Health-related quality of life after treatment for bladder cancer in England

Enhancing recurrence risk prediction for bladder cancer using multi-sequence MRI radiomics

OBJECTIVE

We aimed to develop a radiomics-clinical nomogram using multi-sequence MRI to predict recurrence-free survival (RFS) in bladder cancer (BCa) patients and assess its superiority over clinical models.

METHODS

A retrospective cohort of 229 BCa patients with preoperative multi-sequence MRI was divided into a training set (n = 160) and a validation set (n = 69). Radiomics features were extracted from T2-weighted images, diffusion-weighted imaging, apparent diffusion coefficient, and dynamic contrast-enhanced images. Effective features were identified using the least absolute shrinkage and selection operator (LASSO) method. Clinical risk factors were determined via univariate and multivariate Cox analysis, leading to the creation of a radiomics-clinical nomogram. Kaplan-Meier analysis and log-rank tests assessed the relationship between radiomics features and RFS. We calculated the net reclassification improvement (NRI) to evaluate the added value of the radiomics signature and used decision curve analysis (DCA) to assess the nomogram's clinical validity.

RESULTS

Radiomics features significantly correlated with RFS (log-rank p < 0.001) and were independent of clinical factors (p < 0.001). The combined model, incorporating radiomics features and clinical data, demonstrated the best prognostic value, with C-index values of 0.853 in the training set and 0.832 in the validation set. Compared to the clinical model, the radiomics-clinical nomogram exhibited superior calibration and classification (NRI: 0.6768, 95% CI: 0.5549-0.7987, p < 0.001).

CONCLUSION

The radiomics-clinical nomogram, based on multi-sequence MRI, effectively assesses the BCa recurrence risk. It outperforms both the radiomics model and the clinical model in predicting BCa recurrence risk.

CRITICAL RELEVANCE STATEMENT

The radiomics-clinical nomogram, utilizing multi-sequence MRI, holds promise for predicting bladder cancer recurrence, enhancing individualized clinical treatment, and performing tumor surveillance.

KEY POINTS

• Radiomics plays a vital role in predicting bladder cancer recurrence. • Precise prediction of tumor recurrence risk is crucial for clinical management. • MRI-based radiomics models excel in predicting bladder cancer recurrence.

Development and validation of a novel nomogram model for predicting the survival of patients with T2-4a, N0-x, M0 bladder cancer: a retrospective cohort study

OBJECTIVE

Recent developments in bladder cancer treatment strategies have significantly improved the prognosis of clinically curable muscle invasive bladder cancer (MIBC) patients. Here, the prognostic factors of T2-4a, N0-x, M0 MIBC patients were investigated using the Surveillance, Epidemiology, and End Results (SEER) database and a novel nomogram model was established for prognosis prediction.

METHODS

The data of 7,292 patients with T2-4a, N0-x, M0 MIBC were retrieved from the SEER database (2000-2020) and randomly classified into a training set (n = 5,106) and validation set (n = 2,188). Kaplan-Meier analysis was used to calculate cancer-specific survival (CSS) and overall survival (OS) rates of patients, and differences between survival curves were analyzed using the log-rank test. Cox regression analysis was used to screen and incorporate patient prognosis-affecting independent risk factors into the nomogram model. Consistency index (C-index) values and areas under the time-dependent receiver operating characteristic curve (AUC) were used to evaluate the discriminatory ability, and the calibration curve was used to assess the calibration of the model. Its predictive performance and American Joint Committee on Cancer (AJCC) stage were compared using decision curve analysis (DCA).

RESULTS

The 1-, 3-, and 5-year CSS and OS rates of patients with T2-4a, N0-x, M0 MIBC were 76.9%, 56.0%, and 49.9%, respectively, and 71.3%, 47.9%, and 39.5%, respectively. Cox regression analysis showed that age, marital status, race, pathological type, tumor size, AJCC stage, T stage, N stage, surgery of primary tumor, regional lymph node dissection, radiation, and chemotherapy were independent prognostic risk factors of both CSS and OS (P < 0.05). The C-index and AUC of the nomogram model constructed based on the training and validation sets were both > 0.7, and calibration curves for predicting the 1-, 3-, and 5-year survival were consistent with the ideal curve. The nomogram model showed a higher net benefit with DCA than AJCC stage analysis.

CONCLUSION

The nomogram model could accurately predict the prognosis of patients with T2-4a, N0-x, M0 MIBC. It may help clinicians perform personalized prognosis evaluations and formulate treatment plans.

Lifestyle Factors in Patients with Bladder Cancer: A Contemporary Picture of Tobacco Smoking, Electronic Cigarette Use, Body Mass Index, and Levels of Physical Activity

BACKGROUND

Little is known about contemporary lifestyle choices in patients with bladder cancer (BC). These choices include carcinogenic risk factors and could affect fitness to receive treatments.

OBJECTIVE

To evaluate the contemporary lifestyle choices in BC patients.

DESIGN, SETTING, AND PARTICIPANTS

Self-reported surveys from participants diagnosed with BC in the previous 10 yr captured smoking patterns, e-cigarette use, physical activity using the GODIN Leisure-Time Exercise Questionnaire, long-term conditions (LTCs), relationship status, sociodemographics, and body mass index (BMI; height and weight).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Findings were compared with the general population and men with prostate cancer.

RESULTS AND LIMITATIONS

Completed surveys were received from 2092 participants. Most respondents were ex-smokers (61% vs 10% current vs 29% never). The use of e-cigarettes was uncommon (9%) and at lower rates than the age-equivalent general population. Passive smoke exposure was frequent (48%). Most participants (68%) were "insufficiently active" using the GODIN criteria and less physically active than the age-equivalent general population. Most respondents (44%) were classified as overweight (BMI 25-29.99) or obese (22%, BMI >30). Lifestyle factors varied with age, sex, socioeconomic deprivation, and LTCs. Younger participants were less likely to smoke (p < 0.001), more likely to have used e-cigarettes (p < 0.001), but more likely to have had passive smoke exposure (p = 0.008). Those from less affluent areas were more likely to smoke (p < 0.001), have used e-cigarettes (p < 0.001), and have had passive smoke exposure (p = 0.02). Females were less likely to be smokers (p < 0.001) but more likely to have been exposed to passive smoke (p < 0.001).

CONCLUSIONS

Persons affected by BC often have smoking exposures and high BMI, and are insufficiently active. Rates of e-cigarette use were lower than in the general population. Efforts to improve quality of life in this cohort should include wider advocation of smoking cessation, perhaps including the use of e-cigarettes, and programmes to increase exercise and reduce BMI.

PATIENT SUMMARY

We looked at the lifestyle choices, such as smoking, e-cigarette use, physical activity levels, and obesity, of patients following a bladder cancer diagnosis. We conclude that this population would benefit from healthy lifestyle interventions.

Multimorbidity in people living with and beyond cancer: a scoping review

Globally, both cancer incidence and survival are increasing. Early cancer detection and improved treatment means many people with cancer will survive for ten or more years following diagnosis. Multimorbidity, defined as two or more chronic conditions, is up to three times higher in people living with and beyond cancer (LWBC) compared to the general population. This scoping review summarises the research evidence on the association between cancer and multimorbidity in people LWBC. It explores five key domains in people LWBC: 1) prevalence of multimorbidity, 2) association between ethnicity and socio-economic status (SES) and multimorbidity, 3) association between health status and multimorbidity, 4) adverse health consequences of cancer and related treatments, and 5) whether being a cancer survivor impacts treatment received for multimorbidity. It focuses on ten common cancers with high survival rates: prostate, breast, non-Hodgkin lymphoma, bowel/colorectal, kidney, head and neck, bladder, leukaemia, uterine and myeloma. A search of Medline, CINAHL, Embase, PsychINFO and Web of Science databases identified 9,460 articles, 115 of which met the inclusion criteria. Articles were included in the review that involved multimorbidity in adult cancer patients. An evaluation of the evidence was performed, and a summary of findings was generated according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines. This review included work from 20 countries, most studies were from the US (44%). The results showed that the most common long-term conditions in people LWBC were: hypertension, heart conditions, depression, COPD, and diabetes. The most reported incident comorbidities after a cancer diagnosis were congestive heart failure, chronic pain, and chronic fatigue. Multimorbidity tended to be higher amongst people LWBC from ethnic minority groups and those with lower SES. Quality of life was poorer in people LWBC with multimorbidity. The review identified the need for a uniform approach to measure multimorbidity in cancer patients across the world. Further research is required to compare multimorbidity before and after a cancer diagnosis, to explore the association of multimorbidity with ethnicity and socio-economic status and to determine whether a cancer diagnosis impacts care received for multimorbidity in people LWBC.

