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Ślusarczyk A, Garbas K, Pustuła P, Zapała Ł, Radziszewski P. Assessing the Predictive Accuracy of EORTC, CUETO and EAU Risk Stratification Models for High-Grade Recurrence and Progression after Bacillus Calmette-Guérin Therapy in Non-Muscle-Invasive Bladder Cancer. Cancers (Basel) 2024; 16:1684. [PMID: 38730636 PMCID: PMC11083007 DOI: 10.3390/cancers16091684] [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: 04/04/2024] [Revised: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
The currently available EORTC, CUETO and EAU2021 risk stratifications were originally developed to predict recurrence and progression in non-muscle-invasive bladder cancer (NMIBC). However, they have not been validated to differentiate between high-grade (HG) and low-grade (LG) recurrence-free survival (RFS), which are distinct events with specific implications. We aimed to evaluate the accuracy of available risk models and identify additional risk factors for HG RFS and PFS among NMIBC patients treated with Bacillus Calmette-Guérin (BCG). We retrospectively included 171 patients who underwent transurethral resection of the bladder tumor (TURBT), of whom 73 patients (42.7%) experienced recurrence and 29 (17%) developed progression. Initially, there were 21 low-grade and 52 high-grade recurrences. EORTC2006, EORTC2016 and CUETO recurrence scoring systems lacked accuracy in the prediction of HG RFS (C-index 0.63/0.55/0.59, respectively). EAU2021 risk stratification, EORTC2006, EORTC2016, and CUETO progression scoring systems demonstrated low to moderate accuracy (C-index 0.59/0.68/0.65/0.65) in the prediction of PFS. In the multivariable analysis, T1HG at repeat TURBT (HR = 3.17 p < 0.01), tumor multiplicity (HR = 2.07 p < 0.05), previous history of HG NMIBC (HR = 2.37 p = 0.06) and EORTC2006 progression risk score (HR = 1.1 p < 0.01) were independent predictors for HG RFS. To conclude, available risk models lack accuracy in predicting HG RFS and PFS in -NMIBC patients treated with BCG.
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Affiliation(s)
- Aleksander Ślusarczyk
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, 02-005 Warsaw, Poland
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Deng Z, Dong W, Xiong S, Jin D, Zhou H, Zhang L, Xie L, Deng Y, Xu R, Fan B. Machine learning models combining computed tomography semantic features and selected clinical variables for accurate prediction of the pathological grade of bladder cancer. Front Oncol 2023; 13:1166245. [PMID: 37223680 PMCID: PMC10200894 DOI: 10.3389/fonc.2023.1166245] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/14/2023] [Indexed: 05/25/2023] Open
Abstract
Objective The purpose of this research was to develop a radiomics model that combines several clinical features for preoperative prediction of the pathological grade of bladder cancer (BCa) using non-enhanced computed tomography (NE-CT) scanning images. Materials and methods The computed tomography (CT), clinical, and pathological data of 105 BCa patients attending our hospital between January 2017 and August 2022 were retrospectively evaluated. The study cohort comprised 44 low-grade BCa and 61 high-grade BCa patients. The subjects were randomly divided into training (n = 73) and validation (n = 32) cohorts at a ratio of 7:3. Radiomic features were extracted from NE-CT images. A total of 15 representative features were screened using the least absolute shrinkage and selection operator (LASSO) algorithm. Based on these characteristics, six models for predicting BCa pathological grade, including support vector machine (SVM), k-nearest neighbor (KNN), gradient boosting decision tree (GBDT), logical regression (LR), random forest (RF), and extreme gradient boosting (XGBOOST) were constructed. The model combining radiomics score and clinical factors was further constructed. The predictive performance of the models was evaluated based on the area under the receiver operating characteristic (ROC) curve, DeLong test, and decision curve analysis (DCA). Results The selected clinical factors for the model included age and tumor size. LASSO regression analysis identified 15 features most linked to BCa grade, which were included in the machine learning model. The SVM analysis revealed that the highest AUC of the model was 0.842. A nomogram combining the radiomics signature and selected clinical variables showed accurate prediction of the pathological grade of BCa preoperatively. The AUC of the training cohort was 0.919, whereas that of the validation cohort was 0.854. The clinical value of the combined radiomics nomogram was validated using calibration curve and DCA. Conclusion Machine learning models combining CT semantic features and the selected clinical variables can accurately predict the pathological grade of BCa, offering a non-invasive and accurate approach for predicting the pathological grade of BCa preoperatively.
