Chan V, Nathan A, Cooper D, Aucott L, Marcq G, Teoh JYC, Hensley P, Duncan E, Goulao B, O'Brien T, Nielsen M, Mariappan P, Kasivisvanathan V. Audit, Feedback, and Education to Improve Quality and Outcomes in Transurethral Resection and Single-Instillation Intravesical Chemotherapy for Nonmuscle Invasive Bladder Cancer Treatment: Protocol for a Multicenter International Observational Study With an Embedded Cluster Randomized Trial. JMIR Res Protoc 2023; 12:e42254. [PMID: 37318875 DOI: 10.2196/42254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Nonmuscle invasive bladder cancer (NMIBC) accounts for 75% of bladder cancers. It is common and costly. Cost and detriment to patient outcomes and quality of life are driven by high recurrence rates and the need for regular invasive surveillance and repeat treatments. There is evidence that the quality of the initial surgical procedure (transurethral resection of bladder tumor [TURBT]) and administration of postoperative bladder chemotherapy significantly reduce cancer recurrence rates and improve outcomes (cancer progression and mortality). There is surgeon-reported evidence that TURBT practice varies significantly across surgeons and sites. There is limited evidence from clinical trials of intravesical chemotherapy that NMIBC recurrence rate varies significantly between sites and that this cannot be accounted for by differences in patient, tumor, or adjuvant treatment factors, suggesting that how the surgery is performed may be a reason for the variation. OBJECTIVE This study primarily aims to determine if feedback on and education about surgical quality indicators can improve performance and secondarily if this can reduce cancer recurrence rates. Planned secondary analyses aim to determine what surgeon, operative, perioperative, institutional, and patient factors are associated with better achievement of TURBT quality indicators and NMIBC recurrence rates. METHODS This is an observational, international, multicenter study with an embedded cluster randomized trial of audit, feedback, and education. Sites will be included if they perform TURBT for NMIBC. The study has four phases: (1) site registration and usual practice survey; (2) retrospective audit; (3) randomization to audit, feedback, and education intervention or to no intervention; and (4) prospective audit. Local and national ethical and institutional approvals or exemptions will be obtained at each participating site. RESULTS The study has 4 coprimary outcomes, which are 4 evidence-based TURBT quality indicators: a surgical performance factor (detrusor muscle resection); an adjuvant treatment factor (intravesical chemotherapy administration); and 2 documentation factors (resection completeness and tumor features). A key secondary outcome is the early cancer recurrence rate. The intervention is a web-based surgical performance feedback dashboard with educational and practical resources for TURBT quality improvement. It will include anonymous site and surgeon-level peer comparison, a performance summary, and targets. The coprimary outcomes will be analyzed at the site level while recurrence rate will be analyzed at the patient level. The study was funded in October 2020 and began data collection in April 2021. As of January 2023, there were 220 hospitals participating and over 15,000 patient records. Projected data collection end date is June 30, 2023. CONCLUSIONS This study aims to use a distributed collaborative model to deliver a site-level web-based performance feedback intervention to improve the quality of endoscopic bladder cancer surgery. The study is funded and projects to complete data collection in June 2023. TRIAL REGISTRATION ClinicalTrials.org NCT05154084; https://clinicaltrials.gov/ct2/show/NCT05154084. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/42254.
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Affiliation(s)
- Kevin Gallagher
- Department of Urology, Western General Hospital Edinburgh, Edinburgh, United Kingdom
- British Urology Researchers in Surgical Training, London, United Kingdom
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Nikita Bhatt
- British Urology Researchers in Surgical Training, London, United Kingdom
- Department of Urology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Keiran Clement
- British Urology Researchers in Surgical Training, London, United Kingdom
- Department of Urology, National Health Service Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Eleanor Zimmermann
- British Urology Researchers in Surgical Training, London, United Kingdom
- Department of Urology, University Hospitals Plymouth, Plymouth, United Kingdom
| | - Sinan Khadhouri
- British Urology Researchers in Surgical Training, London, United Kingdom
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Steven MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Meghana Kulkarni
- British Urology Researchers in Surgical Training, London, United Kingdom
- Department of Urology, St. George's University Hospital London, London, United Kingdom
| | - Fortis Gaba
- British Urology Researchers in Surgical Training, London, United Kingdom
- Harvard Business School, Harvard University, Boston, MA, United States
| | - Thineskrishna Anbarasan
- British Urology Researchers in Surgical Training, London, United Kingdom
- Oxford University Hospitals, Oxford, United Kingdom
| | - Aqua Asif
- British Urology Researchers in Surgical Training, London, United Kingdom
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Alexander Light
- British Urology Researchers in Surgical Training, London, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Alexander Ng
- British Urology Researchers in Surgical Training, London, United Kingdom
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Vinson Chan
- British Urology Researchers in Surgical Training, London, United Kingdom
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Arjun Nathan
- British Urology Researchers in Surgical Training, London, United Kingdom
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Gautier Marcq
- Urology Department, Claude Huriez Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
- Cancer Heterogeneity Plasticity and Resistance to Therapies, Institute Pasteur de Lille, University of Lille, Lille, France
| | - Jeremy Yuen-Chun Teoh
- S H Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Patrick Hensley
- Department of Urology, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Eilidh Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Tim O'Brien
- Department of Urology, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Matthew Nielsen
- Department of Urology, University of North Carolina Medical School, Chapel Hill, NC, United States
| | - Paramananthan Mariappan
- Edinburgh Bladder Cancer Surgery, Department of Urology, Western General Hospital Edinburgh, Edinburgh, United Kingdom
| | - Veeru Kasivisvanathan
- British Urology Researchers in Surgical Training, London, United Kingdom
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
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Seiler R, Egger M, De Menna M, Wehrli S, Minoli M, Radić M, Lyatoshinsky P, Hösli R, Blarer J, Abt D, Kruithof-de Julio M. Guidance of adjuvant instillation in intermediate-risk non-muscle invasive bladder cancer by drug screens in patient derived organoids: a single center, open-label, phase II trial. BMC Urol 2023; 23:89. [PMID: 37170307 PMCID: PMC10176900 DOI: 10.1186/s12894-023-01262-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND In intermediate-risk non-muscle invasive bladder cancer (NMIBC) clinical guidelines suggest an adjuvant instillation with a chemotherapeutic agent. However, the agent and regimen are not clearly defined. Worldwide, less than 15% of patients receive this adjuvant chemotherapeutic instillation. We recently developed a pipeline for the generation of patient derived organoids (PDO) in NMIBC. In this phase II trial, we aim to use our in vitro pipeline to select the most effective drug for chemotherapeutic instillation in NMIBC patients. METHODS Patients with first diagnosis of intermediate-risk NMIBC that are directed to transurethral resection of bladder tumor (TURBT) are enrolled. During TURBT, tumor is sampled, and specimens are directed to generate PDO. Once the PDO are formed, drug screens on them for Epirubicin, Mitomycin C, Gemcitabine and Docetaxel are performed. The drug with the highest antitumor activity in vitro will then be selected for 6 adjuvant intravesical instillations once weekly. Thereafter, patients are followed according to clinical guidelines by cystoscopy. DISCUSSION The aim of this trial is to use drug screens in PDO to precise treatment selection for adjuvant instillation therapies in patients with intermediate-risk NMIBC. The ultimate goal of this trial is to reduce the risk of cancer recurrence. In the future, we aim to conduct clinical multicenter trials with an increased sample size, a broader panel of compounds and a focus on the reduction of cancer recurrence by precision delivery of care. Trial registration NCT05024734.
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Affiliation(s)
- Roland Seiler
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland.
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, Bern, Switzerland.
| | - Martin Egger
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland
| | - Marta De Menna
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, Bern, Switzerland
| | - Saskia Wehrli
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland
| | - Martina Minoli
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, Bern, Switzerland
| | - Martina Radić
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, Bern, Switzerland
| | - Pavel Lyatoshinsky
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland
- Department of Urology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | - Raphael Hösli
- Department of Pharmacy, Hospital Center Biel, Biel, Switzerland
| | - Jennifer Blarer
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland
| | - Dominik Abt
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland
| | - Marianna Kruithof-de Julio
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, Bern, Switzerland
- Department for BioMedical Research, Urology Research Laboratory, University of Bern, 3008, Bern, Switzerland
- Department of Urology, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
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10
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Muilwijk T, Akand M, Raskin Y, Jorissen C, Vander Eeckt K, Van Bruwaene S, Van Cleynenbreugel B, Joniau S, Van Der Aa F. Quality Control Indicators for Transurethral Resection of Bladder Tumor: Results from an Embedded Belgian Multicenter Prospective Registry. Eur Urol Oncol 2022:S2588-9311(22)00202-4. [PMID: 36543720 DOI: 10.1016/j.euo.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 10/26/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Quality control indicators (QCIs) can be used to objectively evaluate guideline adherence and benchmark quality among urologists and centers. OBJECTIVE To assess six QCIs for non-muscle-invasive bladder cancer (NMIBC) using a prospective registry of transurethral resection of bladder tumor (TURBT) procedures. DESIGN, SETTING, AND PARTICIPANTS Clinical data for TURBT cases were prospectively collected using electronic case report forms (eCRFs) embedded in the electronic medical record in three centers during 2013-2017. Pathological data were collected retrospectively. Patients with T0 disease or prior T2 disease were excluded. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We assessed six QCIs: complete resection (CR) status, presence of detrusor muscle (DM), re-TURBT, single instillation of mitomycin C (MMC), start of bacillus Calmette-Guérin (BCG) therapy, and therapy ≤6 wk after diagnosis. We assessed the quality of reporting on QCIs and compliance with QCIs, compared compliance between centers and over time, and investigated correlation between compliance and recurrence-free survival (RFS). RESULTS AND LIMITATIONS Data for 1350 TURBT procedures were collected, of which 1151 were included for 907 unique patients. The distribution of European Association of Urology risk categories after TURBT was 271 with low risk, 464 with intermediate risk, and 416 with high risk. The quality of reporting for two QCIs was suboptimal, at 35% for DM and 51% for BCG. QCI compliance was 97% for CR, 31% for DM, 65% for MMC, 33% for re-TURBT, 39% for BCG, and 88% for therapy ≤6 wk after diagnosis. Compliance with all QCIs differed significantly among centers. Compliance with MMC and re-TURBT increased significantly over time, which could be attributed to one center. Compliance with MMC was significantly correlated with RFS. The main study limitation is the retrospective collection of pathology data. CONCLUSIONS A TURBT registry consisting of eCRFs to collect pathology and outcome data allowed assessment of QCIs for NMIBC. Our study illustrates the feasibility of this approach in a real-life setting. Differences in performance on QCIs among centers can motivate urologists to improve their day-to-day care for patients with NMIBC, and can thus improve clinical outcomes. PATIENT SUMMARY Our study demonstrates that quality control indicators for treatment of bladder cancer not invading the bladder muscle can be evaluated using electronic medical records. We assessed results for 1151 procedures in 907 individual patients to remove bladder tumors between 2013 and 2017 at three centers in Belgium. Compliance with the quality control indicators differed between centers, increased over time, and was correlated with recurrence of disease.