A Systematic Review of Population-Based Studies of Chronic Bowel Symptoms in Cancer Survivors following Pelvic Radiotherapy

Pelvic radiotherapy can damage surrounding tissue and organs, causing chronic conditions including bowel symptoms. We systematically identified quantitative, population-based studies of patient-reported bowel symptoms following pelvic radiotherapy to synthesize evidence of symptom type, prevalence, and severity. Medline, CINAHL, EMBASE, and PsychINFO were searched from inception to September 2022. Following independent screening of titles, abstracts, and full-texts, population and study characteristics and symptom findings were extracted, and narrative synthesis was conducted. In total, 45 papers (prostate, n = 39; gynecological, n = 6) reporting 19 datasets were included. Studies were methodologically heterogeneous. Most frequently assessed was bowel function ('score', 26 papers, 'bother', 19 papers). Also assessed was urgency, diarrhea, bleeding, incontinence, abdominal pain, painful hemorrhoids, rectal wetness, constipation, mucous discharge, frequency, and gas. Prevalence ranged from 1% (bleeding) to 59% (anal bleeding for >12 months at any time since start of treatment). In total, 10 papers compared radiotherapy with non-cancer comparators and 24 with non-radiotherapy cancer patient groups. Symptom prevalence/severity was greater/worse in radiotherapy groups and symptoms more common/worse post-radiotherapy than pre-diagnosis/treatment. Symptom prevalence varied between studies and symptoms. This review confirms that many people experience chronic bowel symptoms following pelvic radiotherapy. Greater methodological consistency, and investigation of less-well-studied survivor populations, could better inform the provision of services and support.

Intermediate and high-risk non-muscle-invasive bladder cancer: an overview of epidemiology, burden, and unmet needs

Bladder cancer ranks among the most common cancers globally. At diagnosis, 75% of patients have non-muscle-invasive bladder cancer (NMIBC). Patients with low-risk NMIBC have a good prognosis, but recurrence and progression rates remain high in intermediate- and high-risk NMIBC, despite the decades-long availability of effective treatments for NMIBC such as intravesical Bacillus Calmette-Guérin (BCG). The present review provides an overview of NMIBC, including its burden and treatment options, and then reviews aspects that counteract the successful treatment of NMIBC, referred to as unmet treatment needs. The scale and reasons for each unmet need are described based on a comprehensive review of the literature, including insufficient adherence to treatment guidelines by physicians because of insufficient knowledge, training, or access to certain therapy options. Low rates of lifestyle changes and treatment completion by patients, due to BCG shortages or toxicities and adverse events as well as their impact on social activities, represent additional areas of potential improvement. Highly heterogeneous evidence for the effectiveness and safety of some treatments limits the comparability of results across studies. As a result, efforts are underway to standardize treatment schedules for BCG, but intravesical chemotherapy schedules remain unstandardized. In addition, risk-scoring models often perform unsatisfactorily due to significant differences between derivation and real-world cohorts. Reporting in clinical trials suffers from a lack of consistent outcomes reporting in bladder cancer clinical trials, paired with an under-representation of racial and ethnic minorities in many trials.

Cost-Effectiveness of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy for Patients With Bladder Cancer

Importance

The value to payers of robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) when compared with open radical cystectomy (ORC) for patients with bladder cancer is unclear.

Objectives

To compare the cost-effectiveness of iRARC with that of ORC.

Design, Setting, and Participants

This economic evaluation used individual patient data from a randomized clinical trial at 9 surgical centers in the United Kingdom. Patients with nonmetastatic bladder cancer were recruited from March 20, 2017, to January 29, 2020. The analysis used a health service perspective and a 90-day time horizon, with supplementary analyses exploring patient benefits up to 1 year. Deterministic and probabilistic sensitivity analyses were undertaken. Data were analyzed from January 13, 2022, to March 10, 2023.

Interventions

Patients were randomized to receive either iRARC (n = 169) or ORC (n = 169).

Main Outcomes and Measures

Costs of surgery were calculated using surgery timings and equipment costs, with other hospital data based on counts of activity. Quality-adjusted life-years were calculated from European Quality of Life 5-Dimension 5-Level instrument responses. Prespecified subgroup analyses were undertaken based on patient characteristics and type of diversion.

Results

A total of 305 patients with available outcome data were included in the analysis, with a mean (SD) age of 68.3 (8.1) years, and of whom 241 (79.0%) were men. Robot-assisted radical cystectomy was associated with statistically significant reductions in admissions to intensive therapy (6.35% [95% CI, 0.42%-12.28%]), and readmissions to hospital (14.56% [95% CI, 5.00%-24.11%]), but increases in theater time (31.35 [95% CI, 13.67-49.02] minutes). The additional cost of iRARC per patient was £1124 (95% CI, -£576 to £2824 [US $1622 (95% CI, -$831 to $4075)]) with an associated gain in quality-adjusted life-years of 0.01124 (95% CI, 0.00391-0.01857). The incremental cost-effectiveness ratio was £100 008 (US $144 312) per quality-adjusted life-year gained. Robot-assisted radical cystectomy had a much higher probability of being cost-effective for subgroups defined by age, tumor stage, and performance status.

Conclusions and Relevance

In this economic evaluation of surgery for patients with bladder cancer, iRARC reduced short-term morbidity and some associated costs. While the resulting cost-effectiveness ratio was in excess of thresholds used by many publicly funded health systems, patient subgroups were identified for which iRARC had a high probability of being cost-effective.

Trial Registration

ClinicalTrials.gov Identifier: NCT03049410.

In Vivo Optical Imaging of Bladder Cancer Tissues in an MB49 Bladder Cancer Orthotopic Mouse Model Using the Intravesical or Intravenous Administration of Near-Infrared Fluorescence Probe

Bladder cancer was the twelfth most common cancer worldwide in 2020. Although bladder cancer has been diagnosed using macroscopic techniques, such as white-light cystoscopy and fluorescence blue-light cystoscopy, there is a need to explore more effective noninvasive optical imaging techniques for accurate bladder cancer diagnosis. This study demonstrates the high effectiveness of the near-infrared fluorescence (NIRF) probe ASP5354, which has been developed for ureteral identification during in vivo diagnosis of bladder cancer in an MB49 bladder cancer orthotopic mouse model. After the intravesical injection of 2.4 μM ASP5354 followed by bladder rinsing with saline at 5 min post injection or intravenous administration of ASP5354 at 240 nmol/kg mouse body weight, followed by a waiting period of 5-24 h in mice, ASP5354 was absorbed specifically by cancerous tissue and not by normal tissues in the bladder. NIRF of ASP5354 in cancer tissues was detected using the NIRF imaging camera system. The NIRF clearly showed a boundary between cancerous and normal tissues. Therefore, ASP5354 provides noninvasive and specific optical in vivo imaging of MB49 bladder cancer using intravesical or intravenous injection of ASP5354. ASP5354 may allow for new diagnostic applications for bladder cancer in humans.

Health-related quality of life after curative treatment for muscle-invasive bladder cancer

Muscle-invasive bladder cancer (MIBC) is an aggressive disease for which the gold-standard treatment is radical cystectomy (RC) in combination with cisplatin-based neoadjuvant chemotherapy. Bladder-sparing strategies such as trimodal therapy (TMT) have also emerged to improve health-related quality of life (HRQoL) of patients. However, an improved understanding of the effect of all these treatment modalities on HRQoL is essential to provide personalized patient care. Different combinations of generic, cancer-specific and bladder cancer-specific questionnaires can be used as instruments for HRQoL evaluation in patients with MIBC before and after curative treatments, which can largely affect multiple domains of HRQoL including general health as well as physical, functional, social and emotional well-being. However, diagnosis of MIBC per se is also likely to affect HRQoL, and the perspective of cure after RC or TMT could induce a return to baseline HRQoL values for most of these domains. A considerable amount of data on HRQoL after RC is available, but conflicting results have been reported regarding the effect of urinary diversion (ileal conduit or orthotopic neobladder) and surgical approach (open or robotic surgery) on patient quality of life. Data on HRQoL after TMT are scarce, and additional comparative studies including patients receiving RC (especially using ileal orthotopic neobladder) are needed.