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Affiliation(s)
- Zhikang Deng
- Medical College of Nanchang University, Nanchang University, Nanchang, China
- Department of Nuclear Medicine, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Wentao Dong
- Department of Radiology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Situ Xiong
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Di Jin
- Medical College of Nanchang University, Nanchang University, Nanchang, China
- Department of Radiology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Hongzhang Zhou
- Department of Nuclear Medicine, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Ling Zhang
- Medical College of Nanchang University, Nanchang University, Nanchang, China
- Department of Nuclear Medicine, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - LiHan Xie
- Medical College of Nanchang University, Nanchang University, Nanchang, China
- Department of Nuclear Medicine, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Yaohong Deng
- Department of Research & Development, Yizhun Medical AI Co. Ltd., Beijing, China
| | - Rong Xu
- Department of Nuclear Medicine, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Bing Fan
- Department of Radiology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
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Anderson CB, Chen L, Chang SS, McKiernan JM, Wright J. Intravesical Therapy Compared to Radical Cystectomy Among Patients With Non-Muscle Invasive Bladder Cancer Requiring Additional Treatment After Induction BCG. Clin Genitourin Cancer 2022; 20:595-603. [PMID: 35948482 DOI: 10.1016/j.clgc.2022.07.001] [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: 05/23/2022] [Accepted: 07/05/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Many patients with recurrent high-risk non-muscle invasive bladder cancer after intravesical bacillus calmette-guerin (BCG) face a difficult decision between radical cystectomy (RC) or salvage intravesical therapy (IVT). We sought to determine if there is a difference in overall survival RC and IVT after previous treatment with BCG. METHODS We performed a retrospective cohort study of patients with Ta, T1, and Tis bladder cancer treated with induction BCG in the SEER-Medicare dataset from 2000 to 2015. We used a proportional hazards regression model to compare differences in survival between patients having RC and IVT. We adjusted for confounding using a propensity score and stratified our analysis according to timing of treatment and stage at diagnosis. RESULTS We identified 3940 patients who received either IVT (79%) or RC (21%) following induction BCG. Among patients treated within 12 months of BCG, there was no significant difference in survival between RC and IVT (HR 0.92, 95% CI 0.81-1.04) and 17% of patients having early IVT ultimately required RC. Among patients treated at least 12 months after BCG, RC was associated with worse survival than IVT (HR 1.19, 95% CI 1.06-1.35) and 10% of patients having late IVT ultimately required RC. CONCLUSION Among patients with bladder cancer who required additional treatments after induction BCG, we did not observe a difference in overall survival between IVT and RC within 12 months of starting BCG. While RC remains the gold-standard for high risk recurrent NMIBC after BCG, bladder preservation with IVT may be appropriate for well-selected patients.
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Affiliation(s)
- Christopher B Anderson
- Department of Urology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY.
