A randomized multicenter trial of adjuvant therapy in superficial bladder cancer: transurethral resection only versus transurethral resection plus mitomycin C versus transurethral resection plus bacillus Calmette-Guerin. Participating Clinics

Comparative analysis of adverse events among intravesical drugs in bladder cancer: a real-world study on FAERS database

BACKGROUND

Intravesical therapy is a commonly utilized treatment for non-muscle invasive bladder cancer (NMIBC). This study focuses on summarizing the signals of all intravesical drugs and aims to highlight the comprehensive differences in adverse events (AEs) between these drugs.

RESEARCH DESIGN AND METHODS

We conducted pharmacovigilance data analysis based on the real-world big data from the Food and Drug Administration Adverse Event Reporting System (FAERS) database.

RESULTS

We elucidated all signals compared with the overall FAERS database or other administration routes for Bacillus Calmette-Guerin (BCG), mitomycin, gemcitabine, valrubicin, and epirubicin. Notably, the distribution of reported AEs associated with intravesical therapy exhibited a noticeable inclination toward male patients. Furthermore, all five drugs demonstrated a disproportionate distribution in local AEs, particularly in renal and urinary disorders. Additionally, specific signals and findings were summarized for each individual drug. Finally, we highlighted the AEs that resulted in serious outcomes for each drug.

CONCLUSION

We have compiled an overview of the AEs tied to intravesical drugs whilst considering their individual distinctions. These insightful findings serve to enrich our comprehension of the safety profiles and potential risks linked to intravesical therapy.

The Role of Mitomycin C in Intermediate-risk Non-muscle-invasive Bladder Cancer: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Intravesical mitomycin C (MMC) instillations are recommended to prevent recurrence of intermediate-risk non-muscle-invasive bladder cancer (IR-NMIBC); however, the optimal regimen and dose are uncertain. Our aim was to assess the effectiveness of adjuvant MMC and compare different MMC regimens in preventing recurrence.

METHODS

We performed a comprehensive search in PubMed, Scopus, and Web of Science in November 2023 for studies investigating recurrence-free survival (RFS) among patients with IR-NMIBC who received adjuvant MMC. Prospective trials with different MMC regimens or other intravesical drugs as comparators were considered eligible.

KEY FINDINGS AND LIMITATIONS

Overall, 14 studies were eligible for systematic review and 11 for meta-analysis of RFS. Estimates of 1-yr, 2-yr, and 5-yr RFS rates were 84% (95% confidence interval [CI] 79-89%), 75% (95% CI 68-82%), and 51% (95% CI 40-63%) for patients treated with MMC induction plus maintenance, and 88% (95% CI 83-94%), 78% (95% CI 67-89%), and 66% (95% CI 57-75%) for patients treated with bacillus Calmette-Guérin (BCG) maintenance, respectively. Estimates of 2-yr RFS rates for MMC maintenance regimens were 76% (95% CI 69-84%) for 40 mg MMC (2 studies) and 66% (95% CI 60-72%) for 30 mg MMC (4 studies). Among the studies included, BCG maintenance provided comparable 2-yr RFS to 40 mg MMC with maintenance (78% vs 76%). RFS did not differ by MMC maintenance duration (>1 yr vs 1 yr vs <1 yr).

CONCLUSIONS AND CLINICAL IMPLICATIONS

MMC induction and maintenance regimens seem to provide short-term RFS rates equivalent to those for BCG maintenance in IR-NMIBC. For adjuvant induction and maintenance, 40 mg of MMC appears to be more effective in preventing recurrence than 30 mg. We did not observe an RFS benefit for longer maintenance regimens.

PATIENT SUMMARY

For patients with intermediate-risk non-muscle-invasive bladder cancer, bladder treatments with a solution of a drug called mitomycin C (MMC) seem to be as effective as BCG (bacillus Calmette-Guérin) in preventing recurrence after tumor removal. Further trials are needed for stronger evidence on the best MMC dose and treatment time.

The efficacy and safety outcomes of lower dose BCG compared to intravesical chemotherapy in non-muscle-invasive bladder cancer: A network meta-analysis

This study aimed to assess both efficacy and safety outcomes of lowering the dose of BCG compared to intravesical chemotherapies in non-muscle-invasive bladder cancer (NMIBC) patients using a systematic review, meta-analysis, and network meta-analysis approach. A comprehensive literature search was performed through Pubmed®, Web of Science™, and Scopus® in December 2022 to identify randomized controlled trials comparing the oncologic and/or safety outcomes of reduced dose intravesical BCG and/or intravesical chemotherapies according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement. The outcomes of interest were risk of recurrence, progression, treatment-related adverse events, and discontinuation. Overall, 24 studies were eligible for quantitative synthesis. Among 22 studies that adopted induction followed by maintenance intravesical therapy, with reference to the lower-dose BCG, epirubicin was associated with a significantly higher risk of recurrence (Odds ratio [OR]: 2.82, 95% CI: 1.54-5.15), but not other intravesical chemotherapies. There were no significant differences in risk of progression among the intravesical therapies. On the other hand, standard-dose BCG was associated with a higher risk of any AEs (OR: 1.91, 95% CI: 1.07-3.41) but other intravesical chemotherapies had a comparable risk of AEs compared to lower-dose BCG. The discontinuation rate did not significantly differ between lower-dose and standard-dose BCG (OR: 1.40, 95% CI: 0.81-2.43) as well as other intravesical. According to the surface under the cumulative ranking curve, gemcitabine, and standard-dose BCG were preferable to lower-dose BCG in terms of recurrence risk; gemcitabine was also preferable to lower-dose BCG in terms of risk of AEs. In patients with NMIBC, lowering the dose of BCG decreases the risks of AEs and discontinuation rate compared to standard-dose BCG, but there is no difference in these endpoints compared to other intravesical chemotherapies. Standard-dose of BCG is preferred for all intermediate and high-risk NMIBC patients based on oncologic efficacy; however, lower-dose BCG and intravesical chemotherapies, especially gemcitabine, could be considered a reasonable alternative to BCG in selected patients who suffer from significant AEs or in case standard-dose BCG is not available.