The current use of the EORTC QLQ-NMIBC24 and QLQ-BLM30 questionnaires for the assessment of health-related quality of life in bladder cancer patients: a systematic review

PURPOSE

Investigating the use of the EORTC bladder cancer (BC) modules by evaluating: (a) study contexts/designs; (b) languages/countries in which the modules were administered; (c) their acceptance by patients/investigators; and (d) their psychometric properties.

METHODS

A systematic review was performed with studies from 1998 until 20/10/2021 in five databases. Articles/conference abstracts using the EORTC-QLQBLM30 (muscle invasive BC) and the EORTC-QLQNMIBC24 (previously referred to as QLQ-BLS24; non-muscle invasive BC) were included. Two authors independently screened titles/abstracts/full-texts and performed data extraction.

RESULTS

A total of 76 eligible studies were identified. Most studies included the BLM30 (n = 53), were in a urological surgery context (n = 41) and were cross-sectional (n = 35) or prospective (n = 30) in design. The BC modules were administered in 14 languages across 19 countries. Missing data were low-moderate for all non-sex related questions (< 1% to 15%). Sex-related questions had higher rates of missing data (ranging from 6.9% to 84%). Most investigators did not use all scales of the questionnaires. One validation study for the original BLS24 led to the development of the NMIBC24, which adopted a new scale structure for which good structural validity was confirmed (n = 3). Good reliability and validity was shown for the NMIBC24 module, except for malaise and bloating/flatulence scales. Psychometric evidence for BLM30 is lacking.

CONCLUSION

These results provide insight into how the EORTC BC quality of life modules could be further improved. Current work is ongoing to update the modules and to determine if the two modules can be combined into a single questionnaire that works well in both the NMIBC and MIBC settings.

Systemic therapy issues: Immunotherapy in nonmetastatic urothelial cancer

Non-muscle-invasive bladder cancer is one of the most common malignancies. Patients with intermediate-risk or high-risk disease can be treated with intravesical Bacillus Calmette-Guerin, a vaccine against tuberculosis. However, many of these patients will experience tumor recurrence, despite appropriate treatment. 1 The standard of care in these patients is radical cystectomy (RC) with urinary diversion. 2 Patients diagnosed with muscle-invasive bladder cancer (MIBC) have traditionally faced 2 main treatment options: RC and urinary diversion, as in Bacillus Calmette-Guerin-unresponsive Non-muscle-invasive bladder cancer, or alternatively, trimodal therapy comprising maximal transurethral resection of bladder tumor plus chemoradiation. 3 For patients with MIBC and clinical (c)T2-T4a, neoadjuvant chemotherapy (NAC) preceding RC is supported by Level 1 evidence with a modest 5-year overall survival benefit of 5% with cisplatin-based regimens. 4-9 A number of factors preclude MIBC patients from standard treatment options. For example, patients with serious comorbidities might be unable to tolerate general anesthesia, while others might be unwilling to adapt to the lifestyle changes after RC. 10-12 Likewise, patients with extensive carcinoma in situ or poor bladder function might not be optimal candidates for trimodal therapy or be prepared for the ongoing risk that salvage RC might be ultimately required. Reasons for the underuse of NAC range from the fear of delaying potentially curative surgery in nonresponders to patient ineligibility to cisplatin-based NAC. 13,14 Despite best efforts, in both surgical and bladder-sparing approaches, the 5-year overall survival in treated patients with MIBC is only 35% to 50%. 3,15 Strategies to improve overall prognosis as well as to reduce the indications of RC are desperately needed. Trial results have demonstrated the unprecedented ability of immune-checkpoint inhibitors to induce durable remissions in some patients with metastatic urothelial carcinoma. 16-20 Furthermore, immune-checkpoint inhibitors have shown to be better tolerated than traditional chemotherapy. 16 These successful results have spearheaded the research on these agents in earlier curative settings, with the shared goal of improving overall outcomes, and potentially avoid surgery in patients who show complete response (pT0). Strategies to enhance the immune response by combining immunotherapy with immune sensitizers such as chemotherapy, immunotherapy, targeted therapy or radiation are on the rise.

Female sexual function in bladder cancer: A review of the evidence

Background

Bladder cancer (BC) treatments are known to be invasive; nevertheless, research into the long-term effects is limited and in the context of sexual function often male focussed. Female sexual dysfunction (FSD) has been reported in up to 75% of female patients. This systematic scoping review examines the literature on sexual consequences of BC in female patients.

Objective

This study aimed to systematically evaluate the evidence on female sexual function in BC to identify areas of unmet need and research priorities.

Evidence Acquisition

We performed a critical review of PubMed, PsychMed, CINAHL, MEDLINE and the Cochrane Library in March 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews statement following Levac et al. methodology. Identified reports were reviewed according to the Critical Appraisal Skills Programme (CASP) criteria. 45 publications were included.

Evidence Synthesis

There was an inconsistent use of patient-reported outcome measures (PROMs), with commonly used PROMs having a narrow symptom focus. However, common symptoms emerged: loss of desire, orgasmic disorders, vaginal dryness, dyspareunia, difficult intromission, reduced clitoral sensation, psychological concerns related to diagnosis, fear of contamination and body image. Sexual activity was reduced in most groups, despite women expressing a motivation to retain sexual function. The degree of symptom distress associated with FSD is underreported. Evidence emerged regarding a gap for women in clinician counselling and follow-up.

Conclusions

The patient's perspective of FSD in BC patients is poorly understood and under-addressed in clinical practice. There have been very few qualitative studies of FSD in BC. Any intervention designed to address the problem must start with greater understanding of both the patients' and clinicians' perspective.

Lay Summary

We examined the evidence on sexual consequences of BC in women. It is apparent that despite common themes of sexual dysfunction emerging, the problem is poorly understood and addressed in clinical practice.

Validation and reliability of the Dutch version of the EORTC QLQ-BLM30 module for assessing the health-related quality of life of patients with muscle invasive bladder cancer

BACKGROUND

Quality of Life (QoL) of bladder cancer patients has been largely neglected. This is partly due to the lack of well-validated QoL questionnaires. The aim of this study is to examine the structural validity, reliability (i.e., internal consistency and test-retest reliability), construct validity (i.e., divergent validity and known group validity) and responsiveness of the Dutch version of the European Organisation for Research and Treatment of Cancer QoL questionnaire for muscle invasive bladder cancer (EORTC-QLQ-BLM30).

METHODS

Patients with newly diagnosed muscle invasive bladder cancer (MIBC) participating in the population-based 'Blaaskankerzorg In Beeld' (BlaZIB) study who completed the EORTC-QLQ-BLM30 at baseline were included. BlaZIB is a Dutch nationwide population-based prospective cohort study collecting clinical data and QoL data of bladder cancer patients. QoL is assessed with a self-administered questionnaire at four points in time: 6 weeks (baseline), 6 months, 12 months and 24 months after diagnosis. Confirmatory factor analysis and multitrait scaling analysis were used to investigate and adapt the scale structure. Reliability, construct validity and responsiveness of the revised scales were evaluated.

RESULTS

Of the 1542 patients invited to participate, 650 patients (42.2%) completed the QLQ-BLM30 at baseline. The questionnaire's scale structure was revised into seven scales and eight single items. Internal consistency and test-reliability were adequate for most scales (Cronbach's α ≥0.70 and intraclass correlation coefficient ≥ 0.70, respectively), with the exception of the revised urostomy problem scale and abdominal bloating and flatulence scale. The questionnaire exhibited little overlap with the EORTC-QLQ-C30: all correlations were < 0.40, except for the correlation between emotional function (QLQ-C30) and future worries (QLQ-BLM30). The questionnaire was able to distinguish between patient subgroups formed on the basis of physical function, but not - as hypothesized- based on stage. Changes in health due to treatment were captured by the questionnaire, indicating that the questionnaire is responsive to change.

CONCLUSIONS

This study shows that the adapted scale structure of the EORTC-QLQ-BLM30 generally exhibits good measurement properties in Dutch patients, but needs to be validated in other languages and settings.