| | - Ling Chen
- Department of Gynecology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - James M McKiernan
- Department of Urology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Jason Wright
- Department of Gynecology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY
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Roumiguié M, Kamat AM, Bivalacqua TJ, Lerner SP, Kassouf W, Böhle A, Brausi M, Buckley R, Persad R, Colombel M, Lamm D, Palou-Redorta J, Soloway M, Brothers K, Steinberg G, Lotan Y, Sylvester R, Alfred Witjes J, Black PC. International Bladder Cancer Group Consensus Statement on Clinical Trial Design for Patients with Bacillus Calmette-Guérin-exposed High-risk Non-muscle-invasive Bladder Cancer. Eur Urol 2022; 82:34-46. [PMID: 34955291 DOI: 10.1016/j.eururo.2021.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/22/2021] [Accepted: 12/03/2021] [Indexed: 11/21/2022]
Abstract
CONTEXT A large proportion of patients with non-muscle-invasive bladder cancer (NMIBC) fall in the gap between bacillus Calmette-Guérin (BCG)-naïve and BCG-unresponsive disease. As multiple therapeutic agents move into this gray area, there is a critical need to define the disease state and establish recommendations for optimal trial design. OBJECTIVE To develop a consensus on optimal trial design for patients with BCG-exposed NMIBC, defined as high-grade recurrence after BCG treatment that does not meet the criteria for BCG-unresponsive disease. EVIDENCE ACQUISITION We conducted a literature review using the Cochrane Library, Medline, and Embase and a review of clinical trials in ClinicalTrials.gov as a basis to generate consensus recommendations for clinical trial design in BCG-exposed NMIBC. EVIDENCE SYNTHESIS BCG-exposed NMIBC encompasses BCG resistance (presence of high-grade Ta or carcinoma in situ [CIS] at 3-mo evaluation after induction BCG) and delayed relapse. Randomized controlled trials are required to compare experimental therapies to a control arm receiving additional BCG, although ongoing BCG shortages may impact our ability to follow an optimal trial design. A placebo should be used in combination with BCG if the treatment arm includes BCG plus a study drug. Trials will either need to separate patients with and without CIS into two cohorts, or stratify by the presence of CIS at the time of randomization. If two cohorts are used, the primary endpoint for CIS patients should be complete response within a predetermined time. The primary endpoint in a cohort with Ta/T1 only, or if a single combined cohort is used, should be the duration of event-free survival. Suggested efficacy thresholds and corresponding sample sizes are provided. CONCLUSIONS The International Bladder Cancer Group has developed recommendations regarding definitions, endpoints, and clinical trial design for BCG-exposed NMIBC to encourage uniformity among studies in this disease state. PATIENT SUMMARY Our consensus provides a precise definition of the disease state for bladder cancer not invading the bladder muscle and exposed to bacillus Calmette-Guérin (BCG) treatment. Clear guidance for conducting optimal clinical trials in this disease setting was established and we believe that this will promote further progress in this field.
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Affiliation(s)
- Mathieu Roumiguié
- Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada; Department of Urology, Toulouse Cancer Institute and Toulouse University Hospital, Toulouse, France
| | - Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Trinity J Bivalacqua
- Perelman Center for Advanced Medicine, University of Pennsylvania, Division of Urology, Department of Surgery, Philadelphia, PA.
| | - Seth P Lerner
- Scott Department of Urology, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Wassim Kassouf
- Department of Surgery (Urology), Faculty of Medicine, McGill University, Montreal, Canada
| | - Andreas Böhle
- Departments of Urology, University of Lübeck, Lübeck, Germany; HELIOS Agnes-Karll-Krankenhaus, Bad Schwartau, Germany
| | | | - Roger Buckley
- North York General Hospital, Toronto, Ontario, Canada
| | - Raj Persad
- Department of Urology, Southmead Hospital, North Bristol Hospitals Trust, Bristol, UK
| | - Marc Colombel
- Claude Bernard University, Hôpital Edouard Herriot, Lyon, France
| | - Donald Lamm
- University of Arizona and BCG Oncology, Phoenix, AZ, USA
| | - Juan Palou-Redorta
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mark Soloway
- Division of Urology, Memorial Cancer Institute, Memorial Hospital, Hollywood, FL, USA
| | - Ken Brothers
- Patient Advocate, National Cancer Institute Bladder Cancer Task Force, Snowbasin, UT, USA
| | - Gary Steinberg
- Department of Urology, NYU Langone Health, New York, NY, USA
| | - Yair Lotan
- Department of Urology, UT Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Richard Sylvester
- European Association of Urology Guidelines Office, Brussels, Belgium
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter C Black
- Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada.
