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Compérat E, Amin MB, Cathomas R, Choudhury A, De Santis M, Kamat A, Stenzl A, Thoeny HC, Witjes JA. Current best practice for bladder cancer: a narrative review of diagnostics and treatments. Lancet 2022; 400:1712-1721. [PMID: 36174585 DOI: 10.1016/s0140-6736(22)01188-6] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 05/05/2022] [Accepted: 06/10/2022] [Indexed: 12/20/2022]
Abstract
This Seminar presents the current best practice for the diagnosis and management of bladder cancer. The scope of this Seminar ranges from current challenges in pathology, such as the evolving histological and molecular classification of disease, to advances in personalised medicine and novel imaging approaches. We discuss the current role of radiotherapy, surgical management of non-muscle-invasive and muscle-invasive disease, highlight the challenges of treatment of metastatic bladder cancer, and discuss the latest developments in systemic therapy. This Seminar is intended to provide physicians with knowledge of current issues in bladder cancer.
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Affiliation(s)
- Eva Compérat
- Department of Pathology, Tenon Hospital, Sorbonne University, Paris, France; Department of Pathology, Medical University of Vienna, Vienna, Austria.
| | - Mahul B Amin
- Department of Pathology and Laboratory Medicine and Urology, University of Tennessee Health Science, Memphis, TN, USA
| | - Richard Cathomas
- Department of Oncology/Hematology, Kantonsspital Graubünden, Chur, Switzerland
| | - Ananya Choudhury
- Department of Clinical Oncology, The Christie NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Maria De Santis
- Department of Urology, Charité University Hospital, Berlin, Germany
| | - Ashish Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnulf Stenzl
- Department of Urology, University Hospital, Tübingen, Germany
| | - Harriet C Thoeny
- Department of Radiology, HFR Fribourg-Hôpital Cantonal, University of Fribourg, Villars-sur-Glâne, Switzerland; Department of Urology, Inselspital University Hospital, Bern, Switzerland
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MacLennan S, Duncan E, Skolarus TA, Roobol MJ, Kasivisvanathan V, Gallagher K, Gandaglia G, Sakalis V, Smith EJ, Plass K, Ribal MJ, N'Dow J, Briganti A. Improving Guideline Adherence in Urology. Eur Urol Focus 2022; 8:1545-1552. [PMID: 34702647 DOI: 10.1016/j.euf.2021.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/24/2021] [Accepted: 10/05/2021] [Indexed: 01/25/2023]
Abstract
CONTEXT Clinical practice guidelines (CPGs) distil an evidence base into recommendations. CPG adherence is associated with better patient outcomes. However, preparation and dissemination of CPGs are a costly task involving multiple skilled personnel. Furthermore, dissemination alone does not ensure CPG adherence. Reasons for nonadherence are often complex, but understanding practice variations and reasons for nonadherence is key to improving CPG adherence and harmonising clinically appropriate and cost-effective care. OBJECTIVE To overview approaches to improving guideline adherence, to provide urology-specific examples of knowledge-practice gaps, and to highlight potential solutions informed by implementation science. EVIDENCE ACQUISITION Three common approaches to implementation science (the Knowledge-To-Action framework, the Consolidated Framework for Implementation Research, and the Behaviour Change Wheel), are summarised. EVIDENCE SYNTHESIS Three implementation problems in urology are illustrated: underuse of single instillation of intravesical chemotherapy in non-muscle-invasive bladder cancer, overuse of androgen deprivation therapy in localised prostate cancer, and guideline-discordant imaging in prostate cancer. Research using implementation science approaches to address these implementation problems is discussed. CONCLUSIONS Urologists, patients, health care providers, funders, and other key stakeholders must commit to reliably capturing and reporting data on patient outcomes, practice variations, guideline adherence, and the impact of adherence on outcomes. Leverage of implementation science frameworks is a sound next step towards improving guideline adherence and the associated benefits of evidence-based care. PATIENT SUMMARY Clinical practice guideline documents are created by expert panels. These documents provide overviews of the evidence for the tests and treatments used in patient care. They also provide recommendations and it is expected that in most circumstances clinicians will follow these recommendations. Sometimes, health care professionals cannot or do not follow these recommendations and it is not always clear why. In this review article we look at some examples of research approaches to addressing this problem of nonadherence and we provide some examples specific to urology.