TRIAL REGISTRATION

BlaZIB, NL8106, www.trialregister.nl.

Surveillance and office management of low-grade Ta bladder tumors

OBJECTIVE

Patients with low-grade (LG), grade 1-2, Ta bladder cancer (BC) will frequently have a "recurrence". However, they rarely progress in stage. Although current guidelines mention surveillance and office management for these new or recurrent tumors, transurethral resection (TURBT) is the most common treatment. The purpose of this study is to determine if surveillance and/or office cautery is safe.

MATERIALS AND METHODS

This study was conducted as a retrospective case series analysis of 45 patients who had recurrent LG Ta appearing bladder cancer (BC) and were managed primarily with surveillance and/or office cautery. Patients with carcinoma in-situ were excluded. The primary outcome was stage progression.

RESULTS

Median follow up was 62 months. 41 (91%) patients did not progress in stage. Three patients recurred with HG T1 BC; one is receiving systemic immunotherapy. One patient developed HG T2 BC and was treated with a bladder preservation protocol. 40 (89%) patients underwent office cauterization. Eleven received BCG and 26 received post-cautery intravesical chemotherapy. Five (11%) patients developed HG BC during follow up. No patients died. None of the 17 (38%) Hispanic patients had progression.

CONCLUSIONS

Active surveillance and/or office cautery for patients with small recurrent LG Ta bladder tumors is safe, reduces cost and improves quality of life by avoiding TURBTs.

[Optimal surveillance intensity of cystoscopy in intermediate-risk non-muscle invasive bladder cancer]

OBJECTIVE

To determine the optimal cystoscopic frequency for intermediate-risk non-muscle invasive bladder cancer.

METHODS

Patients with intermediate-risk non-muscle invasive bladder cancer, who underwent transurethral resection of bladder tumor in Peking University People's Hospital from January 2001 to October 2019, were retrospectively analyzed. Their clinical, pathological and follow-up data were collected. In postoperative 2-year period, the patients were underwent cystoscopy every 3 to 6 months. Depending on recurrence and progression of the patients, we hypothesized three strategies of surveillance intensity in the first 2 years after surgery: model 1: 3-month intervals, model 2: 6-month intervals, and model 3: 12-month intervals. The differences in the numbers and time of delayed detection of recurrence and progression were compared among the three models.

RESULTS

A total of 185 patients were enrolled, including 144 males (77.8%) and 41 females (22.2%). The median age was 68 (59-76) years. There were 118 cases (63.8%) with single tumor and 67 cases (36.2%) with multiple tumor. Of the patients 179 (96.8%) had stage Ta and 6 (3.2%) had stage T1. There were 108 cases (58.4%) with high-grade disease and 77 cases (41.6%) with low-grade disease. During the follow-up period of the first 2 years, 52 patients (28.1%) had recurrence, 133 cases (71.9%) had no recurrence, 11 cases (5.9%) had progression and 174 cases (94.1%) had no progression. Compared with model 1, 29 (55.8%) delayed detection of recurrence in model 2 vs. 41 (78.8%) delayed detection of recurrence in model 3, and the difference was statistically significant (P=0.012). The median delayed time of detecting recurrence was 1.00 months in model 1, 1.99 months in model 2 and 4.19 months in model 3, respectively. There were statistically significant differences between mode 1 and model 3 (P=0.001), and between model 2 and model 3 (P=0.013). Compared with model 1, 5 (45.4%) delayed detection of progression in model 2 vs. 8 (72.7%) delayed detection of progression in model 3, and the difference was not statistically significant. The median delayed time of detecting progression was 1.00 month in model 1, 2.00 months in model 2 and 3.00 months in model 3, respectively. There was no statistically significant difference among them.

CONCLUSION

Although providing slightly slower detection of tumor recurrence and progression, compared with 3-month intervals of cystoscopy, 6-month intervals do not result in serious adverse outcomes and reduce cost and pain of the patients, which is feasible in intermediate-risk non-muscle invasive bladder cancer.

Quality of life patterns and its association with predictors among non-muscle invasive bladder cancer survivors: A latent profile analysis

Objective

This study identified group patterns in the quality of life (QOL), as well as examining factors associated with group membership, among non-muscle invasive bladder cancer (NMIBC) survivors.

Methods

This was a cross-sectional study involving 278 participating NMIBC survivors. Mplus version 7.2 was used to perform the latent profile analysis of QOL using the EORTC QLQ-NMIBC-24. The participants’ social support, self-efficacy, knowledge level, depression, perceived severity of and susceptibility of cancer recurrence, and their demographic and clinical characteristics were compared between the subgroups, with a logistic regression analysis being adopted to examine the factors associated with the QOL subgroups.

Results

The NMIBC survivors based on the QOL were classified into two subgroups: “QOL-high” (81.3%) and “QOL-low” (18.7%). Having ≥ 3 disease recurrences, perceived susceptibility toward and severity of cancer recurrence, and having depressive symptoms were significantly associated with the “QOL-low” group.

Conclusions

Participants with frequent recurrences of NMIBC, higher perceived susceptibility and severity levels, and depressive symptoms had lower QOL. Therefore, it is necessary to develop intervention programs targeting participants with these characteristics to improve their QOL.

Associations of self-efficacy, social support and coping strategies with health-related quality of life after radical cystectomy for bladder cancer: A cross-sectional study

OBJECTIVES

Investigating associations between self-efficacy, social support and quality of life (HRQoL) and mediating effects of coping among bladder cancer (BC) patients treated with radical cystectomy (RC).

METHODS

A cross-sectional study was conducted from January 2012 to December 2014 with 99 BC patients. An online survey assessed patient characteristics, HRQoL, coping strategies, self-efficacy and social support. A stepwise multiple linear regression model was used.

RESULTS

Self-efficacy and social support were significantly associated with HRQoL. Complete mediation effects of adaptive/maladaptive coping strategies emerged for the associations between self-efficacy and social support with functional well-being (B = 0.247, 95% CI 0.119-0.374, p < 0.001; B = -0.414, 95% CI -0.526 to -0.302, p < 0.001) and total Functional Assessment of Cancer Therapy-Bladder (FACT-BI) (B = 0.779, 95% CI 0.351-1.207, p < 0.001; B = -1.969, 95% CI -2.344 to -1.594, p < 0.001). Maladaptive coping mediated the associations of self-efficacy and social support with physical well-being (B = -0.667, 95% CI -0.752 to -0.516, p < 0.001) and disease-specific symptoms (B = -0.413, 95% CI -0.521 to -0.304, p < 0.001). A partial mediation effect of adaptive coping was found for the association between self-efficacy and social well-being (B = 0.145, 95% CI 0.016-0.273, p < 0.05). Social support was significantly associated with emotional (B = 0.067, 95% CI 0.027-0.108, p < 0.001) and social well-being (B = 0.200, 95% CI 0.146-0.255, p < 0.001).

CONCLUSION

Interventions should tackle self-efficacy, social support and coping strategies to improve BC patients' HRQoL.

A Novel Nomogram and Risk Classification System Predicting the Cancer-Specific Survival of Muscle-Invasive Bladder Cancer Patients after Partial Cystectomy

Purpose

To establish a prognostic model that estimates cancer-specific survival (CSS) probability for muscle-invasive bladder cancer patients undergoing partial cystectomy. Patients and Methods. 866 patients from the Surveillance, Epidemiology, and End Results (SEER) database (2004–2015) were enrolled in our study. These patients were randomly divided into the development cohort (n = 608) and validation cohort (n = 258) at a ratio of 7 : 3. A Cox regression was performed to select the predictors associated with CSS. The Kaplan–Meier method was used to analyze the survival outcome between different risk groups. The calibration curves, receiver operating characteristic (ROC) curves, and the concordance index (C-index) were utilized to evaluate the performance of the model.

Results

The nomogram incorporated age, histology, T stage, N stage, M stage, regional nodes examined, and tumour size. The C-index of the model was 0.733 (0.696–0.77) in the development cohort, while this value was 0.707 (0.705–0.709) in the validation cohort. The AUC of the nomogram was 0.802 for 1-year, 0.769 for 3-year, and 0.799 for 5-year, respectively, in the development cohort, and was 0.731 for 1-year, 0.748 for 3-year, and 0.752 for 5-year, respectively, in the validation cohort. The calibration curves for 1-year, 3-year, and 5-year CSS showed great concordance. Significant differences were observed between high, medium, and low risk groups (P < 0.001).