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11
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Heer R, Lewis R, Duncan A, Penegar S, Vadiveloo T, Clark E, Yu G, Mariappan P, Cresswell J, McGrath J, N'Dow J, Nabi G, Mostafid H, Kelly J, Ramsay C, Lazarowicz H, Allan A, Breckons M, Campbell K, Campbell L, Feber A, McDonald A, Norrie J, Orozco-Leal G, Rice S, Tandogdu Z, Taylor E, Wilson L, Vale L, MacLennan G, Hall E. Photodynamic versus white-light-guided resection of first-diagnosis non-muscle-invasive bladder cancer: PHOTO RCT. Health Technol Assess 2022; 26:1-144. [PMID: 36300825 PMCID: PMC9639219 DOI: 10.3310/plpu1526] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Around 7500 people are diagnosed with non-muscle-invasive bladder cancer in the UK annually. Recurrence following transurethral resection of bladder tumour is common, and the intensive monitoring schedule required after initial treatment has associated costs for patients and the NHS. In photodynamic diagnosis, before transurethral resection of bladder tumour, a photosensitiser that is preferentially absorbed by tumour cells is instilled intravesically. Transurethral resection of bladder tumour is then conducted under blue light, causing the photosensitiser to fluoresce. Photodynamic diagnosis-guided transurethral resection of bladder tumour offers better diagnostic accuracy than standard white-light-guided transurethral resection of bladder tumour, potentially reducing the chance of subsequent recurrence. OBJECTIVE The objective was to assess the clinical effectiveness and cost-effectiveness of photodynamic diagnosis-guided transurethral resection of bladder tumour. DESIGN This was a multicentre, pragmatic, open-label, parallel-group, non-masked, superiority randomised controlled trial. Allocation was by remote web-based service, using a 1 : 1 ratio and a minimisation algorithm balanced by centre and sex. SETTING The setting was 22 NHS hospitals. PARTICIPANTS Patients aged ≥ 16 years with a suspected first diagnosis of high-risk non-muscle-invasive bladder cancer, no contraindications to photodynamic diagnosis and written informed consent were eligible. INTERVENTIONS Photodynamic diagnosis-guided transurethral resection of bladder tumour and standard white-light cystoscopy transurethral resection of bladder tumour. MAIN OUTCOME MEASURES The primary clinical outcome measure was the time to recurrence from the date of randomisation to the date of pathologically proven first recurrence (or intercurrent bladder cancer death). The primary health economic outcome was the incremental cost per quality-adjusted life-year gained at 3 years. RESULTS We enrolled 538 participants from 22 UK hospitals between 11 November 2014 and 6 February 2018. Of these, 269 were allocated to photodynamic diagnosis and 269 were allocated to white light. A total of 112 participants were excluded from the analysis because of ineligibility (n = 5), lack of non-muscle-invasive bladder cancer diagnosis following transurethral resection of bladder tumour (n = 89) or early cystectomy (n = 18). In total, 209 photodynamic diagnosis and 217 white-light participants were included in the clinical end-point analysis population. All randomised participants were included in the cost-effectiveness analysis. Over a median follow-up period of 21 months for the photodynamic diagnosis group and 22 months for the white-light group, there were 86 recurrences (3-year recurrence-free survival rate 57.8%, 95% confidence interval 50.7% to 64.2%) in the photodynamic diagnosis group and 84 recurrences (3-year recurrence-free survival rate 61.6%, 95% confidence interval 54.7% to 67.8%) in the white-light group (hazard ratio 0.94, 95% confidence interval 0.69 to 1.28; p = 0.70). Adverse event frequency was low and similar in both groups [12 (5.7%) in the photodynamic diagnosis group vs. 12 (5.5%) in the white-light group]. At 3 years, the total cost was £12,881 for photodynamic diagnosis-guided transurethral resection of bladder tumour and £12,005 for white light. There was no evidence of differences in the use of health services or total cost at 3 years. At 3 years, the quality-adjusted life-years gain was 2.094 in the photodynamic diagnosis transurethral resection of bladder tumour group and 2.087 in the white light group. The probability that photodynamic diagnosis-guided transurethral resection of bladder tumour was cost-effective was never > 30% over the range of society's cost-effectiveness thresholds. LIMITATIONS Fewer patients than anticipated were correctly diagnosed with intermediate- to high-risk non-muscle-invasive bladder cancer before transurethral resection of bladder tumour and the ratio of intermediate- to high-risk non-muscle-invasive bladder cancer was higher than expected, reducing the number of observed recurrences and the statistical power. CONCLUSIONS Photodynamic diagnosis-guided transurethral resection of bladder tumour did not reduce recurrences, nor was it likely to be cost-effective compared with white light at 3 years. Photodynamic diagnosis-guided transurethral resection of bladder tumour is not supported in the management of primary intermediate- to high-risk non-muscle-invasive bladder cancer. FUTURE WORK Further work should include the modelling of appropriate surveillance schedules and exploring predictive and prognostic biomarkers. TRIAL REGISTRATION This trial is registered as ISRCTN84013636. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 40. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rakesh Heer
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Anne Duncan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Steven Penegar
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Thenmalar Vadiveloo
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Emma Clark
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Ge Yu
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | | | - Joanne Cresswell
- Department of Urology, South Tees Hospitals NHS Trust, Middlesbrough, UK
| | - John McGrath
- Department of Urology, Royal Devon and Exeter Hospital NHS Trust, Exeter, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Ghulam Nabi
- School of Medicine, University of Dundee, Dundee, UK
| | - Hugh Mostafid
- Department of Urology, Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, UK
| | - John Kelly
- University College London Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Henry Lazarowicz
- Department of Urology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Angela Allan
- Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Matthew Breckons
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Karen Campbell
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Louise Campbell
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Andy Feber
- University College London Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alison McDonald
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Giovany Orozco-Leal
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Rice
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Zafer Tandogdu
- University College London Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Laura Wilson
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
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12
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Kocsmár I, Kocsmár É, Pajor G, Kulka J, Székely E, Kristiansen G, Schilling O, Nyirády P, Kiss A, Schaff Z, Riesz P, Lotz G. Addition of Chromosome 17 Polysomy and HER2 Amplification Status Improves the Accuracy of Clinicopathological Factor-Based Progression Risk Stratification and Tumor Grading of Non-Muscle-Invasive Bladder Cancer. Cancers (Basel) 2022; 14:cancers14194570. [PMID: 36230493 PMCID: PMC9558547 DOI: 10.3390/cancers14194570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/02/2022] [Accepted: 09/16/2022] [Indexed: 12/24/2022] Open
Abstract
Progression of non-muscle-invasive bladder cancer (NMIBC) to muscle-invasive disease (MIBC) significantly worsens life expectancy. Its risk can be assessed by clinicopathological factors according to international guidelines. However, additional molecular markers are needed to refine and improve the prediction. Therefore, in the present study, we aimed to predict the progression of NMIBCs to MIBC by assessing p53 expression, polysomy of chromosome 17 (Chr17) and HER2 status in the tissue specimens of the tumors of 90 NMIBC patients. Median follow-up was 77 months (range 2−158). Patients with Chr17 polysomy or HER2 gene amplification had a higher rate of disease progression (hazard ratio: 7.44; p < 0.001 and 4.04; p = 0.033, respectively; univariate Cox regression). Multivariable Cox regression models demonstrated that the addition of either Chr17 polysomy or HER2 gene amplification status to the European Association of Urology (EAU) progression risk score increases the c-index (from 0.741/EAU/ to 0.793 and 0.755, respectively), indicating that Chr17 polysomy/HER2 amplification status information improves the accuracy of the EAU risk table in predicting disease progression. HER2/Chr17 in situ hybridization can be used to select non-progressive cases not requiring strict follow-up, by reclassifying non-HER2-amplified, non-polysomic NMIBCs from the high- and very high-risk groups of EAU to the intermediate-risk group.