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Musat MG, Kwon CS, Masters E, Sikirica S, Pijush DB, Forsythe A. Treatment Outcomes of High-Risk Non-Muscle Invasive Bladder Cancer (HR-NMIBC) in Real-World Evidence (RWE) Studies: Systematic Literature Review (SLR). Clinicoecon Outcomes Res 2022; 14:35-48. [PMID: 35046678 PMCID: PMC8759992 DOI: 10.2147/ceor.s341896] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/18/2021] [Indexed: 12/30/2022]
Abstract
Background To date, there has been limited synthesis of RWE studies in high-risk non-muscle invasive bladder cancer (HR-NMIBC). The objective of this research was to conduct a systematic review of published real-world evidence to better understand the real-world burden and treatment patterns in HR-NMIBC. Methods An SLR was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with the scope defined by the Population, Intervention Comparators, Outcomes, and Study design (PICOS) criteria. EMBASE, MEDLINE, and Cochrane databases (Jan 2015–Jul 2020) were searched, and relevant congress abstracts (Jan 2018–Jul 2020) identified. The final analysis only included studies that enrolled ≥100 patients with HR-NMIBC from the US, Europe, Canada, and Australia. Results The SLR identified 634 RWE publications in NMIBC, of which 160 studies reported data in HR-NMIBC. The average age of patients in the studies was 71 years, and 79% were males. The rates of BCG intravesical instillations ranged from 3% to 86% (29–95% for induction and 8–83% for maintenance treatment). Five-year outcomes were 17–89% recurrence-free survival (longest survival in patients completing BCG maintenance), 58–89% progression-free survival, 71–96% cancer-specific survival (lowest survival in BCG-unresponsive patients), and 28–90% overall survival (lowest survival in patients who did not receive BCG or instillation therapy). Conclusion BCG treatment rates and survival outcomes in patients with HR-NMIBC vary in the real world, with better survival seen in patients completing maintenance BCG, responding to treatment, and not progressing to muscle-invasive disease. There is a need to better understand the factors associated with BCG use and discontinuation and for an effective treatment that improves outcomes in HR-NMIBC. Generalization of these results is limited by variations in data collection, reporting, and methodologies used across RWE studies.
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Affiliation(s)
- Mihaela Georgiana Musat
- Evidence Generation, Purple Squirrel Economics, a Wholly Owned Subsidiary of Cytel, Inc., Waltham, MA, USA
| | - Christina Soeun Kwon
- Evidence Generation, Purple Squirrel Economics, a Wholly Owned Subsidiary of Cytel, Inc., Waltham, MA, USA
| | | | - Slaven Sikirica
- Global Health Economics and Outcomes Research, Pfizer, New York, NY, USA
| | - Debduth B Pijush
- Global Health Economics and Outcomes Research, Pfizer, New York, NY, USA
| | - Anna Forsythe
- Value and Access, Purple Squirrel Economics, a Wholly Owned Subsidiary of Cytel, Inc., Waltham, MA, USA
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Ilijazi D, Pulverer W, Ertl IE, Lemberger U, Kimura S, Abufaraj M, D’Andrea D, Pradere B, Bruchbacher A, Graf A, Soria F, Susani M, Haitel A, Molinaro L, Pycha A, Comploj E, Pabinger S, Weinhäusel A, Egger G, Shariat SF, Hassler MR. Discovery of Molecular DNA Methylation-Based Biomarkers through Genome-Wide Analysis of Response Patterns to BCG for Bladder Cancer. Cells 2020; 9:cells9081839. [PMID: 32764425 PMCID: PMC7464079 DOI: 10.3390/cells9081839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 01/11/2023] Open
Abstract
Background: Bacillus Calmette-Guérin (BCG) immunotherapy, the standard adjuvant intravesical therapy for some intermediate and most high-risk non-muscle invasive bladder cancers (NMIBCs), suffers from a heterogenous response rate. Molecular markers to help guide responses are scarce and currently not used in the clinical setting. Methods: To identify novel biomarkers and pathways involved in response to BCG immunotherapy, we performed a genome-wide DNA methylation analysis of NMIBCs before BCG therapy. Genome-wide DNA methylation profiles of DNA isolated from tumors of 26 BCG responders and 27 failures were obtained using the Infinium MethylationEPIC BeadChip. Results: Distinct DNA methylation patterns were found by genome-wide analysis in the two groups. Differentially methylated CpG sites were predominantly located in gene promoters and gene bodies associated with bacterial invasion of epithelial cells, chemokine signaling, endocytosis, and focal adhesion. In total, 40 genomic regions with a significant difference in methylation between responders and failures were detected. The differential methylation state of six of these regions, localized in the promoters of the genes GPR158, KLF8, C12orf42, WDR44, FLT1, and CHST11, were internally validated by bisulfite-sequencing. GPR158 promoter hypermethylation was the best predictor of BCG failure with an AUC of 0.809 (p-value < 0.001). Conclusions: Tumors from BCG responders and BCG failures harbor distinct DNA methylation profiles. Differentially methylated DNA regions were detected in genes related to pathways involved in bacterial invasion of cells or focal adhesion. We identified candidate DNA methylation biomarkers that may help to predict patient prognosis after external validation in larger, well-designed cohorts.