Conclusions

We have constructed a highly discriminative and precise nomogram and a corresponding risk classification system to predict the cancer-specific survival for muscle-invasive bladder cancer patients undergoing partial cystectomy. The model can assist in the decision on choice of treatment, patient counselling, and follow-up scheduling.

Efficacy of pembrolizumab and comprehensive CD274/PD-L1 profiles in patients previously treated with chemoradiation therapy as radical treatment in bladder cancer

Background

Chemoradiation therapy (CRT) has been increasingly reported as a possible alternative to total cystectomy (TC) for localized bladder cancer (BC). Pembrolizumab is the standard of care for platinum-refractory metastatic urothelial carcinoma, although it is unknown whether the efficacy of pembrolizumab in patients previously treated with curative CRT varies from the results of benchmark trials.

Methods

We retrospectively assessed whether the survival benefit of pembrolizumab differs between patients previously treated with TC or CRT as radical treatment. A total of 212 patient records were collected for a logistic regression propensity score model. An independent dataset with next-generation sequencing (n=289) and PD-L1 Combined Positive Score (CPS: n=266) was analyzed to assess whether CRT-recurrent tumor harbors distinct CD274/PD-L1 profiles.

Results

Propensity score matching was performed using putative clinical factors, from which 30 patients in each arm were identified as pair-matched groups. There was no significant difference in overall survival from the initiation of pembrolizumab (p=0.80) and objective response rate (p=0.59) between CRT and TC treatment groups. In the independent 289 BC cohort, 22 samples (7.6%) were collected as CRT-recurrent tumors. There was no significant difference in CD274 mRNA expression level between CRT-naïve and CRT-recurrent tumors. The compositions of CD274 isoforms were comparable among all isoforms detected from RNAseq between CRT-naïve (n=267) and CRT-recurrent (n=22) tumors. No actionable exonic mutation in CD274 was detected in CRT-recurrent tumors. PD-L1 CPS was positively correlated with CD274 mRNA expression level, and PD-L1 CPS was comparable between CRT-naïve and CRT-recurrent tumors.

Conclusions

The efficacy of pembrolizumab for patients previously treated with CRT was similar to those treated with TC. The enhanced tumor regression by combining programmed cell death protein 1/PD-L1 inhibitor and CRT might be expected only in the concurrent administration.

Supportive Roles of the Health Care Team Throughout the Illness Trajectory of Bladder Cancer Patients Undergoing Radical Cystectomy: A Qualitative Study Exploring the Patients' Perspectives

OBJECTIVES

To explore patient perspectives of muscle-invasive bladder cancer (MIBC) on how the health care team and their social network can support them during their cancer trajectory.

DATA SOURCES

Sixteen semi-structured interviews were conducted with MIBC survivors who underwent radical cystectomies at Ghent University Hospital. The interviews were audiotaped, transcribed verbatim, and analyzed with an iterative content analysis approach.

CONCLUSION

Information to support people affected by bladder cancer (BC) in several aspects of their disease trajectory (eg, shared decision-making and self-management of their urinary diversion) was most important throughout the interviews (although type and source of required information varied). The clinical nurse specialist was important for informational and emotional support because receiving sufficient information might help patients reduce emotional stress. People affected by BC are still reluctant to consult a psychologist, and several barriers were indicated for this. Also physical needs in the early postoperative phase could be reduced with appropriate information. Communication skills of clinicians in the hospital and knowledge of general practitioners about the important aspects of BC care are also important aspects that should be further optimized. Furthermore, peer support groups and family members can offer important support throughout the BC pathway.

IMPLICATIONS FOR NURSING PRACTICE

This study provides an overview of how people affected by BC want to be supported by their health care team and their social network. This overview can serve as a basis to develop educational interventions for both patients and health care professionals to guide restructuring of BC pathways and can also be used to develop future intervention studies to improve BC outcomes.

Supportive care needs and utilization of bladder cancer patients undergoing radical cystectomy: A longitudinal study

OBJECTIVES

Investigating supportive care (SC) needs and utilization/willingness to use SC services from diagnosis to one year after radical cystectomy in bladder cancer (BC) patients. MATERIALS & METHODS: A longitudinal cohort study was conducted in 90 BC patients at Ghent/Leuven University Hospitals between April 2017 and December 2020. The Supportive Care Needs Survey-short form (SCNS-SF34) was used before radical cystectomy, one, three, six and 12 months after radical cystectomy. Additional questions assessed utilization/willingness to use SC services. Linear mixed models were performed.

RESULTS

The majority of BC patients report at least one moderate or high SC need at diagnosis (82%), month 1 (84%), month 3 (86%), month 6 (64%), and month 12 (60%). Significant decreases over time were seen for all domains (p < 0.001), except for sexuality (p = 0.275). From baseline to month 1, physical needs first significantly increased (p = 0.001) after which they decreased. Psychological (e.g. fears about the future) and informational (e.g. information on how to get better) needs were most common at baseline whereas physical (e.g. lack of energy) and informational needs were more common in the early postoperative phases. The majority of patients (ranging from 81% (month 1) to 91% (month 12)) did not make use of SC services and the majority of the patients (ranging from 81% (month 1) to 88% (month 12)) did not wish to talk about their problems to someone. Those willing to talk to someone preferred their physician.

CONCLUSIONS

A clear gap exists between the large proportion of SC needs experienced by BC patients undergoing radical cystectomy and the low use of SC services.

Patient-Reported Outcomes and Health-Related Quality of Life Following Radiotherapy for Bladder Cancer

Bladder cancer is the 11th most common cancer in the UK and with an ageing population the incidence is increasing. There is a relative lack of prospective quality of life (QoL) data evaluating the impact of the illness and treatment on QoL and patient-reported outcomes (PROs). Here we evaluate the available tools to assess QoL and PROs, and summarise the published data evaluating outcomes in patients treated with radiotherapy for muscle-invasive disease. We also discuss some of the recently completed studies and those ongoing that will help to shape future care and assist in decision making for patients and their clinicians.

A Systematic Review of the Efficacy and Safety of Outpatient Bladder Tumour Ablation

CONTEXT

Management of non-muscle-invasive bladder cancer (NMIBC) is costly and associated with negative health-related quality-of-life effects, in part because of the frequent need for repeated transurethral resections under general/regional anaesthesia. Outpatient-based diathermy or laser ablation is another option, but evidence for its efficacy is mixed and its use is controversial.

OBJECTIVE

To systematically review evidence regarding the efficacy and safety of outpatient diathermy and laser ablation for the treatment of recurrent NMIBC.

EVIDENCE ACQUISITION

The EMBASE, MEDLINE/PubMed, and Cochrane Library were searched from inception to June 26, 2020. All studies evaluating the use of diathermy or laser ablation for bladder tumours (new or recurrent) in an outpatient setting under local anaesthetic were included. Two reviewers independently screened all articles, searched the reference lists of retrieved articles, and performed the data extraction. The quality of evidence and risk of bias were assessed using the GRADE and ROBINS-I tools.

EVIDENCE SYNTHESIS

The search yielded 1328 studies. After excluding duplicates, 1319 titles and abstracts were screened and 17 studies (1584 patients) were eligible for inclusion in the final review. The majority of patients had small, low-grade tumours, but there was heterogeneity in the inclusion criteria. Overall, laser ablation and diathermy resulted in mean recurrence rates of 47% and 32% at follow-up of 22-38 mo, respectively, with a mean progression rate of 3-12% (low certainty of evidence). Both procedures were well tolerated, with low pain scores and low periprocedural complication rates (moderate certainty of evidence).

CONCLUSIONS

Outpatient diathermy and laser ablation have good short-term efficacy in patients with low-grade NMIBC and reduce the need for intervention under general/regional anaesthesia. The procedures are well tolerated with low complication rates. The overall certainty of evidence is low, with heterogeneity between studies and methodological limitations. However, we have highlighted the need for randomised trials with long-term follow-up using standardised risk classification and outcome measures. Despite these limitations, the findings will aid in patient counselling regarding this less invasive treatment option that avoids the morbidity of transurethral resection.