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Affiliation(s)
- Ildikó Kocsmár
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői Street 93, H-1091 Budapest, Hungary
- Department of Urology, Semmelweis University, Üllői Street 78b, H-1082 Budapest, Hungary
- Correspondence: (I.K.); (G.L.); Tel./Fax: +36-1-450-9500 (I.K.); +36-1-215-6921 (G.L.)
| | - Éva Kocsmár
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői Street 93, H-1091 Budapest, Hungary
| | - Gábor Pajor
- Department of Pathology, Medical School and Clinical Center, University of Pécs, Szigeti Street 12, H-7624 Pécs, Hungary
| | - Janina Kulka
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői Street 93, H-1091 Budapest, Hungary
| | - Eszter Székely
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői Street 93, H-1091 Budapest, Hungary
| | - Glen Kristiansen
- Department of Pathology, University Hospital Bonn, Universitätsklinikum Bonn (AöR), Venusberg-Campus 1 Building 62, 53127 Bonn, Germany
| | - Oliver Schilling
- Institute of Surgical Pathology, Medical Center, University of Freiburg, Breisacher Street 115A, 79106 Freiburg im Breisgau, Germany
| | - Péter Nyirády
- Department of Urology, Semmelweis University, Üllői Street 78b, H-1082 Budapest, Hungary
| | - András Kiss
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői Street 93, H-1091 Budapest, Hungary
| | - Zsuzsa Schaff
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői Street 93, H-1091 Budapest, Hungary
| | - Péter Riesz
- Department of Urology, Semmelweis University, Üllői Street 78b, H-1082 Budapest, Hungary
| | - Gábor Lotz
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Üllői Street 93, H-1091 Budapest, Hungary
- Correspondence: (I.K.); (G.L.); Tel./Fax: +36-1-450-9500 (I.K.); +36-1-215-6921 (G.L.)
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13
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Role of Intravesical BCG as a Therapeutic Vaccine for Treatment of Bladder Carcinoma. IRANIAN BIOMEDICAL JOURNAL 2022; 26:340-9. [PMID: 36369747 PMCID: PMC9763876 DOI: 10.52547/ibj.3676] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bacterial products have attracted much attention as potential antitumor agents, with the ability to provide direct tumoricidal effects, leading to the inhibition of tumor growth. Treatment of superficial bladder cancer with intravesical Bacillus Calmette-Guérin (BCG) has a more reduction potential than surgery in tumor recurrence rate. BCG, the gold standard for nonmuscle invasive bladder cancer, is manufactured from different strains and produced commercially with varied strengths. There are a few countries known as the manufacturer of this strategic biopharmaceutical product, and Iran as a member of the Eastern Mediterranean Region plays a vital role in supplying this vaccine. Studies have failed to uncover the exact mechanism of action of the intravesical; however, evidence points toward an immunogenic mechanism that proficiently modifies a biologic response and provokes the immune cells in order to kill and suppress tumors. Among various underlying mechanisms, BCG bacillus attachment to fibronectin through its fibronectin attachment protein is a pivotal mechanism for BCG tumoricidal activity.
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14
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Beardo P, Pinto R, Ayerra H, Agüera J, Armijos S, Álvarez-Ossorio JL. Optimizing treatment for non muscle-invasive bladder cancer with an app. Actas Urol Esp 2022; 46:230-237. [PMID: 35307306 DOI: 10.1016/j.acuroe.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/11/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To evaluate overall and recurrence-progression rate-adjusted concordance of treatment prescription in non-muscle-invasive bladder cancer (NMIBC) of an app based on the best available scientific evidence and the urologist's opinion. METHODS Development of an app (APPv) specifically designed for the treatment and follow-up of NMIBC and validation of the proposed APPv treatment endpoint by means of a prospective double-blind observational concordance study of related samples in 100 patients with initial or successive histological diagnosis of NMIBC. RESULTS The treatment prescribed by the urologist agrees with that proposed by the APPv in 64% of cases (kappa index 0.55, P < 0.0001). Regarding low risk, the agreement is 77% (kappa 0.55, P = 0.002), 63% (kappa 0.52, P < 0.0001) for intermediate risk, 17% (kappa 0.143, P = 0.014) in high risk and 66% (kappa 0.71, P = 0.01) for very high risk. Of patients receiving adjuvant intravesical treatment according to APPv, 89.1% remain free of recurrence vs. 61.1% of those with disagreement (P = 0.0004), with a RR 0.46 (95%CI: 0.25-0.86) vs. RR 2.4 (95%CI: 1.5-3.8, P = 0.001). In the APPv-urologist agreement group, 100% of patients are free of progression and 88.9% in the disagreement group (P = 0.004) with a RR 1 vs. RR 1.125 (95%CI: 1-1.26, P = 0.004). CONCLUSIONS APPv can improve adherence to treatment recommendations according to clinical practice guidelines and health outcomes at NMIBC.
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Affiliation(s)
- P Beardo
- UGC Urología, Hospital Universitario Puerta del Mar, Cádiz, Spain.
| | - R Pinto
- Servicio de Urología, Hospital Universitario de Álava, Vitoria-Gasteiz, Spain
| | - H Ayerra
- Servicio de Urología, Hospital Universitario de Álava, Vitoria-Gasteiz, Spain
| | - J Agüera
- UGC Urología, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - S Armijos
- e-processmed, Vitoria-Gasteiz, Spain
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15
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Gontero P, Babjuk M. Swedish national guidelines on urothelial cancer echo the EAU guidelines but with some regional dialect. Scand J Urol 2022; 56:147-148. [PMID: 35356870 DOI: 10.1080/21681805.2022.2057585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Paolo Gontero
- Division of Urology, Molinette Hospital, University of Studies of Torino, Torino, Italy
| | - Marko Babjuk
- 2nd Faculty of Medicine, Hospital Motol, Charles University, Praha, Czech Republic
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16
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Optimización del tratamiento del cáncer de vejiga no músculo invasivo mediante una app. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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17
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Wang DQ, Huang Q, Huang X, Jin YH, Wang YY, Shi YX, Yan SY, Yang L, Li BH, Liu TZ, Zeng XT. Knowledge of and Compliance With Guidelines in the Management of Non-Muscle-Invasive Bladder Cancer: A Survey of Chinese Urologists. Front Oncol 2021; 11:735704. [PMID: 34778048 PMCID: PMC8580413 DOI: 10.3389/fonc.2021.735704] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 10/07/2021] [Indexed: 02/05/2023] Open
Abstract
Background Non-muscle-invasive bladder cancer (NMIBC) still poses a heavy load for resulting in many new cases which contribute significantly to medical costs. Although many NMIBC guidelines have been developed, their implementation remains deficient. Objective This study was conducted in order to analyze the knowledge of and compliance with the guidelines for NMIBC of Chinese urologists and to identify associated factors. Methods We conducted an online survey between August 2019 and January 2021. Respondents who were more than 65 years old or did not give informed consent were excluded. Linear/logistic regressions were performed to identify factors associated with the knowledge of and compliance with the guidelines of urologists, respectively. McNemar's tests were used to explore the divergence between knowledge and compliance. Results A total of 814 responses were received, and 98.77% of urologists acknowledged the positive effects of high-quality guidelines. The average knowledge score was 6.10 ± 1.28 (out of a full score of 9), and it was positively associated with educational level and the number of guidelines consulted. Only 1.61% and 39.36% of the respondents realized that the guidelines did not recommend further chemotherapy or BCG infusion for low-risk patients. There were 38.87% and 51.84% respondents "often" or more frequently utilizing BCG therapy for intermediate- and high-risk NMIBC patients, respectively. Divergence between knowledge and compliance in performing a second TURBT after incomplete initial resection reached statistical significance (p < 0.001). Conclusions Although the vast majority of urologists acknowledged the positive effects of guidelines, knowledge of and compliance with some recommendations of NMIBC guidelines are still inadequate. Factors associated with guidelines, individual professionals, patients, organizations, and the environment jointly contributed to the non-compliance.
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Affiliation(s)
- Dan-Qi Wang
- Country Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Qiao Huang
- Country Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xing Huang
- Country Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ying-Hui Jin
- Country Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yun-Yun Wang
- Country Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yue-Xian Shi
- School of Nursing, Peking University, Beijing, China
| | - Si-Yu Yan
- Country Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Lu Yang
- Department of Urology, Institute of Urology, West China Hospital of Sichuan University, Chengdu, China
| | - Bing-Hui Li
- Country Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Tong-Zu Liu
- Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xian-Tao Zeng
- Country Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
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18
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Asimakopoulos AD, Colalillo G, Telesca R, Mauriello A, Miano R, Di Stasi SM, Germani S, Finazzi Agrò E, Petrozza V, Caruso G, Carbone A, Pastore AL, Fuschi A. T1 Bladder Cancer: Comparison of the Prognostic Impact of Two Substaging Systems on Disease Recurrence and Progression and Suggestion of a Novel Nomogram. Front Surg 2021; 8:704902. [PMID: 34497827 PMCID: PMC8419324 DOI: 10.3389/fsurg.2021.704902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The T1 substaging of bladder cancer (BCa) potentially impacts disease progression. The objective of the study was to compare the prognostic accuracy of two substaging systems on the recurrence and progression of primary pathologic T1 (pT1) BCa and to test a nomogram based on pT1 substaging for predicting recurrence-free survival (RFS) and progression-free survival (PFS). Methods: The medical records of 204 patients affected by pT1 BCa were retrospectively reviewed. Substaging was defined according to the depth of lamina propria invasion in T1a-c and the extension of the lamina propria invasion to T1-microinvasive (T1m) or T1-extensive (T1e). Uni- and multivariable Cox regression models evaluated the independent variables correlated with recurrence and progression. The predictive accuracies of the two substaging systems were compared by Harrell's C index. Multivariate Cox regression models for the RFS and PFS were also depicted by a nomogram. Results: The 5-year RFS was 47.5% with a significant difference between T1c and T1a (p = 0.02) and between T1e and T1m (p < 0.001). The 5-year PFS was 75.9% with a significant difference between T1c and T1a (p = 0.011) and between T1e and T1m (p < 0.001). Model T1m-e showed a higher predictive power than T1a-c for predicting RFS and PFS. In the univariate and multivariate model subcategory T1e, the diameter, location, and number of tumors were confirmed as factors influencing recurrence and progression after adjusting for the other variables. The nomogram incorporating the T1m-e model showed a satisfactory agreement between model predictions at 5 years and actual observations. Conclusions: Substaging is significantly associated with RFS and PFS for patients affected by T1 BCa and should be included in innovative prognostic nomograms.