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Affiliation(s)
- Dafina Ilijazi
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
| | - Walter Pulverer
- AIT—Austrian Institute of Technology GmbH, Health & Environment Department, Molecular Diagnostics, 1210 Vienna, Austria; (W.P.); (S.P.); (A.W.)
| | - Iris E. Ertl
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
| | - Ursula Lemberger
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
| | - Shoji Kimura
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
- Department of Urology, Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Mohammad Abufaraj
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
- Division of Urology, Department of Special Surgery, The University of Jordan, Amman 11942, Jordan
| | - David D’Andrea
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
| | - Benjamin Pradere
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
- Department of Urology, CHRU Tours, Francois Rabelais University, 37000 Tours, France
| | - Andreas Bruchbacher
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
| | - Anna Graf
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
| | - Francesco Soria
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, 10124 Turin, Italy
| | - Martin Susani
- Clinical Institute of Pathology, Medical University of Vienna, Vienna 1090, Austria; (M.S.); (A.H.); (G.E.)
| | - Andrea Haitel
- Clinical Institute of Pathology, Medical University of Vienna, Vienna 1090, Austria; (M.S.); (A.H.); (G.E.)
| | - Luca Molinaro
- Division of Pathology, Department of Medical Sciences, University of Studies of Torino, 10124 Turin, Italy;
| | - Armin Pycha
- Department of Urology, Central Hospital of Bolzano/Bozen, 39100 Bozen, Italy; (A.P.); (E.C.)
- Sigmund Freud Private University, Medical University, 1020 Vienna, Austria
| | - Evi Comploj
- Department of Urology, Central Hospital of Bolzano/Bozen, 39100 Bozen, Italy; (A.P.); (E.C.)
- College of Health-Care Professions, Claudiana Research, Claudiana, 39100 Bolzano, Italy
| | - Stephan Pabinger
- AIT—Austrian Institute of Technology GmbH, Health & Environment Department, Molecular Diagnostics, 1210 Vienna, Austria; (W.P.); (S.P.); (A.W.)
| | - Andreas Weinhäusel
- AIT—Austrian Institute of Technology GmbH, Health & Environment Department, Molecular Diagnostics, 1210 Vienna, Austria; (W.P.); (S.P.); (A.W.)
| | - Gerda Egger
- Clinical Institute of Pathology, Medical University of Vienna, Vienna 1090, Austria; (M.S.); (A.H.); (G.E.)
- Ludwig Boltzmann Institute Applied Diagnostics, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Shahrokh F. Shariat
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
- Division of Urology, Department of Special Surgery, The University of Jordan, Amman 11942, Jordan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
- Department of Urology, Weill Cornell Medical College, New York, NY 10065, USA
- Karl Landsteiner Institute of Urology and Andrology, 3100 St. Poelten, Austria
- Department of Urology, Second Faculty of Medicine, Charles University, 150 06 Prague, Czech Republic
- Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, 119992 Moscow, Russia
- European Association of Urology research foundation, 6842 Arnhem, Netherlands
- Correspondence: (S.F.S.); (M.R.H.); Tel.: +43-01-40400-26150 (M.R.H.)
| | - Melanie R. Hassler
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria; (D.I.); (I.E.E.); (U.L.); (S.K.); (M.A.); (D.D.); (B.P.); (A.B.); (A.G.); (F.S.)
- Correspondence: (S.F.S.); (M.R.H.); Tel.: +43-01-40400-26150 (M.R.H.)