PATIENT SUMMARY

Outpatient diathermy and laser ablation have good success rates in treating recurrent low-grade bladder tumours in the short term, avoiding the need for more invasive procedures under general/regional anaesthesia, with low rates of side effects. Further studies are needed to determine whether these treatments remain safe and effective in the long term.

Quality of Life After Bladder Cancer: A Cross-sectional Survey of Patient-reported Outcomes

BACKGROUND

Little is known about health-related quality of life (HRQOL) following treatment for bladder cancer (BC).

OBJECTIVE

To determine this, we undertook a cross-sectional survey covering 10% of the English population.

DESIGN, SETTING, AND PARTICIPANTS

Participants 1-10 yr from diagnosis were identified through national cancer registration data.

INTERVENTION

A postal survey was administered containing generic HRQOL and BC-specific outcome measures. Findings were compared with those of the general population and other pelvic cancer patients.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Generic HRQOL was measured using five-level EQ-5D (EQ-5D-5L) and European Organization for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ)-C30. BC-specific outcomes were derived from EORTC QLQ-BLM30 and EORTC QLQ-NMIBC24.

RESULTS AND LIMITATIONS

A total of 1796 surveys were completed (response rate 55%), including 868 (48%) patients with non-muscle-invasive BC, 893 (50%) patients who received radiotherapy or radical cystectomy, and 35 (1.9%) patients for whom treatment was unknown. Most (69%) of the participants reported at least one problem in any EQ-5D dimension. Age/sex-adjusted generic HRQOL outcomes were similar across all stages and treatment groups, whilst problems increased with age (problems in one or more EQ-5D dimensions: <65 yr [67% {95% confidence interval or CI: 61-74}] vs 85+ yr [84% {95% CI: 81-89}], p =  0.016) and long-term conditions (no conditions [53% {95% CI: 48-58}] vs more than four conditions [94% {95% CI: 90-97}], p < 0.001). Sexual problems were reported commonly in men, increasing with younger age and radical treatment. Younger participants (under 65 yr) reported more financial difficulties (mean score 20 [95% CI: 16-25]) than those aged 85+ yr (6.8 [4.5-9.2], p <  0.001). HRQOL for BC patients (for comparison, males with problems in one or more EQ-5D dimensions 69% [95% CI: 66-72]) was significantly worse than what has been found after colorectal and prostate cancers and in the general population (51% [95% CI: 48-53], all p <  0.05).

CONCLUSIONS

HRQOL following BC appears to be relatively independent of disease stage, treatment, and multimodal care. Issues are reported with sexual function and financial toxicity. HRQOL after BC is worse than that after other pelvic cancers.

PATIENT SUMMARY

Patients living with bladder cancer often have reduced quality of life, which may be worse than that for other common pelvic cancer patients. Age and other illnesses appear to be more important in determining this quality of life than the treatments received. Many men complain of sexual problems. Younger patients have financial worries.

Treatment of muscle-invasive bladder cancer in patients without comorbidities and fit for surgery: Trimodality therapy vs radical cystectomy. Development of GRADE (Grades of Recommendation, Assessment, Development and Evaluation) recommendation by the Italian Association of Radiotherapy and Clinical Oncology (AIRO)

AIM

To compare trimodality therapy (TMT) versus radical cystectomy (RC) and develop GRADE (Grades of Recommendation, Assessment, Development and Evaluation) Recommendation by the Italian Association of Radiotherapy and Clinical Oncology (AIRO) for treatment of muscle-invasive bladder cancer (MIBC).

MATERIAL AND METHODS

Prospective and retrospective studies comparing TMT and RC for MIBC patients were included. Qualitative and quantitative evaluation of evidence was made.

RESULTS

Ten studies were included in the analysis. Pooled analysis showed salvage cystectomy and pathological complete response rates after TMT of 12 % and 72-77.5 %, respectively. Pooled rates of G3-G4 GU toxicity and serious toxicity rate were 18 vs 3% and 45 vs 29 % for patients undergoing TMT vs RC, respectively. The panel assessed a substantial equivalence in terms of OS and CSS at 5 years between TMT and RC.

CONCLUSIONS

TMT could be suggested as an alternative treatment to RC in non-metastatic MIBC patients, deemed fit for surgery.

Value-Based Healthcare in Urology: A Collaborative Review

CONTEXT

In response to growing concerns over rising costs and major variation in quality, improving value for patients has been proposed as a fundamentally new strategy for how healthcare should be delivered, measured, and remunerated.

OBJECTIVE

To systematically review the literature regarding the implementation and impact of value-based healthcare in urology.

EVIDENCE ACQUISITION

A systematic review was performed to identify studies that described the implementation of one or more elements of value-based healthcare in urologic settings and in which the associated change in healthcare value had been measured. Twenty-two publications were selected for inclusion.

EVIDENCE SYNTHESIS

Reorganization of urologic care around medical conditions was associated with increased use of guidelines-compliant care for men with prostate cancer, and improved outcomes for patients with lower urinary tract symptoms. Measuring outcomes for every patient was associated with improved prostate cancer outcomes, while the measurement of costs using time-driven activity-based costing was associated with reduced resource utilization in a pediatric multidisciplinary clinic. Centralization of urologic cancer care in the UK, Denmark, and Canada was associated with overall improved outcomes, although systems integration in the USA yielded mixed results among urologic cancer patients. No studies have yet examined bundled payments for episodes of care, expanding the geographic reach for centers of excellence, or building enabling information technology platforms.

CONCLUSIONS

Few studies have critically assessed the actual or simulated implementation of value-based healthcare in urology, but the available literature suggests promising early results. In order to effectively redesign care, there is a need for further research to both evaluate the potential results of proposed value-based healthcare interventions and measure their effects where already implemented.

PATIENT SUMMARY

While few studies have evaluated the implementation of value-based healthcare in urology, the available literature suggests promising early results.

Radical Cystectomy Against Intravesical BCG for High-Risk High-Grade Nonmuscle Invasive Bladder Cancer: Results From the Randomized Controlled BRAVO-Feasibility Study

High-grade nonmuscle invasive bladder cancer (HRNMIBC) is a heterogeneous disease. Treatments include intravesical maintenance Bacillus Calmette-Guerin (mBCG) and radical cystectomy (RC). We wanted to understand whether a randomized trial comparing these options was possible.

Development of a pre- and postoperative physical activity promotion program integrated in the electronic health system of patients with bladder cancer (The POPEYE study): An intervention mapping approach

INTRODUCTION

Uptake of sufficient physical activity before and after radical cystectomy is important to improve physical and psychosocial outcomes in bladder cancer (BC) patients.

METHODS

In this paper, we describe the development of an evidence-based and theory-informed intervention, guided by the steps of the Intervention Mapping approach, to promote physical activity before and after radical cystectomy in patients with BC.

RESULTS

The intervention is a home-based physical activity program. The preoperative timeframe of the intervention is 4 or 12 weeks, depending on administration of neoadjuvant chemotherapy. Postoperatively, the intervention will last for 12 weeks. The intervention consists of a digital oncological platform (DOP), several consultations with healthcare professionals, personal booklet and follow-up phone calls. DOP includes information, diaries, visual representation of progress, mailbox, videos of peers and treating physician explaining the benefits of physical activity, photo material of exercises and a walking program with an activity tracker. Individual goals will be set and will be self-monitored by the patient through DOP. Patients will receive alerts and regular feedback.

CONCLUSIONS

Intervention Mapping ensures transparency of all intervention components and offers a useful approach for the development of behaviour change interventions for cancer patients and for translation of theories into practice.

RAC3 Promotes Proliferation, Migration and Invasion via PYCR1/JAK/STAT Signaling in Bladder Cancer

Background

Bladder cancer (BCa) represents one of the most common malignant cancers with high incidence and mortality rates globally. Dysregulation of gene expression has been shown to play critical roles in cancer progression. RAC3 is up-regulated to play an oncogenic role in several cancers, however, the underlying mechanism of RAC3 in BCa is yet to be elucidated. Therefore, this study aimed to investigate the function and mechanism of RAC3 in BCa.

Methods

Bioinformatics analysis was employed to demonstrate the expression of RAC3 and PYCR1 in BCa tissues, as well as, its correlation with the overall survival rate of BCa patients. RT-qPCR was performed to detect and quantify the mRNA levels of RAC3 and PYCR1 in BCa cells and immortalized human bladder epithelial cells. MTT, colony formation and Transwell assays were employed to determine cell proliferation, migration, and invasion. Western blotting was performed to detect and quantity proteins expressed.