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Affiliation(s)
| | - Gaia Colalillo
- Division of Urology, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Rossana Telesca
- Pathology, Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Alessandro Mauriello
- Pathology, Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Roberto Miano
- Division of Urology, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Savino Mauro Di Stasi
- Division of Urology, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Stefano Germani
- Division of Urology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Enrico Finazzi Agrò
- Division of Urology, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Vincenzo Petrozza
- Pathology, Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Gianluca Caruso
- Pathology, Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Antonio Carbone
- Urology Unit ICOT, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, Latina, Italy
| | - Antonio Luigi Pastore
- Urology Unit ICOT, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, Latina, Italy
| | - Andrea Fuschi
- Urology Unit ICOT, Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University of Rome, Latina, Italy
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19
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Struck JP, Hennig MJP, Hupe MC, Moharam N, Paffenholz P, Nestler T, Frank T, Worst TS, Grabbert M, Pohlmann PF, Dogan S, Hofbauer SL, Kalogirou C, Mattigk A, Brandt MP, Krabbe LM, Reis H, Dressler FF, Kramer MW, Salem J. Discrepancy between German S3 Guideline Recommendations and Daily Urologic Practice in the Management of Nonmuscle Invasive Bladder Cancer: Results of a Binational Survey. Urol Int 2021; 107:35-45. [PMID: 34515257 DOI: 10.1159/000518166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/22/2021] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Guideline recommendations are meant to help minimize morbidity and to improve the care of nonmuscle invasive bladder cancer (NMIBC) patients but studies have suggested an underuse of guideline-recommended care. The aim of this study was to evaluate the level of adherence of German and Austrian urologists to German guideline recommendations. METHODS A survey of 27 items evaluating diagnostic and therapeutic recommendations (15 cases of strong consensus and 6 cases of consensus) for NMIBC was administered among 14 urologic training courses. Survey construction and realization followed the checklist for reporting results of internet e-surveys and was approved by an internal review board. RESULTS Between January 2018 and June 2019, a total of 307 urologists responded to the questionnaire, with a mean response rate of 71%. The data showed a weak role of urine cytology (54%) for initial diagnostics although it is strongly recommended by the guideline. The most frequently used supporting diagnostic tool during transurethral resection of the bladder was hexaminolevulinate (95%). Contrary to the guideline recommendation, 38% of the participants performed a second resection in the case of pTa low-grade NMIBC. Correct monitoring of Bacille Calmette-Guérin (BCG) response with cystoscopy and cytology was performed by only 34% of the urologists. CONCLUSIONS We found a discrepancy between certain guideline recommendations and daily routine practice concerning the use of urine cytology for initial diagnostics, instillation therapy with a low monitoring rate of BCG response, and follow-up care with unnecessary second resection after pTa low-grade NMIBC in particular. Our survey showed a moderate overall adherence rate of 73%. These results demonstrate the need for sharpening awareness of German guideline recommendations by promoting more intense education of urologists to optimize NMIBC care thus decreasing morbidity and mortality rates.
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Affiliation(s)
- Julian P Struck
- Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Martin J P Hennig
- Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Marie C Hupe
- Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Nadim Moharam
- Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Pia Paffenholz
- Department of Urology, Uro-Oncology, Robot Assisted and Reconstructive Urologic Surgery, University Hospital Cologne, Cologne, Germany
| | - Tim Nestler
- Department of Urology, Uro-Oncology, Robot Assisted and Reconstructive Urologic Surgery, University Hospital Cologne, Cologne, Germany
| | - Tanja Frank
- Department of Urology and Pediatric Urology, RoMed Hospital Rosenheim, Rosenheim, Germany
| | - Thomas S Worst
- Department of Urology, University Medical Centre Mannheim, Mannheim, Germany
| | - Markus Grabbert
- Department of Urology, Medical Centre, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Serkan Dogan
- Department of Urology, Heilig Geist Hospital Cologne, Cologne, Germany
| | | | - Charis Kalogirou
- Department of Urology and Pediatric Urology, Julius-Maximilians-University of Würzburg, Würzburg, Germany
| | - Angelika Mattigk
- Department of Urology and Pediatric Urology, University Hospital Ulm, Ulm, Germany
| | | | - Laura-Maria Krabbe
- Department of Urology, The University of Münster Medical Center, Münster, Germany
| | - Henning Reis
- Institute of Pathology, University Hospital Essen, Essen, Germany
| | - Franz F Dressler
- Institute of Pathology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Mario W Kramer
- Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Johannes Salem
- Department of Urology, Clinic LINKS VOM RHEIN, Cologne, Germany
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20
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Russo GI, Sholklapper TN, Cocci A, Broggi G, Caltabiano R, Smith AB, Lotan Y, Morgia G, Kamat AM, Witjes JA, Daneshmand S, Desai MM, Gill IS, Cacciamani GE. Performance of Narrow Band Imaging (NBI) and Photodynamic Diagnosis (PDD) Fluorescence Imaging Compared to White Light Cystoscopy (WLC) in Detecting Non-Muscle Invasive Bladder Cancer: A Systematic Review and Lesion-Level Diagnostic Meta-Analysis. Cancers (Basel) 2021; 13:4378. [PMID: 34503188 PMCID: PMC8431313 DOI: 10.3390/cancers13174378] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
Despite early detection and regular surveillance of non-muscle invasive bladder cancer (NMIBC), recurrence and progression rates remain exceedingly high for this highly prevalent malignancy. Limited visualization of malignant lesions with standard cystoscopy and associated false-negative biopsy rates have been the driving force for investigating alternative and adjunctive technologies for improved cystoscopy. The aim of our systematic review and meta-analysis was to compare the sensitivity, specificity, and oncologic outcomes of photodynamic diagnosis (PDD) fluorescence, narrow band imaging (NBI), and conventional white light cystoscopy (WLC) in detecting NMIBC. Out of 1,087 studies reviewed, 17 prospective non-randomized and randomized controlled trials met inclusion criteria for the study. We demonstrated that tumor resection with either PDD and NBI exhibited lower recurrence rates and greater diagnostic sensitivity compared to WLC alone. NBI demonstrated superior disease sensitivity and specificity as compared to WLC and an overall greater hierarchical summary receiver operative characteristic. Our findings are consistent with emerging guidelines and underscore the value of integrating these enhanced technologies as a part of the standard care for patients with suspected or confirmed NMIBC.
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Affiliation(s)
- Giorgio I. Russo
- Urology Section, Department of Surgery, University of Catania, 95123 Catania, Italy;
| | - Tamir N. Sholklapper
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA; (T.N.S.); (S.D.); (M.M.D.); (I.S.G.)
| | - Andrea Cocci
- Department of Minimally Invasive and Robotic Urologic Surgery and Kidney Transplantation, University of Florence, 50100 Florence, Italy;
| | - Giuseppe Broggi
- Department of Medical and Surgical Sciences and Advanced Technologies, G.F. Ingrassia, Anatomic Pathology, University of Catania, 95123 Catania, Italy; (G.B.); (R.C.)
| | - Rosario Caltabiano
- Department of Medical and Surgical Sciences and Advanced Technologies, G.F. Ingrassia, Anatomic Pathology, University of Catania, 95123 Catania, Italy; (G.B.); (R.C.)
| | - Angela B. Smith
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Giuseppe Morgia
- Urology Section, Department of Surgery, University of Catania, 95123 Catania, Italy;
- Department of Experimental Oncology, Mediterranean Institute of Oncology (IOM), 95029 Catania, Italy
| | - Ashish M. Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Pressler, Unit 1373, Houston, TX 77030, USA;
| | - J. Alfred Witjes
- Department of Urology, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands;
| | - Siamak Daneshmand
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA; (T.N.S.); (S.D.); (M.M.D.); (I.S.G.)
| | - Mihir M. Desai
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA; (T.N.S.); (S.D.); (M.M.D.); (I.S.G.)
| | - Indebir S. Gill
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA; (T.N.S.); (S.D.); (M.M.D.); (I.S.G.)
| | - Giovanni E. Cacciamani
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA; (T.N.S.); (S.D.); (M.M.D.); (I.S.G.)
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21
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Lobo DA, Ginestra P, Ceretti E, Miquel TP, Ciurana J. Cancer Cell Direct Bioprinting: A Focused Review. MICROMACHINES 2021; 12:764. [PMID: 34203530 PMCID: PMC8305105 DOI: 10.3390/mi12070764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 12/24/2022]
Abstract
Three-dimensional printing technologies allow for the fabrication of complex parts with accurate geometry and less production time. When applied to biomedical applications, two different approaches, known as direct or indirect bioprinting, may be performed. The classical way is to print a support structure, the scaffold, and then culture the cells. Due to the low efficiency of this method, direct bioprinting has been proposed, with or without the use of scaffolds. Scaffolds are the most common technology to culture cells, but bioassembly of cells may be an interesting methodology to mimic the native microenvironment, the extracellular matrix, where the cells interact between themselves. The purpose of this review is to give an updated report about the materials, the bioprinting technologies, and the cells used in cancer research for breast, brain, lung, liver, reproductive, gastric, skin, and bladder associated cancers, to help the development of possible treatments to lower the mortality rates, increasing the effectiveness of guided therapies. This work introduces direct bioprinting to be considered as a key factor above the main tissue engineering technologies.