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Affiliation(s)
- Steven MacLennan
- Academic Urology Unit, Institute of Applied Health Sciences, The University of Aberdeen, Aberdeen, UK; European Association of Urology Guidelines Office and Methodology Committee, Arnhem, The Netherlands.
| | - Eilidh Duncan
- Health Services Research Unit, Institute of Applied Health Sciences, The University of Aberdeen, Aberdeen, UK
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA; Veterans Affairs Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Veeru Kasivisvanathan
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Kevin Gallagher
- Department of Urology, Western General Hospital, Edinburgh, UK
| | - Giorgio Gandaglia
- Department of Urology, University Vita e Salute-San Raffaele, Milan, Italy
| | - Vasileios Sakalis
- Department of Urology, General Hospital Agios Pavlos, Thessaloniki, Greece
| | - Emma Jane Smith
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Karin Plass
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Maria J Ribal
- European Association of Urology Guidelines Office, Arnhem, The Netherlands; Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - James N'Dow
- Academic Urology Unit, Institute of Applied Health Sciences, The University of Aberdeen, Aberdeen, UK; European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Alberto Briganti
- Department of Urology, University Vita e Salute-San Raffaele, Milan, Italy; European Association of Urology Guidelines Office, Arnhem, The Netherlands
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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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Dunsmore J, Duncan E, Mariappan P, de Bruin M, MacLennan S, Dimitropoulos K, Kasivisvanathan V, Mostafid H, Briganti A, N'Dow J, MacLennan S. What influences adherence to guidance for postoperative instillation of intravesical chemotherapy to patients with bladder cancer? BJU Int 2021; 128:225-235. [PMID: 33450116 DOI: 10.1111/bju.15336] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To understand the barriers and facilitators to single instillation of intravesical chemotherapy (SI-IVC) use after resection of non-muscle-invasive bladder cancer (NMIBC) in Scotland and England using a behavioural theory-informed approach. SUBJECTS AND METHODS In a cross-sectional descriptive study of practices at seven hospitals, we investigated care pathways, policies, and interviewed 30 urology staff responsible for SI-IVC. We used the Theoretical Domains Framework (TDF) to organise our investigation and conducted deductive thematic analyses, while inductively coding emergent beliefs. RESULTS Barriers to SI-IVC were present at different organisational levels and professional roles. In four hospitals, there was a policy to not instil SI-IVC in theatre. Six hospitals' staff reported delays in mitomycin C (MMC) ordering and/or local storage. Lack of training, skills and perceived workload affected motivation. Facilitators included access to modern instilling devices (four hospitals) and incorporating reminders in operation proforma (four hospitals). Performance targets (with audit and feedback) within a national governance framework were present in Scotland but not England. Differences in coordinated leadership, sharing best practices, and disliking being perceived as underperforming, were evident in Scotland. CONCLUSIONS High-certainty evidence shows that SI-IVC, such as MMC, after NMIBC resection reduces recurrences. This evidence underpins international guidance. The number of eligible patients receiving SI-IVC is variable indicating suboptimal practice. Improving SI-IVC adherence requires modifications to theatre instilling policies, delivery and storage of MMC, staff training, and documentation. Centralising care, with bladder cancer expert leadership and best practices sharing with performance targets, likely led to improvements in Scotland. National quality improvement, incorporating audit and feedback, with additional implementation strategies targeted to professional role could improve adherence and patient outcomes elsewhere. This process should be controlled to clarify implementation intervention effectiveness.
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Affiliation(s)
| | - Eilidh Duncan
- Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Paramananthan Mariappan
- Department of Urology, Edinburgh Bladder Cancer Surgery, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Marijn de Bruin
- IQ Healthcare, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, the Netherlands.,Aberdeen Health Psychology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Sara MacLennan
- Academic Urology Unit, Institute of Applied Health Sciences, UK
| | - Konstantinos Dimitropoulos
- Academic Urology Unit, Institute of Applied Health Sciences, UK.,Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | | | - Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Alberto Briganti
- IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy.,European Association of Urology Guidelines Office, Arnhem, the Netherlands
| | - James N'Dow
- Academic Urology Unit, Institute of Applied Health Sciences, UK.,Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK.,European Association of Urology Guidelines Office, Arnhem, the Netherlands
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