Results

Bioinformatics analysis showed that RAC3 was up-regulated in BCa tissues when compared to normal tissues. Patients with up-regulated RAC3 expression had lower overall survival than patients with down-regulated RAC3 expression. The mRNA level of RAC3 was higher in BCa cells than in immortalized human bladder epithelial cell. RAC3 promoted cell proliferation, migration, and invasion by activating Janus kinases (JAKs) and signal transducers and activators of transcription (STATs) signaling. Notably, RAC3 up-regulated PYCR1, which is positively correlated with RAC3, and thus played an oncogenic role in BCa cells. Moreover, we demonstrated that RAC3 overexpression activated JAK/STAT signaling via PYCR1 axis.

Conclusion

RAC3 promoted cell proliferation, migration, and invasion. This is likely due to its role in activating JAK/STAT signaling, which was mediated by PYCR1. This study provides a novel biomarker and target for diagnostic or therapeutic intervention for BCa.

Critical analysis of quality of life and cost-effectiveness of enhanced recovery after surgery (ERAS) for patient's undergoing urologic oncology surgery: a systematic review

PURPOSE

Enhanced recovery after surgery (ERAS) protocols have been implemented across a variety of disciplines to improve outcomes. Herein we describe the impact of ERAS on quality of life (QOL) and cost for patients undergoing urologic oncology surgery.

METHODS

A systematic literature search using the MEDLINE, Scopus, Clinictrials.gov, and Cochrane Review databases for studies published between 1946 and 2020 was conducted. Articles were reviewed and assigned a risk of bias by two authors and were included if they addressed ERAS and either QOL or cost-effectiveness for patients undergoing urologic oncology surgery.

RESULTS

The literature search yielded a total of 682 studies after removing duplicates, of which 10 (1.5%) were included in the review. Nine articles addressed radical cystectomy, while one addressed ERAS and QOL for laparoscopic nephrectomy. Six publications assessed the impact of ERAS on QOL domains. Questionnaires used for assessment of QOL varied across studies, and timing of administration was heterogeneous. Overall, ERAS improved patient QOL during early phases of recovery within the realms of bowel function, physical/social/cognitive functioning, sleep and pain control. Costs were assessed in 4 retrospective studies including 3 conducted in the United States and one from China all addressing radical cystectomy. Studies demonstrated either decreased costs associated with ERAS as a result of decreased length of stay or no change in cost based on ERAS implementation.

CONCLUSION

While limited studies are published on the subject, ERAS implementation for radical cystectomy and laparoscopic nephrectomy improved patient-reported QOL during early phases of recovery. For radical cystectomy, there was a decreased or neutral overall financial cost associated with ERAS. Further studies assessing QOL and cost-effectiveness over the entire global period of care in a variety of urologic oncology surgeries are warranted.

Quality Indicators for Bladder Cancer Services: A Collaborative Review

CONTEXT

There is a lack of accepted consensus on what should constitute appropriate quality-of-care indicators for bladder cancer.

OBJECTIVE

To evaluate the optimal management of bladder cancer and propose quality indicators (QIs).

EVIDENCE ACQUISITION

A systematic review was performed to identify literature on current optimal management and potential quality indicators for both non-muscle-invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer. A panel of experts was convened to select a recommended list of QIs.

EVIDENCE SYNTHESIS

For NMIBC, preoperative QIs include tobacco cessation counselling and appropriate imaging before initial transurethral resection of bladder tumour (TURBT). Intraoperative QIs include administration of antibiotics, proper safe conduct of TURBT using a checklist, and performing restaging TURBT with biopsy of the prostatic urethra in appropriate cases. Postoperative QIs include appropriate receipt of perioperative adjuvant therapy, risk-stratified surveillance, and appropriate decision to change therapy when indicated (eg, bacillus Calmette-Guerin [BCG] unresponsive). For MIBC, preoperative QIs include multidisciplinary care, selection for candidates for continent urinary diversion, receipt of neoadjuvant cisplatin-based chemotherapy, time to commencing radical treatment, consideration of trimodal therapy as a bladder-sparing alternative in select patients, preoperative counselling with stoma marking, surgical volume of radical cystectomy, and enhanced recovery after surgery protocols. Intraoperative QIs include adequacy of lymphadenectomy, blood loss, and operative time. Postoperative QIs include prospective standardised monitoring of morbidity and mortality, negative surgical margins for pT2 disease, appropriate surveillance after primary treatment, and adjuvant cisplatin-based chemotherapy in appropriate cases. Participation in clinical trials was highlighted as an important component indicating high quality of care.

CONCLUSIONS

We propose a set of QIs for both NMIBC and MIBC based on established clinical guidelines and the available literature. Although there is currently a lack of level 1 evidence for the benefit of implementing these QIs, we believe that the measurement of these QIs could aid in the improvement and benchmarking of optimal care for bladder cancer.

PATIENT SUMMARY

After a systematic review of existing guidelines and literature, a panel of experts has recommended a set of quality indicators that can help providers and patients measure and strive towards optimal outcomes for bladder cancer care.

CALIBER: a phase II randomized feasibility trial of chemoablation with mitomycin-C vs surgical management in low-risk non-muscle-invasive bladder cancer

OBJECTIVES

To evaluate the activity of intravesical mitomycin-C (MMC) to ablate recurrent low-risk non-muscle-invasive bladder cancer (NMIBC) and assess whether it may enable patients to avoid surgical intervention for treatment of recurrence.

PATIENTS AND METHODS

CALIBER is a phase II feasibility study. Participants were randomized (2:1) to treatment with four once-weekly MMC 40-mg intravesical instillations (chemoablation arm) or to surgical management. The surgical group was included to assess the feasibility of randomization. The primary endpoint was complete response to intravesical MMC in the chemoablation arm at 3 months, reported with exact 95% confidence intervals (CIs). Secondary endpoints included time to subsequent recurrence, summarized by Kaplan-Meier methods.

RESULTS

Between February 2015 and August 2017, 82 patients with visual diagnosis of recurrent low-risk NMIBC were enrolled from 24 UK hospitals (chemoablation, n = 54; surgical management, n =28). The median follow-up was 24 months. Complete response at 3 months was 37.0% (20/54; 95% CI 24.3-51.3) with chemoablation and 80.8% (21/26; 95% CI 60.6-93.4) with surgical management. Amongst patients with complete response at 3 months, a similar proportion was recurrence-free by 12 months in both groups (84%). Amongst those with residual disease at 3 months, the 12-month recurrence-free proportion was lower in the surgical management group (40.0%) than in the chemoablation group (84%). Recruitment stopped early as chemoablation did not meet the prespecified threshold of 45% complete responses at 3 months.

CONCLUSION

Intravesical chemoablation in low-risk NMIBC is feasible and safe, but did not demonstrate sufficient response in the present trial. After chemoablation there may be a reduction in recurrence rate, even in non-responders, that is greater than with surgery alone. Further research is required to investigate the role and optimal schedule of neoadjuvant intravesical chemotherapy prior to surgery for NMIBC.

KEYNOTE-676: Phase III study of BCG and pembrolizumab for persistent/recurrent high-risk NMIBC

Background: Nonmuscle-invasive bladder cancer (NMIBC) is the most common form of bladder cancer, with high rates of disease recurrence and progression. Current treatment for high-risk NMIBC involves Bacillus Calmette-Guérin (BCG) therapy, but treatment options are limited for patients with recurrent or BCG-unresponsive disease. Aberrant programmed death 1 signaling has been implicated in BCG resistance and bladder cancer recurrence and progression, and pembrolizumab has shown efficacy in patients with BCG-unresponsive high-risk NMIBC. Aim: To describe the rationale and design for the randomized, comparator-controlled Phase III KEYNOTE-676 study, which will evaluate the efficacy and safety of pembrolizumab in combination with BCG in patients with persistent/recurrent high-risk NMIBC after BCG induction therapy. Trial registration number: NCT03711032.