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Affiliation(s)
- David Angelats Lobo
- Department of Mechanical and Industrial Engineering, University of Brescia, V. Branze 38, 25123 Brescia, Italy; (D.A.L.); (E.C.)
- New Therapeutic Targets Laboratory (TargetsLab), Oncology Unit, Department of Medical Sciences, Girona Institute for Biomedical Research, University of Girona, Emili Grahit 77, 17003 Girona, Spain;
| | - Paola Ginestra
- Department of Mechanical and Industrial Engineering, University of Brescia, V. Branze 38, 25123 Brescia, Italy; (D.A.L.); (E.C.)
| | - Elisabetta Ceretti
- Department of Mechanical and Industrial Engineering, University of Brescia, V. Branze 38, 25123 Brescia, Italy; (D.A.L.); (E.C.)
| | - Teresa Puig Miquel
- New Therapeutic Targets Laboratory (TargetsLab), Oncology Unit, Department of Medical Sciences, Girona Institute for Biomedical Research, University of Girona, Emili Grahit 77, 17003 Girona, Spain;
| | - Joaquim Ciurana
- Product, Process and Production Engineering Research Group (GREP), Department of Mechanical Engineering and Industrial Construction, University of Girona, Maria Aurèlia Capmany 61, 17003 Girona, Spain;
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22
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Russell B, Kotecha P, Thurairaja R, Nair R, Malde S, Kumar P, Khan MS. Endoscopic surveillance for bladder cancer: a systematic review of contemporary worldwide practices. Transl Androl Urol 2021; 10:2750-2761. [PMID: 34295760 PMCID: PMC8261410 DOI: 10.21037/tau-20-1363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/25/2021] [Indexed: 11/06/2022] Open
Abstract
Background The aim of this systematic review was to identify the current endoscopic surveillance strategies in use across the world and to determine whether these were sufficient or if any recommendations for changes in the guidelines could be made. This review focused on the cystoscopic follow-up of non-muscle invasive bladder cancer (NMIBC) patients and muscle invasive bladder cancer (MIBC) patients who had undergone bladder sparing treatments. Methods A literature search was carried out on Medline and Embase using OVID gateway according to a pre-defined protocol. Systematic screening of the identified studies was carried out by two authors. Quality assessment was performed using the Joanna Briggs critical appraisal tools. Data was extracted on various aspects including the follow-up regime utilised, patients included, outcomes investigated and a summary of the results. The studies were compared in a narrative nature. Results A total of 2,604 studies were identified from the search strategy, of which 14 were deemed suitable for inclusion following the screening process. The studies identified were from nine countries and were mainly observational or qualitative. There was a huge variation in the follow-up regimes utilised within the studies with no clear consensus as to which regime was the most suitable. However, all studies utilised an initial cystoscopy at three months post-TURBT. No studies were identified which investigated the endoscopic follow-up strategies for MIBC patients who opted for bladder conservation with chemoradiation. Conclusions There is no universally accepted protocol for endoscopic follow-up of patients with NMIBC bladder cancer. Guidance on cystoscopic monitoring of bladder in patients who have undergone chemoradiation for MIBC is also lacking.
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Affiliation(s)
- Beth Russell
- Translational Oncology and Urology Research, King's College London, London, UK
| | - Pinky Kotecha
- Translational Oncology and Urology Research, King's College London, London, UK
| | - Ramesh Thurairaja
- Department of Urology, Guy's and St. Thomas NHS Foundation Trust, London, UK
| | - Rajesh Nair
- Department of Urology, Guy's and St. Thomas NHS Foundation Trust, London, UK
| | - Sachin Malde
- Department of Urology, Guy's and St. Thomas NHS Foundation Trust, London, UK
| | - Pardeep Kumar
- Department of Urology, Royal Marsden NHS Foundation Trust, London, UK
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23
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van Hoogstraten LMC, Witjes JA, Ripping TM, Nooter RI, Kiemeney LA, Aben KKH. Low Risk of Severe Complications After a Single, Post-Operative Instillation of Intravesical Chemotherapy in Patients with TaG1G2 Urothelial Bladder Carcinoma. Bladder Cancer 2021; 7:193-203. [PMID: 38994541 PMCID: PMC11181802 DOI: 10.3233/blc-201515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/07/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND EAU guidelines recommend a single instillation (SI) of intravesical chemotherapy (e.g. Mitomycin C) within 24 hours after transurethral resection of a bladder tumour (TURBT) in patients with low- to intermediate risk non-muscle invasive bladder cancer without (suspected) bladder perforation or bleeding requiring bladder irrigation. However, remarkable variation exists in the use of SI. The risk of severe complications is likely to contribute to this variation, but evidence is limited. OBJECTIVE To investigate the absolute severe complication and mortality risk after SI in low- and intermediate risk bladder cancer. METHODS In this observational, historic cohort study, data on 25,567 patients diagnosed with TaG1G2 urothelial bladder carcinoma (UBC) between 2009 and 2018 who underwent TURBT were collected from the Netherlands Cancer Registry. Data were supplemented with information on cause of death and severe complications after cancer treatment by re-examining the electronic health records and the 14-day complication risk and the 30-day mortality risk were evaluated. RESULTS On average, 55% of patients had a SI after TURBT, varying from 0->80% between hospitals. The 30-day mortality risk was 0.02% and the 14-day risk of severe complications was 1.6%. CONCLUSIONS As the absolute risk of mortality and severe complications is very low, SI after TURBT can be considered a safe treatment in patients with low- to intermediate UBC without contraindications for SI. These results imply that a part of eligible patients is denied effective treatment.
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Affiliation(s)
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Ronald I Nooter
- Department of Urology, Franciscus Gasthuis & Vlietland hospital, Rotterdam, The Netherlands
| | - Lambertus A Kiemeney
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Katja K H Aben
- Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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24
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Kayama E, Shigeta K, Kikuchi E, Ogihara K, Hakozaki K, Iwasawa T, Kamisawa K, Kanai K, Ide H, Hara S, Mizuno R, Oya M. Guideline adherence for radical cystectomy significantly affects survival outcomes in non-muscle-invasive bladder cancer patients. Jpn J Clin Oncol 2021; 51:1303-1312. [PMID: 34009374 DOI: 10.1093/jjco/hyab060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The relationship between guideline adherence for radical cystectomy of non-muscle-invasive bladder cancer and patient prognoses currently remains unclear. We investigated whether guideline adherence at the time of non-muscle-invasive bladder cancer affects the oncological outcomes of bladder cancer patients who underwent radical cystectomy. METHODS Among 267 cTa-4N0-2M0 bladder cancer patients, 70 who underwent radical cystectomy under the non-muscle-invasive bladder cancer or muscle-invasive bladder cancer status that progressed from non-muscle-invasive bladder cancer were identified. Patients who followed the guidelines from initial transurethral resection of bladder tumors to radical cystectomy were defined as the guideline adherent group (n = 52), while those who did not were the guideline non-adherent group (n = 18). RESULTS In the guideline non-adherent group, 8 (44.4%) out of 18 were diagnosed with highest risk non-muscle-invasive bladder cancer for Bacillus Calmette Guérin-naïve patients and 7 (38.9%) had a Bacillus Calmette Guérin unresponsive tumor status. Five-year recurrence-free survival and cancer-specific survival rates for the guideline non-adherent group vs guideline adherent group were 38.9% vs 69.8% (P = 0.018) and 52.7% vs 80.1% (P = 0.006), respectively. A multivariate analysis identified guideline non-adherence as one of independent indicators for disease recurrence (hazard ratio = 2.81, P = 0.008) and cancer-specific death (hazard ratio = 4.04, P = 0.003). In a subgroup analysis of 49 patients with cT1 or less non-muscle-invasive bladder cancer at the time of radical cystectomy, guideline non-adherence remained an independent prognostic factor for cancer-specific survival (hazard ratio = 3.46, P = 0.027). CONCLUSIONS Guideline adherence during the time course of the non-muscle-invasive bladder cancer stage may result in a favorable prognosis of patients who receive radical cystectomy. Even under non-muscle-invasive bladder cancer status, radical cystectomy needs to be performed with adequate timing under guideline recommendations.
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Affiliation(s)
- Emina Kayama
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Keisuke Shigeta
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Eiji Kikuchi
- Department of Urology, Keio University School of Medicine, Tokyo, Japan.,Department of Urology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Koichiro Ogihara
- Department of Urology, Kawasaki Municipal Hospital, Kanagawa, Japan
| | - Kyohei Hakozaki
- Department of Urology, National Hospital Organization Saitama National Hospital, Saitama, Japan
| | - Tomohiro Iwasawa
- Department of Urology, Kawasaki Municipal Hospital, Kanagawa, Japan
| | - Ken Kamisawa
- Department of Urology, Saiseikai Central Hospital, Tokyo, Japan
| | - Kunimitsu Kanai
- Department of Urology, National Hospital Organization Saitama National Hospital, Saitama, Japan
| | - Hiroki Ide
- Department of Urology, Saiseikai Central Hospital, Tokyo, Japan
| | - Satoshi Hara
- Department of Urology, Kawasaki Municipal Hospital, Kanagawa, Japan
| | - Ryuichi Mizuno
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
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25
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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: 5] [Impact Index Per Article: 1.7] [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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26
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Rouprêt M, Morère JF, Touboul C, Lhomel C, Couraud S, de la Motte Rouge T. Knowledge of bladder cancer in the French population: results of the EDIFICE 6 survey. Eur J Cancer Care (Engl) 2020; 30:e13392. [PMID: 33336542 DOI: 10.1111/ecc.13392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/26/2020] [Accepted: 12/01/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess awareness of bladder cancer (BCa) in France. METHODS The French nationwide observational survey EDIFICE 6 was conducted online (26 June-28 July 2017) in 12,046 individuals (age, 18-69 years). The present analysis focuses on laypersons' knowledge of the severity and frequency of BCa, signs and symptoms, associated risk factors and screening tests. Quantitative data were expressed as means and standard deviation, and categorical data as percentages. RESULTS Analyses were conducted on 11,313 questionnaires. Among the top five acknowledged risk factors for BCa, tobacco was ranked as having the second lowest impact (5.9/10 [2.5]). Only 28% of the study population were aware that active tobacco smoking is a major risk factor for BCa (rating ≥8/10); 61% of the study population was unaware of the existence of any signs or symptoms of BCa, and 69% was not able to cite any of the most widely used diagnostic tests. CONCLUSIONS We found that the French population has a poor knowledge of BCa risk factors, early signs and diagnostic tests. Effective prevention of BCa requires dissemination of clear information and prevention messages to the lay population, focusing particularly on tobacco consumption and early signs of the disease.