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Kamat AM, Lerner SP, O'Donnell M, Georgieva MV, Yang M, Inman BA, Kassouf W, Boorjian SA, Tyson MD, Kulkarni GS, Chang SS, Konety BR, Svatek RS, Balar A, Witjes JA. Evidence-based Assessment of Current and Emerging Bladder-sparing Therapies for Non-muscle-invasive Bladder Cancer After Bacillus Calmette-Guerin Therapy: A Systematic Review and Meta-analysis. Eur Urol Oncol 2020; 3:318-340. [PMID: 32201133 DOI: 10.1016/j.euo.2020.02.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/15/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
CONTEXT Currently, there is no standard of care for patients with non-muscle-invasive bladder cancer (NMIBC) who recur despite bacillus Calmette-Guerin (BCG) therapy. Although radical cystectomy is recommended, many patients decline to undergo or are ineligible to receive it. Multiple agents are being investigated for use in this patient population. OBJECTIVE To systematically synthesize and describe the efficacy and safety of current and emerging treatments for NMIBC patients after treatment with BCG. EVIDENCE ACQUISITION A systematic literature search of MEDLINE, Embase, and the Cochrane Controlled Register of Trials (period limited to January 2007-June 2019) was performed. Abstracts and presentations from major conference proceedings were also reviewed. Randomized controlled trials were assessed using the Cochrane risk of bias tool. Data for single-arm trials were pooled using a random-effect meta-analysis with the proportions approach. Trials were grouped based on the minimum number of prior BCG courses required before enrollment and further stratified based on the proportion of patients with carcinoma in situ (CIS). EVIDENCE SYNTHESIS Thirty publications were identified with data from 23 trials for meta-analysis, of which 17 were single arm. Efficacy and safety outcomes varied widely across studies. Heterogeneity across trials was reduced in subgroup analyses. The pooled 12-mo response rates were 24% (95% confidence interval [CI]: 16-32%) for trials with two or more prior BCG courses and 36% (95% CI: 25-47%) for those with one or more prior BCG courses. In a subgroup analysis, inclusion of ≥50% of patients with CIS was associated with a lower response. CONCLUSIONS The variability in efficacy and safety outcomes highlights the need for consistent endpoint reporting and patient population definitions. With promising emerging treatments currently in development, efficacious and safe therapeutic options are urgently needed for this difficult-to-treat patient population. PATIENT SUMMARY We examined the efficacy and safety outcomes of treatments for non-muscle-invasive bladder cancer after bacillus Calmette-Guerin therapy. Outcomes varied across studies and patient populations, but emerging treatments currently in development show promising efficacy.
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Affiliation(s)
- Ashish M Kamat
- University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - J Alfred Witjes
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Fukuokaya W, Kimura T, Miki J, Kimura S, Watanabe H, Bo F, Okada D, Aikawa K, Ochi A, Suzuki K, Shiga N, Abe H, Egawa S. Red cell distribution width predicts time to recurrence in patients with primary non-muscle-invasive bladder cancer and improves the accuracy of the EORTC scoring system. Urol Oncol 2020; 38:638.e15-638.e23. [PMID: 32184059 DOI: 10.1016/j.urolonc.2020.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE To investigate the clinical prognostic value of red cell distribution width (RDW) in patients with non-muscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS We retrospectively evaluated 582 consecutive patients with primary NMIBC. The efficacy of preoperative RDW at predicting treatment outcome was assessed. A cut-off point for predicting recurrence was also identified. Uni- and multivariable analyses of time to recurrence (TTR) and progression were conducted. Harrell's concordance index (c-index) was used to evaluate the additive value of RDW to the European Organization of Research and Treatment of Cancer (EORTC) risk scoring model for recurrence. RESULTS According to the receiver operating characteristic curve of RDW for recurrence, a RDW ≥ 14.5% was classified as high. In the multivariable analysis, a high RDW could independently predict shorter TTR (subdistribution hazard ratio [SHR]: 2.65, 95% confidence interval [CI]: 1.83-3.84, P < 0.001), irrespective of tumor characteristics. No significant relationship was observed between RDW and time to progression (SHR: 1.75, 95% CI: 0.76-4.08, P = 0.19). Adding binary-coded RDW to the EORTC risk scoring model significantly improved its discriminatory performance in assessing recurrence risk (c-index: 0.62, improvement: 0.052, P < 0.001). High RDW was associated with shorter TTR in patients treated with bacillus Calmette-Guerin in the multivariable analysis (SHR: 2.0, 95% CI: 1.01-3.98, P = 0.047). CONCLUSIONS RDW was an independent, significant prognostic factor of TTR in patients with primary NMIBC. Adding RDW to the EORTC risk model significantly improved the model's predictability for tumor recurrence.