BCG in Bladder Cancer Immunotherapy

BCG is a live attenuated strain of Mycobacterium bovis that is primarily used as a vaccine against tuberculosis. In the past four decades, BCG has also been used for the treatment of non-muscle invasive bladder cancer (NMIBC). In patients with NMIBC, BCG reduces the risk of tumor recurrence and decreases the likelihood of progression to more invasive disease. Despite the long-term clinical experience with BCG, its mechanism of action is still being elucidated. Data from animal models and from human studies suggests that BCG activates both the innate and adaptive arms of the immune system eventually leading to tumor destruction. Herein, we review the current data regarding the mechanism of BCG and summarize the evidence for its clinical efficacy and recommended indications and clinical practice.

Bacillus Calmette-Guérin immunotherapy for bladder cancer: a review of immunological aspects, clinical effects and BCG infections

Bacillus Calmette-Guérin (BCG) immunotherapy for bladder cancer has been used since 1976 when the first evidence of its ability to lower recurrence and progression rates was published. Today, BCG immunotherapy is the choice of care for high-grade non-muscle invasive bladder cancer (NMIBC) after transurethral resection. This article presents indications and procedure of BCG instillations, and outlines the effects on recurrence and progression of NMIBC. The BCG-induced immunity in NMIBC is not yet fully understood. Animal studies point towards BCG inducing specific tumour immunity. We describe the current knowledge of how this immunity is induced, from internalization of BCG bacilli in urothelial cells, to cytokine- and chemokine-mediated recruitment of neutrophils, monocytes, macrophages, T cells, B cells and natural killer cells. In addition, we describe the process of trained immunity, the non-specific protective effects of BCG. Recent studies also indicate that dysbiosis of the urinary microbiome may cause lower urinary tract dysfunction. Side effects of BCG bladder instillations range from common, mild and transient symptoms, such as dysuria and flu-like symptoms, to more severe and rarely occurring life-threatening complications. We review the literature and give an overview of reported incidences and management of BCG infections after intravesical instillation.

Intravesical Bacillus Calmette-Guérin versus mitomycin C for Ta and T1 bladder cancer

BACKGROUND

People with urothelial carcinoma of the bladder are at risk for recurrence and progression following transurethral resection of a bladder tumour (TURBT). Mitomycin C (MMC) and Bacillus Calmette-Guérin (BCG) are commonly used, competing forms of intravesical therapy for intermediate- or high-risk non-muscle invasive (Ta and T1) urothelial bladder cancer but their relative merits are somewhat uncertain.

OBJECTIVES

To assess the effects of BCG intravesical therapy compared to MMC intravesical therapy for treating intermediate- and high-risk Ta and T1 bladder cancer in adults.

SEARCH METHODS

We performed a systematic literature search in multiple databases (CENTRAL, MEDLINE, Embase, Web of Science, Scopus, LILACS), as well as in two clinical trial registries. We searched reference lists of relevant publications and abstract proceedings. We applied no language restrictions. The latest search was conducted in September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared intravesical BCG with intravesical MMC therapy for non-muscle invasive urothelial bladder cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the literature, extracted data, assessed risk of bias and rated the quality of evidence according to GRADE per outcome. In the meta-analyses, we used the random-effects model.

MAIN RESULTS

We identified 12 RCTs comparing BCG versus MMC in participants with intermediate- and high-risk non-muscle invasive bladder tumours (published from 1995 to 2013). In total, 2932 participants were randomised. Time to death from any cause: BCG may make little or no difference on time to death from any cause compared to MMC (hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.79 to 1.20; participants = 1132, studies = 5; 567 participants in the BCG arm and 565 in the MMC arm; low-certainty evidence). This corresponds to 6 fewer deaths (40 fewer to 36 more) per 1000 participants treated with BCG at five years. We downgraded the certainty of the evidence two levels due to study limitations and imprecision. Serious adverse effects: 12/577 participants treated with BCG experienced serious non-fatal adverse effects compared to 4/447 participants in the MMC group. The pooled risk ratio (RR) is 2.31 (95% CI 0.82 to 6.52; participants = 1024, studies = 5; low-certainty evidence). Therefore, BCG may increase the risk for serious adverse effects compared to MMC. This corresponds to nine more serious adverse effects (one fewer to 37 more) with BCG. We downgraded the certainty of the evidence two levels due to study limitations and imprecision. Time to recurrence: BCG may reduce the time to recurrence compared to MMC (HR 0.88, 95% CI 0.71 to 1.09; participants = 2616, studies = 11, 1273 participants in the BCG arm and 1343 in the MMC arm; low-certainty evidence). This corresponds to 41 fewer recurrences (104 fewer to 29 more) with BCG at five years. We downgraded the certainty of the evidence two levels due to study limitations, imprecision and inconsistency. Time to progression: BCG may make little or no difference on time to progression compared to MMC (HR 0.96, 95% CI 0.73 to 1.26; participants = 1622, studies = 6; 804 participants in the BCG arm and 818 in the MMC arm; low-certainty evidence). This corresponds to four fewer progressions (29 fewer to 27 more) with BCG at five years. We downgraded the certainty of the evidence two levels due to study limitations and imprecision. Quality of life: we found very limited data for this outcomes and were unable to estimate an effect size.

AUTHORS' CONCLUSIONS

Based on our findings, BCG may reduce the risk of recurrence over time although the Confidence Intervals include the possibility of no difference. It may have no effect on either the risk of progression or risk of death from any cause over time. BCG may cause more serious adverse events although the Confidence Intervals once again include the possibility of no difference. We were unable to determine the impact on quality of life. The certainty of the evidence was consistently low, due to concerns that include possible selection bias, performance bias, given the lack of blinding in these studies, and imprecision.

Bayesian Autoregressive Frailty Models for Inference in Recurrent Events

We propose autoregressive Bayesian semi-parametric models for gap times between recurrent events. The aim is two-fold: inference on the effect of possibly time-varying covariates on the gap times and clustering of individuals based on the time trajectory of the recurrent event. Time-dependency between gap times is taken into account through the specification of an autoregressive component for the frailty parameters influencing the response at different times. The order of the autoregression may be assumed unknown and is an object of inference. We consider two alternative approaches to perform model selection under this scenario. Covariates may be easily included in the regression framework and censoring and missing data are easily accounted for. As the proposed methodologies lie within the class of Dirichlet process mixtures, posterior inference can be performed through efficient MCMC algorithms. We illustrate the approach through simulations and medical applications involving recurrent hospitalizations of cancer patients and successive urinary tract infections.