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Affiliation(s)
- Morgan Rouprêt
- Sorbonne Université, GRC n°5, PREDICTIVE ONCO-URO, Assistance Publique - Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
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27
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Bhatt NR, Czarniecki SW, Borgmann H, van Oort IM, Esperto F, Pradere B, van Gurp M, Bloemberg J, Darraugh J, Rouprêt M, Loeb S, N'Dow J, Ribal MJ, Giannarini G. A Systematic Review of the Use of Social Media for Dissemination of Clinical Practice Guidelines. Eur Urol Focus 2020; 7:1195-1204. [PMID: 33172773 DOI: 10.1016/j.euf.2020.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/10/2020] [Accepted: 10/19/2020] [Indexed: 01/30/2023]
Abstract
CONTEXT Clinical practice guideline (CPG) uptake does not occur spontaneously and requires active implementation, especially for long-term implementation. Social media (SoMe) with its power of rapid and global information exchange among physicians, patients, organizations, and stakeholders in the medical field can open up unprecedented opportunities for CPG dissemination. OBJECTIVE The aim of this review was to assess the current use of SoMe in CPG dissemination across different medical specialties. EVIDENCE ACQUISITION A systematic review (SR) of the literature was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Medline, Embase, and Cochrane databases and the general platform Google were searched for all relevant publications (no limitation for publication time and no language restrictions). The search revealed 1881 citations; following title and abstract review, 22 studies were identified; and five studies were finally included after full-text review. EVIDENCE SYNTHESIS All included studies were published in the past 5 yr; there was a significant improvement in knowledge, awareness, compliance, and positive behavior toward CPGs with the use of SoMe dissemination compared with traditional methods. A large audience (healthcare professionals and patients) viewed and engaged with the SoMe process of CPG dissemination, and expressed an intent to engage in this method in the future. The studies included in the SR reported variable methods of SoMe use and similarly variable methods of analyzing the outcomes. CONCLUSIONS Owing to the recent application of SoMe in the context of CPG dissemination, there is no standardized format for its use, and the data available are variable and limited. However, encouraging preliminary results have been reported using SoMe for CPG dissemination in multiple fields, and we have provided a pragmatic method of SoMe usage in CPG dissemination based on the review. It is vital to ensure a uniform method of application and assessment of SoMe use in CPG dissemination and implementation going forward. PATIENT SUMMARY Social media (SoMe) plays an important role in rapid and global information exchange among physicians, patients, organizations, and stakeholders in the medical field, and its power can be harnessed in the dissemination of evidence-based clinical practice guidelines (CPGs) that guide clinicians in practice. Our review reveals that SoMe use for CPG dissemination is a relatively new concept published approximately 5 yr ago, and it has led to significant improvement in knowledge, awareness, compliance, and positive behavior with respect to the CPGs compared with traditional methods. A large audience (healthcare professionals and patients) viewed and engaged with the SoMe process. We have produced a pragmatic method of using SoMe in CPG dissemination. Considering the importance of CPGs in practice and the ever increasing role of SoMe in the medical profession, a new role for SoMe in CPG dissemination could be established.
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Affiliation(s)
- Nikita R Bhatt
- Department of Urology, East of England deanery, Cambridge, UK.
| | | | - Hendrick Borgmann
- Department of Urology, University Medicine Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Inge M van Oort
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Francesco Esperto
- Department of Urology, Campus Bio-Medico University, Rome, Italy; Department of Urology, Tours University Hospital, Tours, France
| | - Benjamin Pradere
- Department of Urology, Campus Bio-Medico University, Rome, Italy; Department of Urology, Tours University Hospital, Tours, France
| | - Mark van Gurp
- Communications, European Association of Urology, Arnhem, The Netherlands
| | - Jarka Bloemberg
- Communications, European Association of Urology, Arnhem, The Netherlands
| | - J Darraugh
- Guidelines, European Association of Urology, Arnhem, The Netherlands
| | - Morgan Rouprêt
- Department of Urology, La Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Stacy Loeb
- Department of Urology and Population Health, New York University, New York, NY, USA; Manhattan Veterans Affairs Medical Center, New York, NY, USA
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Maria J Ribal
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Spain
| | - Gianluca Giannarini
- Urology Unit, Academic Medical Centre "Santa Maria della Misericordia", Udine, Italy
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Yang Y, Liu C, Yang X. Endoscopic Molecular Imaging plus Photoimmunotherapy: A New Strategy for Monitoring and Treatment of Bladder Cancer. MOLECULAR THERAPY-ONCOLYTICS 2020; 18:409-418. [PMID: 32913890 PMCID: PMC7452043 DOI: 10.1016/j.omto.2020.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Due to the high recurrence and progression rate of non-muscle invasive bladder cancer after transurethral resection of bladder tumor, some new optical imaging technologies have arisen as auxiliary imaging modes for white light cystoscopy to improve the detection rate of small or occult tumor lesions, such as photodynamic diagnosis, narrow-band imaging, and molecular imaging. White light cystoscopy is inadequate and imperfect for bladder cancer detection, and thus residual tumors or coexisting flat malignant lesions, especially carcinoma in situ, would be ignored during conventional resection. The bladder, a hollow organ with high compliance, provides an ideal closed operation darkroom for endoscopic molecular imaging free from interference of external light sources. Also, intravesical instillation of a molecular fluorescent tracer is simple and convenient before surgery through the urethra. Molecular fluorescent tracer has high sensitivity and specificity to tumor cells, and its mediated molecular imaging allows small or occult tumor lesion detection while minimizing false-positive results. Meanwhile, endoscopic molecular imaging provides a real-time and dynamic image during surgery, which helps urologists to perform high-quality and complete tumor resection through accurate judgment of tumor boundaries and depth of invasion. Photoimmunotherapy is a novel molecular targeted therapeutic pattern of photodynamic therapy that kills malignant cells selectively and minimizes the cytotoxicity to normal tissues. The combination of endoscopic molecular imaging and photoimmunotherapy used in initial treatment may avoid the need of repeat transurethral resection in strictly selected patients and improve oncological outcomes such as recurrence-free survival and overall survival after operation.
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Affiliation(s)
- Yongjun Yang
- First Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Chao Liu
- First Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiaofeng Yang
- First Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi, China.,Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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Low compliance to guidelines in nonmuscle-invasive bladder carcinoma: A systematic review. Urol Oncol 2020; 38:774-782. [PMID: 32654948 DOI: 10.1016/j.urolonc.2020.06.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/02/2020] [Accepted: 06/13/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE This systematic review assessed compliance to guidelines for the management of nonmuscle-invasive bladder carcinoma (NMIBC). METHODS The PUBMED, Web of Science, Cochrane Library, and Scopus databases were searched in November 2019 in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement. RESULTS Fifteen studies incorporating a collective total of 10,575 NMIBC patients were eligible for inclusion in this systematic review. We found that the rates of compliance were 53.0% with a single immediate intravesical instillation in patients with presumed low or intermediate risk, 37.1% with intravesical bacillus Calmette-Guerin or chemotherapy in those with intermediate risk, 43.4% with performance of a second transurethral resection in high-risk patients, 32.5% with administration of adjuvant intravesical bacillus Calmette-Guerin in high-risk patients, 36.1% with radical cystectomy in highest-risk patients, and 82.2% with cystoscopy for follow-up. CONCLUSIONS Compliance with NMIBC guidelines remains low. Better guideline education and understanding holds the key to achieving high compliance. Strategies to improve guideline compliance at the physician level are urgently required.
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30
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Cai T, Cocci A, Gacci M, Verze P, Bonkat G, Koves B, Wagenlehner F, Bartoletti R, Bjerklund Johansen TE. Guidelines in urology: Lights and shadows. Urologia 2020; 87:125-129. [PMID: 32342733 DOI: 10.1177/0391560320917805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Clinical practice guidelines have become increasingly important in the decision-making process in many clinical conditions and have been recognized as key instruments to improve the quality of care. On the one hand, guidelines represent a good tool for improving patient's outcome, and on the other hand, the adherence to guidelines and good practice recommendations is mandatory to reduce the risk of legal disputes. A recent revision by the Italian Parliament of the legal system that rules the responsibilities of health professionals and health care safety stimulated all clinicians to improve their adhesion to clinical guidelines. It is justified by the high-quality level obtained in the recent years by the international guidelines. In the recent years, a revision of the clinical guideline development has been done. In particular, the European Association of Urology Guideline Office changed the "Guidelines for Guidelines," and a rigorous development process has been established. A clinical recommendation is produced after a rigorous methodological process using an analysis of all published clinical trials, and the expert opinion is not yet considered. For oncological guidelines, the adherence to the producing process is easily feasible due to the high number of clinical trials; for non-oncological guidelines, instead, the small number of clinical trials could represent a problem for obtaining recommendation based on rigorous methodology. Here, on the basis of these considerations, we aim to discuss the lights and the shadows of the clinical applicability of guidelines in urology.