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Affiliation(s)
- Wataru Fukuokaya
- Department of Urology, Kameda Medical Center, Kamogawa City, Chiba, Japan; Department of Urology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Jun Miki
- Department of Urology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Shoji Kimura
- Department of Urology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Hisaki Watanabe
- Department of Urology, Kameda Medical Center, Kamogawa City, Chiba, Japan; Department of Urology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Fan Bo
- Department of Urology, Kameda Medical Center, Kamogawa City, Chiba, Japan
| | - Daigo Okada
- Department of Urology, Kameda Medical Center, Kamogawa City, Chiba, Japan
| | - Koichi Aikawa
- Department of Urology, Kameda Medical Center, Kamogawa City, Chiba, Japan; Department of Urology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Atsuhiko Ochi
- Department of Urology, Kameda Medical Center, Kamogawa City, Chiba, Japan
| | - Koichiro Suzuki
- Department of Urology, Kameda Medical Center, Kamogawa City, Chiba, Japan
| | - Naoki Shiga
- Department of Urology, Kameda Medical Center, Kamogawa City, Chiba, Japan
| | - Hirokazu Abe
- Department of Urology, Kameda Medical Center, Kamogawa City, Chiba, Japan
| | - Shin Egawa
- Department of Urology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
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Li R, Sundi D, Zhang J, Kim Y, Sylvester RJ, Spiess PE, Poch MA, Sexton WJ, Black PC, McKiernan JM, Steinberg GD, Kamat AM, Gilbert SM. Systematic Review of the Therapeutic Efficacy of Bladder-preserving Treatments for Non-muscle-invasive Bladder Cancer Following Intravesical Bacillus Calmette-Guérin. Eur Urol 2020; 78:387-399. [PMID: 32143924 DOI: 10.1016/j.eururo.2020.02.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/14/2020] [Indexed: 12/17/2022]
Abstract
CONTEXT There is a critical need for effective bladder-sparing therapies for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC). Owing to the current lack of effective agents that can be used as a control, the US Food and Drug Administration began to accept single-arm trials for patients with carcinoma in situ (CIS), using complete response rate (CRR) and duration of response as the primary endpoints to support marketing applications. Despite the ensuing growth of clinical trials in this space, no consensus exists on a clinically relevant benchmark for CRR. OBJECTIVE To elucidate the CRR and recurrence-free rate (RFR) using bladder-sparing agents after BCG failure in order to provide a frame of reference for future clinical trial results. EVIDENCE ACQUISITION We performed a systematic review of clinical trials utilizing bladder-sparing therapeutics for NMIBC recurring after intravesical BCG (PROSPERO CRD42019130553). The search was performed in MEDLINE, EMBASE, and Cochrane Library. Relevant studies identified from bibliography search and conference abstracts were searched to complement the systematic review. A total of 42 studies utilizing 24 treatment options and consisting of 2254 patients were included for final analysis. EVIDENCE SYNTHESIS Median CRRs in the treatment of CIS-containing tumors were 26% at 6 mo, 17% at 12 mo, and 8% at 24 mo after treatment. In comparison, median RFRs in the papillary-only studies were 67% at 6 mo, 44% at 12 mo, and 10% at 24 mo. Specifically in the BCG-unresponsive population, 6- and 12-mo CRRs in CIS-containing patients treated with Mycobacterium phlei cell wall-nucleic acid complex were 45% and 27%, respectively, and the median 6-, 12-, and 24-mo disease-free rates in the other studies were 43%, 35%, and 18%, respectively. The median progression-free rate was 91%: 95% in the CIS-containing studies and 89% in studies restricted to papillary-only recurrences. Toxicities of intravesical agents were generally mild, with very few dose limiting toxicities. CONCLUSIONS We demonstrate that, to date, bladder-sparing therapies achieved modest efficacy in patients with NMIBC after BCG. Results from the current study will serve as a frame of reference for emerging trial results in the BCG-unresponsive space. PATIENT SUMMARY In this study, we found that bladder-sparing therapies achieved modest efficacy in patients with non-muscle-invasive bladder cancer after bacillus Calmette-Guérin (BCG). These results will serve to inform future clinical trial results for salvage agents used to treat BCG-unresponsive bladder cancer.
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Affiliation(s)
- Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
| | - Debasish Sundi
- Department of Urology, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Peter C Black
- Vancouver Prostate Center, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
| | | | | | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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