Anti-EGFR Indocyanine Green-Mitomycin C-Loaded Perfluorocarbon Double Nanoemulsion: A Novel Nanostructure for Targeted Photochemotherapy of Bladder Cancer Cells

The use of phototherapy as an adjuvant bladder cancer treatment has long been considered, but its application has been severely hampered due to a lack of tumor specificity, unpredicted cytotoxicity, and insufficient anticancer efficacy. In this study, we aim to manufacture anti-EGFR indocyanine green (ICG) mitomycin C (MMC) encapsulated perfluorocarbon double nanoemulsions (EIMPDNEs), and explore their photochemotherapeutic efficacy on EGFR-expressing bladder cancer cells in vitro. The EIMPDNEs were manufactured using a double emulsification technique followed by antibody conjugation on the particles’ surfaces. The EIMPDNE were 257 ± 19.4 nm in size, with a surface charge of −12.3 ± 2.33 mV. The EGFR targetability of the EIMPNDE was confirmed by its enhanced binding efficiency to T24 cells when compared with the performance of nanodroplets without EGFR conjugation (p < 0.05). In comparison with freely dissolved ICG, the EIMPDNEs with equal ICG content conferred an improved thermal stability to the encapsulated ICG, and were able to provide a comparable hyperthermia effect and significantly enhanced the production of singlet oxygen under 808 nm near infrared (NIR) exposure with an intensity of 6 W cm−2 for 5 min (p < 0.05). Based on viability analyses, our data showed that the EIMPDNEs were effective in bladder cancer cell eradication upon NIR exposure (808 nm; 6 W cm−2), and the resulting cell death rate was even higher than that caused by a five-fold higher amount of entrapped MMC alone. With the merits of improved ICG stability, EGFR binding specificity, and effective cancer cell eradication, the EIMPDNEs exhibit potential for use in EGFR-expressing bladder cancer therapy with lower chemotoxicity.

Prognostic impact of Bacillus Calmette-Guérin interruption at the time of induction and consolidation

CONTEXT

Intravesical Bacillus Calmette-Guérin (BCG) is a cause of bladder and systemic toxicity that is difficult to prevent and is responsible for treatment drop out in bladder cancer patients. More recently, BCG shortage has become the main cause of incomplete treatment.

AIMS

The aim of this study was to examine the impact on long-term prognosis of bladder cancer patients following discontinuation of BCG instillations.

SETTINGS AND DESIGN

In this retrospective study, data were examined from 333 consecutive nonmuscle invasive bladder cancer patients treated from 2005 to 2015 by transurethral resection (TUR) and had undergone adjuvant BCG therapy after TUR.

SUBJECTS AND METHODS

Rate of complete cure, the reason for the interruption, toxicity, and the associations between discontinuance of BCG therapy, tumor characteristics, association with carcinoma in situ and tumor recurrence or progression were analyzed.

STATISTICAL ANALYSIS USED

Recurrence and progression-free survival rate curves were estimated using the Kaplan-Meier method and were compared using the log-rank test. Univariate and multivariate analyses were performed using the Cox proportional hazards model. Differences among groups were considered as statistically significant when P < 0.05.

RESULTS

Overall, 303 patients were eligible for analysis. Median follow up was 36 (confidence interval: 7-120) months. A total of 55 (18.1%) had <6 installations (Group I); 87 (28.7%) completed induction and 1-year maintenance (Group III); and 161 (53.1%) completed the induction course, but not the 1-year maintenance (Group II). Grade III-IV toxicity rates were significantly higher in Group I than Group II and III. Interruption for BCG shortage was the main cause of interrupting BCG in Group II. Multivariate analysis showed that discontinuation of BCG induction therapy was an independent predictor for tumor recurrence (P < 0.001) and 1-year BCG maintenance therapy for tumor progression (P = 0.005).

CONCLUSIONS

Discontinuation of BCG therapy has a significantly deleterious effect on tumor recurrence and progression rates. Although BCG toxicity is a major cause of drop out, BCG shortage became a major cause of discontinuation. All effort must be done today to restore normal production of BCG worldwide.

Bladder cancer: Present and future

Bladder cancer has a high incidence and involves high associated morbidity and mortality. Since its initial clinical suspicion, early diagnostic confirmation and multimodal treatment involve different medical specialties. For this reason, we consider it important to spread the current consensus for its management. Recent advances in immunology and Chemotherapy make it necessary to expose and reflect on future perspectives.

Single Arm Phase I/II Study of Everolimus and Intravesical Gemcitabine in Patients with Primary or Secondary Carcinoma In Situ of the Bladder who failed Bacillus Calmette Guerin (NCT01259063)

Background: Standard treatment for BCG-refractory urothelial cancer is radical cystectomy. Identification of active agents is clearly warranted.

Objective: To determine a safe dose of oral everolimus in combination with standard intravesical gemcitabine and to evaluate the efficacy of this combination.

Methods: Patients with carcinoma in situ refractory to intravesical bacillus Calmette-Guérin and refusing cystectomy were eligible. Patients in the phase I part of the trial received one of three dose levels of oral everolimus. Patients also received a fixed dose of intravesical gemcitabine. Maintenance everolimus was given for 12 months in patients achieving a complete response confirmed by cystoscopy and cytology. Patients in phase II received continuous everolimus administered at 10 mg daily with intravesical gemcitabine followed by everolimus maintenance for 12 months of total therapy. The enrollment goal for the phase II was 33 patients.

Results: 14 patients were enrolled in phase I of the trial. 23 patients were enrolled in phase II of the trial and 19 were evaluable for primary and secondary endpoints. Four patients withdrew consent prior to treatment initiation. Of the 19 patients evaluable for response, 3 (16%, 95% confidence interval [CI] 3% – 40%) were disease free at 1 yr. The probability of RFS was 20% (95% CI 5% – 42%) at 12 months. Ten patients out of 19 had grade 3 or greater toxicity events. Seven withdrew consent or were taken off study.

Conclusions: Many patients withdrew, and enrollment was halted. Continuous oral everolimus plus intravesical gemcitabine was not well tolerated in this patient population where the threshold for tolerability is low.