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Affiliation(s)
- Tommaso Cai
- Department of Urology, Santa Chiara Hospital, Trento, Italy
| | - Andrea Cocci
- Department of Urology, University of Florence, Florence, Italy
| | - Mauro Gacci
- Department of Urology, University of Florence, Florence, Italy
| | - Paolo Verze
- Department of Urology, University of Naples Federico II, Naples, Italy
| | - Gernot Bonkat
- Department of Urology, alta uro AG, Basel, Switzerland
| | - Bela Koves
- Department of Urology, South-Pest Teaching Hospital, Budapest, Hungary
| | - Florian Wagenlehner
- Department of Urology, Paediatric Urology and Andrology, Justus-Liebig-University, Gießen, Germany
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31
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Current European Trends in Endoscopic Imaging and Transurethral Resection of Bladder Tumors. J Endourol 2020; 34:312-321. [DOI: 10.1089/end.2019.0651] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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32
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Guallar-Garrido S, Julián E. Bacillus Calmette-Guérin (BCG) Therapy for Bladder Cancer: An Update. Immunotargets Ther 2020; 9:1-11. [PMID: 32104666 PMCID: PMC7025668 DOI: 10.2147/itt.s202006] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 01/28/2020] [Indexed: 01/02/2023] Open
Abstract
Physicians treating patients affected by nonmuscle-invasive bladder cancer (NMIBC) have been in shock during the last six years since manufacturing restrictions on the production of the first-option medicine, Mycobacterium bovis Bacillus Calmette-Guérin (BCG), have resulted in worldwide shortages. This shortage of BCG has led to a rethinking of the established treatment guidelines for the rationing of the administration of BCG. Some possible schedule modifications consist of a decrease in the length of maintenance treatment, a reduction in the dose of BCG in intravesical instillations or the use of different BCG substrains. All these strategies have been considered valuable in times of BCG shortage. In addition, the lack of availability of BCG has also led to the general recognition of the need to find new treatment options for these patients so that they are not dependent on a single treatment. Few alternatives are committed to definitively replacing BCG intravesical instillations, but several options are being evaluated to improve its efficacy or to combine it with other chemotherapeutic or immunotherapeutic options that can also improve its effect. In this article, we review the current state of the treatment with BCG in terms of all of the aforementioned aspects.
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Affiliation(s)
- Sandra Guallar-Garrido
- Departament de Genètica i de Microbiologia, Facultat de Biociències, Universitat Autònoma de Barcelona, Bellaterra (Barcelona), Spain
| | - Esther Julián
- Departament de Genètica i de Microbiologia, Facultat de Biociències, Universitat Autònoma de Barcelona, Bellaterra (Barcelona), Spain
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33
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Danforth KN, Sidell MA, Luong TQ, Yi DK, Yamamoto A, Kawatkar AA, Kim PH, Loo RK, Williams SG. Care Quality and Variability in the Use of Intravesical Therapy for Initial Treatment of Nonmuscle Invasive Bladder Cancer Within a Large, Diverse Integrated Delivery System. Urology 2019; 131:93-103. [PMID: 31129191 DOI: 10.1016/j.urology.2019.03.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/08/2019] [Accepted: 03/20/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To examine treatment variability, disparities, and quality among newly diagnosed nonmuscle invasive bladder cancer (NMIBC) patients, and to identify factors associated with treatment use in a large, diverse integrated delivery system. METHODS Retrospective cohort study of 5386 NMIBC patients diagnosed between January 2001 and June 2015 within Kaiser Permanente Southern California. Electronic health data were used to identify treatment outcomes and patient, provider, and tumor characteristics. Outcomes were use of (1) postoperative intravesical chemotherapy, (2) induction Bacille Calmette-Guérin (BCG) immunotherapy, and (3) any intravesical therapy. Multivariable odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using generalized linear mixed models with a binary outcome and urologist as a random effect. RESULTS From 2001 to 2015, 41% of newly diagnosed NMIBC patients were treated with intravesical therapy. Postoperative chemotherapy use increased significantly over this period (OR per-year = 1.16, 95% CI: 1.07-1.25). BCG use was strongly associated with tumor characteristics: patients with high-grade or carcinoma in situ tumors were more likely to receive BCG (OR = 10.10, 95% CI: 8.39-12.16). Few treatment differences were found by sex or race/ethnicity, but were observed by age. Wide treatment variability across urologists was observed, with some urologists never using intravesical therapy as part of initial treatment while others almost always used it. Differences across urologists accounted for more variability in postoperative chemotherapy (intraclass correlation coefficient = 0.52) than BCG immunotherapy (intraclass correlation coefficient = 0.11) use. CONCLUSION Substantial variability in initial treatment of NMIBC was observed across urologists, accounting for tumor, patient, and provider characteristics. Results suggest a considerable opportunity for quality improvement programs to reduce unwanted treatment variability and improve care for patients.
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Affiliation(s)
- Kim N Danforth
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
| | - Margo A Sidell
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Tiffany Q Luong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - David K Yi
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Ayae Yamamoto
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA; Department of Quality and Risk Management, Kaiser Foundation Hospital and Health Plan, Pasadena, CA
| | - Aniket A Kawatkar
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Philip H Kim
- Department of Urology, Southern California Permanente Medical Group, San Diego, CA
| | - Ronald K Loo
- Department of Urology, Southern California Permanente Medical Group, Downey, CA
| | - Stephen G Williams
- Department of Urology, Southern California Permanente Medical Group, Riverside, CA
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34
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Soria F, Marra G, D'Andrea D, Gontero P, Shariat SF. The rational and benefits of the second look transurethral resection of the bladder for T1 high grade bladder cancer. Transl Androl Urol 2019; 8:46-53. [PMID: 30976568 PMCID: PMC6414350 DOI: 10.21037/tau.2018.10.19] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The second look transurethral resection of the bladder (TURB) represents a fundamental step in the treatment of papillary non-muscle invasive bladder cancer (NMIBC); it is therefore recommended by all guidelines. However, not all the literature agrees on its staging value and its ability to improve oncological outcomes of patients. Therefore, the purpose of this review is to evaluate the strengths and weaknesses of second look TURB, trying to depict its evolving role in the management of high grade NMIBC. Using Medline, a non-systematic review was performed including articles between January 2000 and June 2018. English language original articles, reviews and editorials were selected based on their clinical relevance. To date, TURB seems to be largely inadequate in retrieving a correct diagnosis and in removing all tumor tissue. Second look TURB maximizes staging accuracy, allows to clear residual cancer and yields prognostic advantages allowing key information to identify possible candidates for immediate radical cystectomy for very high risk T1HG tumors. Moreover, it seems to have a therapeutic benefit by improving recurrence- and progression-free survivals. However, few recent large studies showed that these advantages seem to be limited to patients without detrusor muscle present at first resection. Similarly, the presence of residual disease and the risk of upstaging are related to the presence of detrusor muscle in specimen. It could well be that in the future the presence of detrusor muscle would be a quality criteria to avoid an unnecessary second look TURB as shown by recent studies using the en-bloc resection technique. Finally, it has to be underlined that this is a surgical procedure not free of risks and complications and with a non-negligible impact on patients’ quality of life, waiting lists and healthcare costs. Therefore, future studies trying to identify the criteria that may better allow which patients to select for a second look TURB while avoiding an unnecessary intervention with possible risks and associated cost are needed to allow a personalized approach to even this one size fits all strategy.
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Affiliation(s)
- Francesco Soria
- Department of Urology and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.,Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Giancarlo Marra
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - David D'Andrea
- Department of Urology and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Shahrokh F Shariat
- Department of Urology and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria.,Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA.,Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA
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35
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Rahnama'i MS, Vrijens DMJ, Hajebrahimi S, van Koeveringe GA, Marcelissen TAT. The discrepancy between European Association of Urology (EAU) guidelines and daily practice in the evaluation and management of nocturia: results of a Dutch survey. World J Urol 2019; 37:2517-2522. [PMID: 30656496 DOI: 10.1007/s00345-019-02638-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/10/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVE In addition to the evaluation of voiding symptoms, in the evaluation of patients with nocturia, one should also consider other related causes such as sleep disorders, obstructive sleep apnoea (OSAS), diabetes and heart failure. In this study, we have aimed to assess the current knowledge and implementation of the EAU guidelines regarding nocturia in common urological practice in the Netherlands. SETTING AND PARTICIPANTS In a national cross-sectional survey distributed among 450 urologists and urology residents in the Netherlands, the implementation of the recommendations of the European Association of Urology (EAU) guidelines on nocturia evaluation and management was studied. RESULTS AND LIMITATIONS This survey revealed that only some aspects of the EAU guidelines are applied in the daily clinical practice and that some important parts are not. For example, only a minority asks about alcohol consumption and symptoms suggestive for diabetes or OSAS. In addition, a majority reported to use a bladder diary for 1-3 days instead of for a minimum of 3 days as recommended by the EAU guidelines. In the management of nocturia, a trial of timed diuretic therapy is only reported by a minority, whereas the use of beta-3 antagonists, which is not mentioned in the guidelines, is applied by a large majority. Desmopressin recommended for nocturnal polyuria is prescribed by two-third of Dutch urologists. CONCLUSIONS These observations mandate better education and campaigns to raise the awareness on the EAU-guideline recommendations for nocturia.