5-Aminolevulinic acid in intraoperative photodynamic therapy of bladder cancer (results of multicenter trial)

The results of multicenter prospective trial for efficacy of combined modality treatment: transurethral resection (TUR)+photodynamic therapy (PDT) with alasens for bladder cancer are represented in the article. Trials were organized by Research Institute of Organic Intermediates and Dyes and conducted according to clinical protocol approved by Ministry of Health of Russia, at the sites of leading Russian cancer clinical centers. The trial included 45 subjects with verified diagnosis of non-muscle-invasive bladder cancer. Patients underwent TUR of bladder with simultaneous PDT as anti-relapse treatment. Alasens was administered to patients as intravesicular instillation of 3% solution in volume of 50ml with 1.5-2h exposure (prior to TUR). TUR was performed after instillation. PDT session was conducted immediately after the completion of TUR on a single occasion by means of combined local irradiation on tumor bed with diffuse irradiation on whole urinary bladder mucosa (light dose of local irradiation - 100J/cm2, diffuse irradiation - 20J/cm2). Good tolerance of the treatment was noticed, there were no complications. Among 45 patients included in the trial, 35 (78%) completed 12 month protocol follow-up without relapse. In our study PDT with alasens after TUR reported a recurrence rate of non-muscle-invasive bladder cancer for 1st year after treatment of 22%. TUR with intraoperative PDT with 5-aminolevulinic acid may offer an alternative in the treatment of non-muscle-invasive intermediate and high-risk bladder cancer.

Antitumour responses induced by a cell-based Reovirus vaccine in murine lung and melanoma models

BACKGROUND

The ever increasing knowledge in the areas of cell biology, the immune system and the mechanisms of cancer are allowing a new phase of immunotherapy to develop. The aim of cancer vaccination is to activate the host immune system and some success has been observed particularly in the use of the BCG vaccine for bladder cancer as an immunostimulant. Reovirus, an orphan virus, has proven itself as an oncolytic virus in vitro and in vivo. Over 80 % of tumour cell lines have been found to be susceptible to Reovirus infection and it is currently in phase III clinical trials. It has been shown to induce immune responses to tumours with very low toxicities.

METHODS

In this study, Reovirus was examined in two main approaches in vivo, in mice, using the melanoma B16F10 and Lewis Lung Carcinoma (LLC) models. Initially, mice were treated intratumourally (IT) with Reovirus and the immune responses determined by cytokine analysis. Mice were also vaccinated using a cell-based Reovirus vaccine and subsequently exposed to a tumourigenic dose of cells (B16F10 or LLC). Using the same cell-based Reovirus vaccine, established tumours were treated and subsequent immune responses and virus retrieval investigated.

RESULTS

Upregulation of several cytokines was observed following treatment and replication-competent virus was also retrieved from treated tumours. Varying levels of cytokine upregulation were observed and no replication-competent virus was retrieved in vaccine-treated mice. Prolongation of survival and delayed tumour growth were observed in all models and an immune response to Reovirus, either using Reovirus alone or a cell-based vaccine was also observed in all mice.

CONCLUSION

This study provides evidence of immune response to tumours using a cell-based Reovirus vaccine in both tumour models investigated, B16F10 and LLC, cytokine induction was observed with prolongation of survival in almost all cases which may suggest a new method for using Reovirus in the clinic.

Comparison of intravesical bacillus Calmette-Guerin and mitomycin C administration for non-muscle invasive bladder cancer: A meta-analysis and systematic review

The aim of the present meta-analysis was to compare the benefits of Bacillus Calmetter-Guerin (BCG) and mitomycin C in the treatment of patients with superficial bladder cancer. The present meta-analysis analyzed the benefits of BCG and mitomycin C in the treatment of patients with superficial bladder cancer by comparing progression-free survival (PFS) rates in patients treated with either of the drugs following transurethral resection. The Medline, Cochrane and EMBASE databases were searched between January 1966 and August 31, 2014 for studies that investigated the efficacy of the intravesical instillation of chemotherapy in patients with non-muscle invasive bladder cancer who had been treated with transurethral resection. Search terms included: ‘Urinary bladder neoplasms’, ‘superficial bladder cancer’ and ‘non-muscle invasive bladder cancer’; ‘bacillus Calmette-Guerin’ or ‘BCG’; ‘mitomycin C’; and ‘intravesical administration’. Sensitivity and data quality analyses were performed. A total of 6 randomized controlled studies were included with 1,289 patients. Complete 5-year PFS data for patients who received intravesical resection and were treated with mitomycin C or BCG was provided for 3 of the 6 studies, which were therefore included in the meta-analysis. The overall analysis revealed a significant benefit of BCG compared with mitomycin C in terms of 5-year PFS rate (odds ratio, 0.53; 95% confidence interval, 0.38–0.75; P<0.001), indicating that BCG was superior to mitomycin C therapy in patients with non-muscle invasive bladder cancer following transurethral resection.

Intravesical and alternative bladder-preservation therapies in the management of non-muscle-invasive bladder cancer unresponsive to bacillus Calmette-Guérin

Intravesical Bacillus Calmette-Guérin (BCG) remains the standard of care in the treatment of bladder carcinoma in situ and as adjuvant therapy after thorough transurethral resection of high-grade non-muscle-invasive bladder cancer. Despite BCG therapy, in up to 40% of patients it would recur and 60% to 70% of those would fail repeat BCG induction be deemed BCG unresponsive. For such patients, cystectomy remains the preferred treatment option per the American Urological Association and European Association of Urology, though some patients would be medically unfit or refuse radical surgery. Further intravesical therapy for bladder-preservation therapies may preserve quality of life in these patients and in some cases can be curative. There are numerous non-BCG intravesical salvage options available, including immunotherapy, single-agent chemotherapy, combination chemotherapy, and device-assisted chemotherapy. In addition, investigation of radiation-based treatment and other novel therapies including checkpoint inhibitors (programmed death-1/programmed death ligand-1), are currently underway. In this review, we examine the current status of alternatives to BCG in salvage therapy for bladder preservation.

Bayesian semiparametric analysis of recurrent failure time data using copulas

The analysis of recurrent event data is of particular importance in medical statistics where patients suffering from chronic diseases often present with multiple recurring relapses or cancer patients experience several tumor recurrences. Whereas individual subjects can be assumed to be independent, the times between events of one subject are neither independent nor identically distributed. Apart from the marginal approach by Wei et al. (1989), the shared frailty model, see for example Duchateau and Janssen (2008), has been used extensively to analyze recurrent event data, where the correlation between sequential times is implicitly taken into account via a random effect. Oakes (1989) and Romeo et al. (2006) showed and exemplified the equivalence of frailty models for bivariate survival data to Archimedean copulas. Despite the fact that copula-based models have been used to model parallel survival data, their application to recurrent failure time data has only recently been suggested by Lawless and Yilmaz (2011) for the bivariate case. Here, we extend this to more than two recurrent events and model the joint distribution of recurrent events explicitly using parametric copulas within a Bayesian framework. This framework allows for parametric as well as a nonparametric modeling of the marginal baseline hazards and models the influence of covariates on the marginals via a proportional hazards assumption. Furthermore, the parameters of the copula may also depend on the covariates. We illustrate the flexibility of this approach using data from an asthma prevention trial in young children.

Intravesical ALT-803 and BCG treatment reduces tumor burden in a carcinogen induced bladder cancer rat model; a role for cytokine production and NK cell expansion

Intravesical Bacillus Calmette-Guérin (BCG) has been shown to induce a specific immunologic response (i.e., activation of IL-2 and effector T-cells), while preclinical studies using ALT-803 (mutated IL-15 analogue combined with IL-15Rα-Fc fusion) have shown promising results by prolonging the agent's half-life and stimulating CD8+ T-cells. Based on these results, we hypothesized that the intravesical administration of ALT-803 along with BCG will generate an immunologic response leading to significant bladder tumor burden reduction. Using a well-established carcinogen induced rat non-muscle invasive bladder cancer (NMIBC) model, we studied the effects of intravesical ALT-803 with and without BCG. Rat tissues were evaluated to document treatment response. Intravesical ALT-803 was safe and well tolerated alone and in combination with BCG. As a single treatment agent, ALT-803 reduced tumor burden by 35% compared to control whereas BCG alone only reduced tumor burden by 15%. However, the combination of ALT-803 plus BCG reduced tumor burden by 46% compared to control. Immune monitoring suggested that the antitumor response was linked to the production and secretion of IL-1α, IL-1β and RANTES, which in turn, induced the proliferation and activation of NK cells. Lastly, tumoral responses of the combinational treatment were associated with 76% reduction in angiogenesis, which is significantly higher than when assessed with either agent alone. The enhanced therapeutic index seen with this duplet provides justification for the development of this regimen for future clinical trials.

Subclinical miliary Mycobacterium bovis following BCG immunotherapy for transitional cell carcinoma of the bladder

The authors present an unusual case of a 51-year-old man who developed relatively mild non-specific symptoms following intravesical BCG instillation for superficial transitional cell carcinoma of the bladder, with radiological investigations demonstrating typical features of miliary tuberculosis (TB). Transbronchial biopsy showed small foci of poorly formed granuloma suggestive of Mycobacterium infection. The patient's respiratory symptoms only became apparent 7 days after discharge having had 4 weeks of unremarkable inpatient stay where he remained clinically well. Prompt anti-TB treatment resulted in a remarkable improvement in his symptoms and radiological appearance, supporting the diagnosis of disseminated Mycobacterium bovis infection. This case highlights the importance of recognising miliary M bovis as a potential complication in patients receiving BCG immunotherapy, and that the disease course can be subclinical with delayed onset of symptoms.

[Quality of care in patients with newly diagnosed bladder cancer: a prospective assessment in northern Germany]

INTRODUCTION

The aim of this study was to evaluate the current quality of care in newly diagnosed bladder cancer patients in a regional representative sample of German urologists.

MATERIAL AND METHODS

Using a standardized questionnaire clinical and pathological data from over 400 patients with newly diagnosed urothelial carcinoma of the bladder (UCB) between January and December 2010 were collected from urology health care practitioners in northern Germany. As diagnostic and therapeutic decisions were not influenced by a specific protocol these findings represent current regional practice patterns.

RESULTS

Complete data of 359 patients were available for analysis. The median patient age at diagnosis was 72 years (range 29-98 years) with a male:female ratio of 3:1. The main reasons for transurethral resection of the bladder (TURB) were microhematuria (45.4 %), conspicuous ultrasound findings (12.8 %) and gross hematuria (11.7 %). Using photodynamic diagnosis (PDD) TURB was performed in 78 patients (21.7 %). The results of histopathology showed papillary urothelial neoplasm of low malignant potential (PUNLMP) in 8 patients (2.2 %), pTa in 202 (56.3 %), pTis in 7 (1.9 %), pT1 in 88 (24.5 %) and ≥pT2 bladder cancer in 54 (15 %) patients. Multiple tumors were recorded in 107 patients (29.8 %). A repeat TURB was performed in 130 patients (36.8 %) in a median of 45 days and residual tumor tissue was found in 79 of these patients (60.8 %). Immediate postoperative instillation chemotherapy was performed in 152 patients (42.3 %) and adjuvant intravesical maintenance therapy was performed in 142 patients (39.6 %, mitomycin 29.2 % vs. BCG 10.4 %). Patients treated with repeat TURB or adjuvant instillation therapy were more likely to have higher tumor stages and grades (p-values< 0.001). Overall 25 patients (7.7 %) experienced disease recurrence within 3 months. Lower tumor stage and grade, performance of repeat TURB and administration of adjuvant intravesical therapy were associated with reduced early disease recurrence (p-values ≤ 0.009).

CONCLUSIONS

The current study presents contemporary findings and practice patterns in patients with newly diagnosed bladder cancer. Interestingly, the rates of immediate postoperative instillation chemotherapy and maintenance intravesical therapy were lower than expected. Utilization of PDD-TURB is still underrepresented. Remarkable is the high number of patients with residual tumor in the repeat TURB. Differences in patient counselling, hospital practice standards and compliance factors most likely contribute to variations in guideline adherence.

Superficial bladder cancer: part 2. Management

In the second section of a two-part article, the recent literature is reviewed and the management of nonmuscle-invasive transitional cell carcinoma of the bladder is discussed. Particular attention is given to the indications and timing of intravesical chemotherapy and immunotherapy and the differences in efficacy and side-effect profiles of the available agents. The indications and role of second-look transurethral resection are reviewed. Additionally, the role of bacillus Calmette-Guerin in the management of this disease in terms of definitive treatment and maintenance therapy is discussed. We also offer a review of the literature regarding therapies for bacillus Calmette-Guerin-refractory nonmuscle-invasive transitional cell carcinoma of the bladder and their current place in practice.