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Affiliation(s)
- M S Rahnama'i
- Department of Urology, Uniklinik RWTH Aachen, Aachen, Germany. .,Department of Urology, Maastricht University, Maastricht, The Netherlands. .,Society of Urological Research and Education (SURE), Heerlen, The Netherlands.
| | - D M J Vrijens
- Department of Urology, Maastricht University, Maastricht, The Netherlands.,Society of Urological Research and Education (SURE), Heerlen, The Netherlands
| | - S Hajebrahimi
- Department of Urology, Research Centre of Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - G A van Koeveringe
- Department of Urology, Maastricht University, Maastricht, The Netherlands.,Maastricht University Medical Centre, Maastricht, The Netherlands
| | - T A T Marcelissen
- Department of Urology, Maastricht University, Maastricht, The Netherlands.,Society of Urological Research and Education (SURE), Heerlen, The Netherlands.,Maastricht University Medical Centre, Maastricht, The Netherlands
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36
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Onishi T, Sekito S, Shibahara T, Uchida K, Sasaki T. The role of continuous saline bladder irrigation after transurethral resection in patients with high-grade non-muscle-invasive bladder cancer. Scand J Urol 2019; 52:385-388. [DOI: 10.1080/21681805.2018.1548502] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
| | - Sho Sekito
- Department of Urology, Ise Red Cross hospital, Ise, Japan
| | | | | | - Takeshi Sasaki
- Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu, Japan
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37
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Mostafid H, Palou J, Burger M, Babjuk M. T1 High-grade Bladder Cancer: The Search for the Optimal Management Continues. Eur Urol 2018; 74:609-610. [DOI: 10.1016/j.eururo.2018.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 08/10/2018] [Indexed: 10/28/2022]
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38
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Immunotherapy for bladder cancer: the fight is on. World J Urol 2018; 36:1699-1701. [PMID: 30167832 DOI: 10.1007/s00345-018-2468-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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39
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Unmet Clinical Needs and Future Perspectives in Non-muscle-invasive Bladder Cancer. Eur Urol Focus 2018; 4:472-480. [PMID: 30172757 DOI: 10.1016/j.euf.2018.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/05/2018] [Accepted: 08/16/2018] [Indexed: 12/18/2022]
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40
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Babjuk M, Burger M, Compérat EM, Gontero P, Mostafid HA, Palou J, van Rhijn BWG, Rouprêt M, Shariat SF, Sylvester R, Zigeuner R, Capoun O, Cohen D, Dominguez-Escrig JL, Hernández V, Peyronnet B, Seisen T, Soukup V. Indication for a Single Postoperative Instillation of Chemotherapy in Non-muscle-invasive Bladder Cancer: What Factors Should Be Considered? Eur Urol Focus 2018; 4:525-528. [PMID: 30061076 DOI: 10.1016/j.euf.2018.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/08/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022]
Abstract
An early single instillation of intravesical chemotherapy (SICI) used immediately after transurethral resection of the bladder (TURB) can significantly reduce the recurrence rate in selected patients with non-muscle-invasive bladder cancer (NMIBC). SICI should be used in patients with low-risk and with selected intermediate-risk tumours, in particular for multiple primary small papillary tumours, single primary papillary tumours >3cm, and single recurrent papillary tumours recurring >1yr after the previous resection. The available data do not support any recommendation to reduce the role of SICI in patients after fluorescence cystoscopy-guided TURB or en bloc TURB. SICI can even provide some benefit in patients with intermediate-risk tumours subsequently treated with further instillations. During instillation, contraindications should be taken into account and safety measures should be applied. PATIENT SUMMARY: An early single instillation of intravesical chemotherapy immediately after transurethral resection of the bladder can significantly reduce the recurrence rate in selected patients with non-muscle-invasive bladder cancer. It should be used in patients with low-risk and selected intermediate-risk tumours.
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Affiliation(s)
- Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Praha, Czech Republic; Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Eva M Compérat
- Department of Pathology, Hôpital Tenon, AP-HP, Sorbonne University, Paris, France
| | - Paolo Gontero
- Department of Urology, San Giovanni Battista Hospital, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Hugh A Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Bas W G van Rhijn
- Department of Urology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Morgan Rouprêt
- Department of Urology, Hôpital La Pitié-Salpétrière, AP-HP, Sorbonne University, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Praha, Czech Republic; Medical University of Vienna, Vienna General Hospital, Vienna, Austria; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Richard Sylvester
- European Association of Urology Guidelines Office, Brussels, Belgium
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Otakar Capoun
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Daniel Cohen
- Department of Surgery and Cancer, Imperial College London, London, UK; Department of Urology, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | | | - Virginia Hernández
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Thomas Seisen
- Department of Urology, Hôpital La Pitié-Salpétrière, AP-HP, Sorbonne University, Paris, France
| | - Viktor Soukup
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
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41
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An increased body mass index is associated with a worse prognosis in patients administered BCG immunotherapy for T1 bladder cancer. World J Urol 2018; 37:507-514. [PMID: 29992381 DOI: 10.1007/s00345-018-2397-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/28/2018] [Indexed: 12/16/2022] Open
Abstract
PURPOSE The body mass index (BMI) may be associated with an increased incidence and aggressiveness of urological cancers. In this study, we aimed to evaluate the impact of the BMI on survival in patients with T1G3 non-muscle-invasive bladder cancer (NMIBC). METHODS A total of 1155 T1G3 NMIBC patients from 13 academic institutions were retrospectively reviewed and patients administered adjuvant intravesical Bacillus Calmette-Guérin (BCG) immunotherapy with maintenance were included. Multivariable Cox regression analysis was performed to identify factors predictive of recurrence and progression. RESULTS After re-TURBT, 288 patients (27.53%) showed residual high-grade NMIBC, while 867 (82.89%) were negative. During follow-up, 678 (64.82%) suffered recurrence, and 303 (30%) progression, 150 (14.34%) died of all causes, and 77 (7.36%) died of bladder cancer. At multivariate analysis, tumor size (hazard ratio [HR]:1.3; p = 0.001), and multifocality (HR:1.24; p = 0.004) were significantly associated with recurrence (c-index for the model:55.98). Overweight (HR: 4; p < 0.001) and obesity (HR:5.33 p < 0.001) were significantly associated with an increased risk of recurrence. Addition of the BMI to a model that included standard clinicopathological factors increased the C-index by 9.9. For progression, we found that tumor size (HR:1.63; p < 0.001), multifocality (HR:1.31; p = 0.01) and concomitant CIS (HR: 2.07; p < 0.001) were significant prognostic factors at multivariate analysis (C-index 63.8). Overweight (HR: 2.52; p < 0.001) and obesity (HR: 2.521 p < 0.001) were significantly associated with an increased risk of progression. Addition of the BMI to a model that included standard clinicopathological factors increased the C-index by 1.9. CONCLUSIONS The BMI could have a relevant role in the clinical management of T1G3 NMIBC, if associated with bladder cancer recurrence and progression. In particular, this anthropometric factor should be taken into account at initial diagnosis and in therapeutic strategy decision making.
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van Osch FHM, Jochems SHJ, Reulen RC, Pirrie SJ, Nekeman D, Wesselius A, James ND, Wallace DMA, Cheng KK, van Schooten FJ, Bryan RT, Zeegers MP. The association between smoking cessation before and after diagnosis and non-muscle-invasive bladder cancer recurrence: a prospective cohort study. Cancer Causes Control 2018; 29:675-683. [PMID: 29846846 PMCID: PMC5999150 DOI: 10.1007/s10552-018-1046-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/28/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Smoking is a major risk factor for bladder cancer, but the relationship between smoking cessation after initial treatment and bladder cancer recurrence has been investigated less frequently and not prospectively yet. METHODS 722 non-muscle-invasive bladder cancer (NMIBC) patients (pTa, pT1, and CIS) from the prospective Bladder Cancer Prognosis Programme (BCPP) cohort, selected in the UK between 2005 and 2011, provided complete data on smoking behavior before and up to 5 years after diagnosis. The impact of smoking behavior on NMIBC recurrence was explored by multivariable Cox regression models investigating time-to-first NMIBC recurrence. RESULTS Over a median follow-up period of 4.21 years, 403 pathologically confirmed NMIBC recurrences occurred in 210 patients. Only 25 current smokers at diagnosis quit smoking (14%) during follow-up and smoking cessation after diagnosis did not decrease risk of recurrence compared to continuing smokers (p = 0.352). CONCLUSIONS Although quitting smoking after diagnosis might reduce the risk of recurrence based on retrospective evidence, this is not confirmed in this prospective study because the number of NMIBC patients quitting smoking before their first recurrence was too low. Nevertheless, this indicates an important role for urologists and other health care professionals in promoting smoking cessation in NMIBC.
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Affiliation(s)
- Frits H M van Osch
- Unit of Nutritional and Cancer Epidemiology, Chairgroup of Complex Genetics and Epidemiology, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands.
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.
| | - Sylvia H J Jochems
- Unit of Nutritional and Cancer Epidemiology, Chairgroup of Complex Genetics and Epidemiology, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Raoul C Reulen
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK
| | - Sarah J Pirrie
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Duncan Nekeman
- Unit of Nutritional and Cancer Epidemiology, Chairgroup of Complex Genetics and Epidemiology, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Anke Wesselius
- Unit of Nutritional and Cancer Epidemiology, Chairgroup of Complex Genetics and Epidemiology, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Nicholas D James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- University Hospital Birmingham, NHS Foundation Trust, Birmingham, UK
| | - D Michael A Wallace
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- University Hospital Birmingham, NHS Foundation Trust, Birmingham, UK
| | - K K Cheng
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK
| | - Frederik J van Schooten
- Department of Pharmacology and Toxicology, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Richard T Bryan
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Maurice P Zeegers
- Unit of Nutritional and Cancer Epidemiology, Chairgroup of Complex Genetics and Epidemiology, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- Chairgroup of Complex Genetics and Epidemiology, Care and Public Health Research Institute (CAPRHI), Maastricht University, Maastricht, The Netherlands
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