Prophylactic effects of Bacille Calmette-Guérin intravesical instillation therapy: time period-related comparison between Japan and Western countries

Guidelines change every few years regarding the prophylactic use of Bacille Calmette-Guérin (BCG) against non-muscle invasive bladder cancer. We performed a retrospective comparison to clarify the differences in BCG efficacy, based on time period, between Japan and Western countries . Published literature on 18 Japanese and 28 Western patient studies were compared to evaluate differences in BCG efficacy. Additionally, Internet searches were performed to obtain comparative Japanese and Western data. BCG efficacy in Japanese literature tended to show decreasing non-recurrence rates by time period. Non-recurrence rates in Western countries increased each year. This discrepancy may stem from a number of factors, including changes in accepted BCG indications, the introduction of restaging transurethral resection (re-TUR), the concept of BCG maintenance, and the evolution of histopathological diagnostic criteria.

Experience with newer intravesical chemotherapy for high-risk non-muscle-invasive bladder cancer

The definitive treatment for patients with high-risk non-muscle-invasive bladder cancer (NMIBC) who fail to respond to intravesical bacillus Calmette-Guérin (BCG) is cystectomy. However, many patients who experience recurrence after BCG are either poor operative candidates or refuse surgery due to the long-term impact on their quality of life. In the last decade, there has been an increased interest in alternative intravesical therapies, and several novel chemotherapeutics have emerged as promising agents for high-risk NMIBC patients unable or unwilling to undergo cystectomy. Additionally, extended treatment regimens with combined induction and maintenance therapy have been investigated, and may increase the durability of response to these new agents, as has been shown for conventional intravesical therapy.

Adjuvant intravesical bacillus calmette-guérin therapy and survival among elderly patients with non-muscle-invasive bladder cancer

PURPOSE

National guidelines recommend adjuvant intravesical Bacillus Calmette-Guérin (BCG) therapy for higher-risk non-muscle-invasive bladder cancer (NMIBC). Although a survival benefit has not been demonstrated, randomized trials have shown reduced recurrence and delayed progression after its use. We investigated predictors of BCG receipt and its association with survival for older patients with NMIBC.

PATIENTS AND METHODS

We identified individuals with NMIBC registered in the Surveillance, Epidemiology, and End Results-Medicare database from 1991 to 2003. We used logistic regression to compare those treated with BCG within 6 months of initial diagnosis with those not treated, adjusting for demographic and clinical factors. Cox proportional hazards modeling was used to analyze the association between BCG and overall survival (OS) and bladder cancer-specific survival (BCSS) for the entire cohort and within tumor grades.

RESULTS

Of 23,932 patients with NMIBC identified, 22% received adjuvant intravesical BCG. Predictors of receipt were stages Tis and T1, higher grade, and urban residence. Age > 80 years, fewer than two comorbidities, and not being married were associated with decreased use. In the survival analysis, BCG use was associated with better OS (hazard ratio [HR], 0.87; 95% CI, 0.83 to 0.92) in the entire cohort and BCSS among higher-grade cancers (poorly differentiated: HR, 0.78; 95% CI, 0.72 to 0.85; undifferentiated: HR, 0.66; 95% CI, 0.56 to 0.77).

CONCLUSION

Despite guidelines recommending its use, BCG is administered to less than one quarter of eligible patients. This large population-based study found improved OS and BCSS were associated with use of adjuvant intravesical BCG among older patients with NMIBC. Better-designed clinical trials focusing on higher-grade cancers are needed to confirm these findings.

Current and Potential Uses of Immunocytokines as Cancer Immunotherapy

Immunocytokines (ICs) are a class of molecules created by linking tumor-reactive monoclonal antibodies to cytokines that are able to activate immune cells. Tumor selective localization is provided by the ability of the mAb component to bind to molecules found on the tumor cell surface or molecules found selectively in the tumor microenvronment. In this way the cytokine component of the immunocytokine is selectively localized to sites of tumor and can activate immune cells with appropriate receptors for the cytokine. Immunocytokines have been made and tested by us, and others, using a variety of tumor-reactive mAbs linked to distinct cytokines. To date, the majority of clinical progress has been made with ICs that have linked human interleukin-2 (IL2) to a select number of tumor reactive mAbs that had already been in prior clinical testing as non-modified mAbs (Figure 1). Here we briefly review the background for the creation of ICs, summarize current clinical progress, emphasize mechanisms of action for ICs that are distinct from those of their constituent components, and present some directions for future development and testing.

Update on the management of non-muscle invasive bladder cancer

Non-muscle invasive bladder cancer (NMIBC) is a heterogeneous population of tumours accounting for 80% of bladder cancers. Over the years, the management of this disease has been changing with improvements in results and outcomes. In this review, we focus on the latest updates on the management of NMIBC.

Enhancing photodynamyc therapy efficacy by combination therapy: dated, current and oncoming strategies

Combination therapy is a common practice in many medical disciplines. It is defined as the use of more than one drug to treat the same disease. Sometimes this expression describes the simultaneous use of therapeutic approaches that target different cellular/molecular pathways, increasing the chances of killing the diseased cell. This short review is concerned with therapeutic combinations in which PDT (Photodynamyc Therapy) is the core therapeutic partner. Besides the description of the principal methods used to assess the efficacy attained by combinations in respect to monotherapy, this review describes experimental results in which PDT was combined with conventional drugs in different experimental conditions. This inventory is far from exhaustive, as the number of photosensitizers used in combination with different drugs is very large. Reports cited in this work have been selected because considered representative. The combinations we have reviewed include the association of PDT with anti-oxidants, chemotherapeutics, drugs targeting topoisomerases I and II, antimetabolites and others. Some paragraphs are dedicated to PDT and immuno-modulation, others to associations of PDT with angiogenesis inhibitors, receptor inhibitors, radiotherapy and more. Finally, a look is dedicated to combinations involving the use of natural compounds and, as new entries, drugs that act as proteasome inhibitors.

Effectiveness of an immediate mitomycin C instillation in patients with superficial bladder cancer receiving periodic mitomycin C instillation

Purpose

We analyzed the impact of immediate intravesical mitomycin C instillation after transurethral resection of the bladder (TURB) on tumor recurrence and progression in patients with periodic mitomycin C instillation.

Materials and Methods

Between June 2000 and June 2006, a retrospective study was performed in a total of 115 patients with primary bladder tumors receiving a 6-week course of mitomycin C instillation after TURB. The patients were assigned to two groups: 53 patients in the immediate mitomycin C (I-MMC) group were treated by immediate instillation of mitomycin C after TURB and periodic instillation (6 times, 1 time per week), and 62 patients in the MMC group received only periodic instillation. Tumor recurrence and progression were compared in the two groups.

Results

During the mean follow-up period of 46.5 months in the I-MMC group and 47.2 months in the MMC group, early recurrence (within 1 year) occurred in 6 of 53 patients (11.3%) in the I-MMC group and in 18 of 62 patients (29.0%) in the MMC group (p<0.02). Although a significantly lower early recurrence rate was observed in the I-MMC group, this difference was not significant for recurrence within 2 or 3 years or for total recurrence. Progression was not significantly different between the two groups regarding the early and total period.

Conclusions

Our study confirmed the positive effect of a single, immediate mitomycin C instillation in patients with non-muscle-invasive bladder tumors who received periodic mitomycin C instillation. This benefit was limited to early recurrence and was not maintained with long-term follow-up. This approach can be an alternative to periodic mitomycin C instillation without immediate instillation.

Intravesical therapy for urothelial carcinoma of the urinary bladder: a critical review

The management of non-muscle-invasive urothelial carcinoma of the bladder (UCB) is a challenge for physicians and patients alike. This is largely due to the heterogeneous natural history of this disease, in which tumors range from indolent to rapidly progressive and eventually fatal. Moreover, the high rate of recurrence and progression cause significant morbidity, expense, and detriment to quality of life. The advent of effective and safe intravesical therapies has improved the management of non-muscle-invasive UCB. Nevertheless, despite over 30 years of research and clinical experience, the mechanism, risks, benefits, and optimal regimens and treatment algorithms remain unclear. Although immunotherapy with bacillus Calmette-Guerin (BCG) has been the mainstay of intravesical treatment and represents a significant advance in the interaction of immunology and oncology, its clinical effectiveness is accompanied by a wide range of adverse events. Here, we review the literature on intravesical immunotherapy and chemotherapy with the aim of evaluating the clinical utility of the different treatments and providing recommendations. Many studies over the years have compared efficacy and toxicities of different agents and regimens, and certain conclusions are now well supported by high-level evidence. Future perspectives and promising advances in drug development are discussed and areas of improvement are identified in order to promote better cancer control and decrease the rate and severity of side-effects.

Update on intravesical agents for non-muscle-invasive bladder cancer

Major controversies still exist with regard to the indication, type and regimen of intravesical therapy for non-muscle-invasive bladder cancer. Other areas of controversy are the criteria for response/failure of treatment and for decisions regarding secondary intravesical therapy versus radical cystectomy. In this article, we analyze the different intravesical therapeutic strategies and compare their safety and efficacy. Well-designed clinical trials have found that the addition of bacillus Calmette-Guerin (BCG) to transurethral resection (TUR) decreases the risk for both disease recurrence and progression. These encouraging results are sustained even in patients with recurrent or aggressive disease, including patients whose prior intravesical chemotherapy has failed. Most investigators believe that the efficacy of BCG therapy can be maximized with maintenance therapy. Mitomycin C (MMC), the most commonly used intravesical chemotherapy to date, decreases the risk of disease recurrence but not disease progression when used after TUR compared with TUR alone. The oncologic efficacy of intravesical MMC can be optimized by increasing its concentration in addition to alkalinizing and reducing urine production. For patients at high risk of disease progression, BCG with maintenance therapy should be the preferred primary intravesical therapeutic strategy. However, MMC can be considered as a viable alternative for patients with papillary tumors (no carcinoma in situ) that are at low or intermediate risk of disease progression. Combination intravesical therapy may be more successful than single-agent strategies. Intravesical therapy failures indicate the need to include radical cystectomy as an option in the management decision.

Novel intravesical therapies for non-muscle-invasive bladder cancer refractory to BCG

The definitive treatment for patients with non-muscle-invasive bladder cancer (NMIBC) who fail to respond to intravesical BCG is cystectomy. When a patient is deemed BCG-refractory and cannot or will not undergo cystectomy, alternative intravesical therapy may be the most effective way to minimize recurrence and progression. A number of immunotherapeutic and chemotherapeutic agents have been given intravesically over the years, and several recently and currently investigated novel agents appear to be particularly promising for the management of BCG-refractory NMIBC. The most effective treatments in the future will likely utilize targeted therapies based on the underlying genetic mutations associated with each individual diagnosis of NMIBC.

The effects of intravesical chemoimmunotherapy with gemcitabine and Bacillus Calmette-Guérin in superficial bladder cancer: a preliminary study

This prospective study investigated the long-term effects of intravesical chemoimmunotherapy with gemcitabine (GEM) and bacillus Calmette-Guérin (BCG; n = 36) versus BCG alone (n = 51) for the treatment of superficial bladder cancer. For the chemoimmunotherapy (GEM + BCG) group, GEM (1000 mg) was instilled immediately after transurethral resection of bladder tumour (TURBT) and again (2000 mg) 1 week later. From 2 to 7 weeks after TURBT, BCG was instilled into the bladder of all patients once weekly. The recurrence-free period of the GEM + BCG group (24.13 months) was significantly longer than that of the BCG monotherapy group (19.81 months). The overall recurrence rate was similar between the groups, although at 6 and 9 months post-TURBT, GEM + BCG produced a significantly lower rate of recurrence compared with BCG alone. This study suggests that intravesical chemoimmunotherapy with GEM + BCG is effective in reducing early tumour recurrence and in prolonging the recurrence-free period of superficial bladder cancer.

Intravesical therapy for superficial bladder cancer: a systematic review of randomised trials and meta-analyses

BACKGROUND

In 2002 there were estimated to be 357,000 new cases of bladder cancer worldwide and 145,000 deaths making bladder cancer the 9th most common malignancy globally. At diagnosis, 60-80% of tumours are superficial and endoscopic resection is the initial treatment for this disease. In patients with low, medium or high risk disease, about 20%, 40% and 90%, respectively, will develop tumour recurrence. To delay or prevent recurrence, intravesical therapy is routinely used. Commonly used intravesical agents include immunotherapy with BCG and chemotherapy with cytotoxics such as Mitomycin C, Adriamycin, Epirubicin and Gemcitabine. However, controversy exists as to which agent and schedule should be used.

METHODS

An overarching search of the literature was used to identify relevant studies to assess the clinical benefit of intravesical therapy and provide clinical guidance in a comprehensive systematic review of randomised trials and meta-analyses of intravesical therapy for superficial bladder cancer. Findings and interpretation the search identified over 80 randomised trials and 11 meta-analyses. The extensive evidence suggests that an immediate post-operative instillation of a chemotherapeutic agent, such as Mitomycin C or Epirubicin, is effective in reducing tumour recurrence. In intermediate or high risk patients, further intravesical induction and maintenance therapy with BCG is recommended.

CONCLUSION

Intravesical chemotherapy with either Mitomycin C or Epirubicin would be an option for those patients failing or who are unsuitable for BCG therapy. Intravesical BCG is superior to chemotherapy in terms of complete response and disease-free survival. However, there is no conclusive evidence that one agent is superior in terms of overall survival.

Understanding the role of smoking in the aetiology of bladder cancer

Bladder cancer is common in the UK. Of all the aetiological factors associated with the development of the disease, cigarette smoking is the most important, in industrialized countries. It is estimated that 60% of all bladder cancers result from smoking. The management of bladder cancer is governed by specific guidelines. Superficial cancers are managed surgically with transurethral resection, while more aggressive tumours are managed with cystectomy (removal of the bladder). Additional treatment includes cytotoxic therapy with intravesical chemotherapy and immunotherapy agents. However, while treatments may be effective in reducing tumour recurrence, the side effects of treatments on the individual's quality of life can be devastating. This paper seeks to provide an overview of bladder cancer, namely how the disease presents and is subsequently treated. The role of smoking is discussed in relation to the development of bladder cancer. Also, whether health promotion and education are effective in increasing the individual's awareness of the dangers of smoking are explored.

[Intravesical therapy in non-muscle-invasive bladder cancer: indications and practical considerations]

Intravesical treatment with various agents is an accepted standard for treating patients with non-muscle-invasive bladder cancer; all guidelines recommend its use. Depending on the agent and the instillation schedule, a reduction in recurrence and a decrease in the progression rate can be achieved.However, many of the recommendations in the various guidelines are currently under debate. Early instillation with a chemotherapeutic agent is probably overtreatment in patients requiring further induction or maintenance therapy because it adds no further benefit. The economic aspects of early instillations are also being discussed. Recent studies question the ability of bacillus Calmette-Guérin (BCG) instillations to reduce the progression of non-muscle-invasive bladder cancer. Furthermore, the superiority of maintenance therapies compared with induction schedules is under debate.There is a great body of evidence that the effectiveness of intravesical chemotherapy can be increased by simple measures. Reduction of BCG side effects without compromising the oncological outcome is possible.

Pathological upstaging during radical cystectomy is associated with worse recurrence-free survival in patients with bacillus Calmette-Guerin-refractory bladder cancer

OBJECTIVES

To compare the outcomes of patients who were upstaged to pT2 at the time of radical cystectomy (RC) to those who were correctly staged as T2 before RC.

METHODS

The clinical and pathologic data were reviewed of 496 patients who underwent RC from 1994 to 2008. Patients who underwent RC for high-grade T1 (HGT1) or carcinoma in situ (CIS) (184) were compared with those with known muscle-invasive cancer (312) before RC. Patients were substratified based on preoperative intravesical therapy status. Recurrence-free survival (RFS) for patients who were upstaged to muscle-invasive disease was compared with patients who were correctly staged T2 preoperatively.

RESULTS

Patients who were upstaged to pT2 disease had significantly worse 3- and 5-year RFS compared with those who where accurately staged (cT2 = pT2) (64% and 61% vs 83% and 74%, respectively; P = .04). Upstaging to pT2 in patients with a history of bacillus Calmette-Guerin treatment resulted in worse 3- and 5-year RFS rates compared with those accurately staged (69% and 57% vs 100% and 86%, respectively; P = .03).

CONCLUSIONS

Upstaging to pT2 among patients with HGT1 or CIS is associated with worse RFS compared with patients with known muscle invasion before RC (HGT1/CIS = pT2 vs cT2 = pT2). This finding was most significant among patients with a history of bacillus Calmette-Guerin treatment. Factors such as understaging of disease or treatment delay may contribute to worse outcomes among this subset of patients and should be considered when discussing treatment options.

Second-Line Intravesical Gemcitabine in High Risk Superficial Bladder Cancer: Our Experience

Purpose

Intravesical instillation of Gemcitabine may represent a useful second-line chemotherapy in case of non-muscle-invasive bladder cancer. Herein, we reported our experience with intravesical Gemcitabine in a group of patients affected by high-grade transitional cell carcinoma (TCC) of the bladder.

Materials and Methods

We retrospectively analyzed a total of 17 patients (15 males and 2 females), affected by high-risk superficial bladder cancer, who were refractory, intolerant or not eligible to intravesical BCG immunotherapy. Each patient received 2000 mg of Gemcitabine diluted in 100 mL of 0.9% saline solution, administered twice a week for 6 weeks. At start, TCC stage and grade were: CIS in 10 patients, TaG3 in 5 and T1G3 in the remaining 2 cases. Those with no macroscopic lesion and negative cytology and histology were considered as complete responders; those with only positive cytology as partial responders, and those with positive biopsy or evidence of macroscopic lesions as non-responders.

Results

Patients’ mean age was 71.5 yrs (± 7.3 yrs standard deviation). Overall, median follow-up was 12 months [interquartile range (IQR) 9–15 months]. A complete remission was achieved in 10 cases (58.8%), a partial response in 2 (11.8%), while 5 patients (29.4%) were considered as non-responders. Tumor stage and/or grade progression was observed in 26.7% of the cases. Overall, the 6-month recurrence-free survival was 33.3%. Drug toxicity was relatively low: 2 patients developed a grade II dysuria (NCI-CTC criteria); fever >38° was observed in 1 case.

Conclusions

Although our experience and follow-up are still rather limited to formulate any conclusive assessment, our study seems to confirm that Gemcitabine could be used as a safe and efficient intravesical chemotherapy agent even in high grade TCCs, representing a promising second-line option in those cases who failed, were intolerant or not eligible to BCG therapy. (Urologia 2009; 76: 178–84)