Treatment Allocation and Survival in Patients Diagnosed with Nonmetastatic Muscle-invasive Bladder Cancer: An Analysis of a National Patient Cohort in England

BACKGROUND

UK Bladder cancer survival remains low. Nonmetastatic muscle-invasive bladder cancer (MIBC) is potentially curable. It is unclear how many patients receive nonradical treatment owing to advanced age, comorbidities, or alternative factors.

OBJECTIVE

To describe treatments and assess survival by disease stage and sex for all newly diagnosed nonmetastatic MIBC in England in 2016, and to observe associations between comorbidities and treatments.

DESIGN, SETTING, AND PARTICIPANTS

All new nonmetastatic MIBC diagnoses in England in 2016 were identified retrospectively using National Cancer Registration and Analysis Service, Radiotherapy Datasets, Systemic Anti-Cancer Therapy, and Hospital Episode Statistics databases.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Age, Charlson Comorbidity Index (CCI), and treatments were ascertained, and 1-yr survival was estimated using Pohar-Perme and Kaplan-Meier methods.

RESULTS AND LIMITATIONS

Nonmetastatic MIBC diagnoses were registered for 2519 patients (median age 76 yr). Radical cystectomy was performed in 24%, 37% of whom received neoadjuvant chemotherapy (NAC). Radical radiotherapy was performed in 29%, 48% of whom received NAC. NAC alongside radical treatment was associated with higher 1-yr overall survival (OS)-91% (88-93%) with NAC and 83% (80-85%) without (p = 0.05). Nonradical treatments occurred for 47%, with corresponding lower OS. Females with stage II and III disease had significantly lower net survival (NS). Radically treated patients had lower CCIs.

CONCLUSIONS

This analysis provides an overview of all nonmetastatic MIBC diagnosed in England in 2016. Just over half of the patients received curative-intent treatment. Of them, only 43% received NAC. One-year OS was disparate, correlating with treatment intensity. Those receiving NAC and radical therapy demonstrated highest OS. Female patients had significantly inferior NS. The data highlight a prescient unmet research need to understand the patient demographic and reasons behind treatment allocation, to address the poor survival observed in those treated nonradically, and the low NAC utilisation. The significantly aged population requires specific future focus.

PATIENT SUMMARY

We looked at all patients in England in 2016 who were diagnosed with bladder cancer invading the bladder muscle. Many patients were elderly, and the most intensive treatments aiming for cure were frequently not used. Survival in women was found to be considerably worse, as was survival for less intensively treated patients.

Bioinformatic Identification of Potential Hub Genes in Muscle-Invasive Bladder Urothelial Carcinoma

Despite aggressive treatment approaches, muscle-invasive bladder urothelial carcinoma (MIBC) patients still have a 50% chance of developing general incurable metastases. Therefore, there is an urgent need for candidate markers to enhance diagnosis and generate effective treatments for this disease. We evaluated four mRNA microarray datasets to find differences between non-MIBC (NMIBC) and MIBC tissues. Through a gene expression profile analysis via the Gene Expression Omnibus database, we identified 56 differentially expressed genes (DEGs). Enrichment analysis of gene ontology, Kyoto Encyclopedia of Genes and Genomes, and Reactome pathways revealed the interactions between these DEGs. Next, we established a protein-protein interaction network to determine the interrelationship between the DEGs and selected 10 hub genes accordingly. Bladder urothelial carcinoma (BLCA) patients with COL1A2, COL5A1, and COL5A2 alterations showed poor disease-free survival rates, while BLCA patients with COL1A1 and LUM alterations showed poor overall survival rates. Oncomine analysis of MIBC versus NMIBC tissues showed that COL1A1, COL5A2, COL1A2, and COL3A1 were consistently among the top 20 overexpressed genes in different studies. Using the TCGAportal, we noted that the high expression of each of the four genes led to shorter BLCA patient overall survival. It was evident that BLCA patients with an elevated high combined gene expression had significantly shorter overall survival and relapse-free survival than those with low combined gene expression using PROGgeneV2. Using Gene Expression Profiling Interactive Analysis, we noted that COL1A1, COL1A2, COL3A1, and COL5A2 were positively correlated with each other in BLCA. These genes are considered as clinically relevant genes, suggesting that they may play an important role in the carcinogenesis, development, invasion, and metastasis of MIBC. However, considering we adopted a bioinformatic approach, more research is crucial to confirm our results. Nonetheless, our findings may have important prospective clinical implementations.

Health-related quality of life around the time of diagnosis in patients with bladder cancer

OBJECTIVES

To quantify the health-related quality of life (HRQoL) of patients with bladder cancer around the time of diagnosis and to test the hypotheses of a two-factor model for the HRQoL questionnaire QLQ-C30.

METHODS

From participants in the Bladder Cancer Prognoses Programme, a multicentre cohort study, sociodemographic data were collected using semi-structured face-to-face interviews. Answers to the QLQ-C30 were transformed into a scale from 0 to 100. HRQoL data were analysed in multivariate analyses. The hypothesized two-factor (Physical and Mental Health) domain structure of the QLQ-C30 was also tested with confirmatory factor analyses (CFA).

RESULTS

A total of 1160 participants (78%) completed the questionnaire after initial visual diagnosis and before pathological confirmation. Despite non-muscle-invasive bladder cancer (NMIBC) being associated with a higher HRQoL than carcinoma invading bladder muscle, only the domain Role Functioning was clinically significantly better in patients with NMIBC. Age, gender, bladder cancer stage and comorbidity all had a significant influence on QLQ-C30 scores. The CFA showed an overall good fit of the hypothesized two-factor model.

CONCLUSION

This study identified a baseline reference value for HRQoL for patients with bladder cancer, which allows better evaluation of any changes in HRQoL as disease progresses or after treatment. In addition, a two-factor (Physical and Mental Health) model was developed for the QLQ-C30.

Expression of miR-182 and Foxo3a in patients with bladder cancer correlate with prognosis

OBJECTIVE

FoxO3a is a specific tumor suppressor gene in the forkhead transcription factor O subfamily (FoxO). Studies show that its expression plays a role in bladder cancer. The abnormal expression of miR-182 in bladder cancer suggests that miR-182 may be an oncogene in bladder cancer. Bioinformatic analysis showed that there is a target complementary binding site between miR-182 and Foxo3a. In this study, the expression of miR-182 and Foxo3a in cancer tissues of patients with bladder cancer was detected. The expression of miR-182 and Foxo3a in bladder cancer tissues and their relationship with the prognosis of the patients were analyzed, and the role of miR-182 in regulating the expression of Foxo3a and the biologic process of cell proliferation and apoptosis in bladder cancer cells was explored.

METHODS

Tumor tissues of patients with bladder cancer were collected and the normal bladder mucosa was used as a control. The expression of Foxo3a was detected by western blot. The expression of miR-182 and Foxo3a mRNA was detected by qRT-PCR. The relationship between miR-182, Foxo3a mRNA and the clinical features of patients was analyzed. The median expression of miR-182 and Foxo3a mRNA was bounded, and Log Rank test was used to compare the survival rate of low and high expression of miR-182 and Foxo3a mRNA. The double luciferase reporter gene assay was used to confirm a target regulatory effect between miR-182 and Foxo3a. In vitro, RT112 and T24 cells were divided into 2 groups: group miR-NC, and group miR-182 inhibitor. qRT-PCR and western blot were used to detect the expression of Foxo3a, flow cytometry was used to detect cell apoptosis, and EdU staining was used to detect cell proliferation.

RESULTS

Compared with normal bladder tissue, the expression of miR-182 in bladder cancer tissue was significantly increased, and it was related to tumor size, TNM stage, and lymph node metastasis (P < 0.05). The expression of Foxo3a mRNA was significantly decreased, and was related to tumor size, TNM stage, histopathologic classification, and lymph node metastasis (P < 0.05). There was a significant negative correlation between the expression of miR-182 and Foxo3a mRNA in bladder cancer (r = -0.602, P < 0.05). The prognosis of patients with high expression of miR-182 was significantly worse than that of those with low miR-182 expression. The prognosis of patients with low expression of Foxo3a was significantly better than those with high Foxo3a. Double luciferase reporter gene experiments confirmed that there was a target regulatory relationship between miR-182 and Foxo3a. Transfection of miR-182 inhibitor significantly increased the expression of Foxo3a in RT112 and T24 cells, significantly reducing cell proliferation, and significantly increasing apoptosis.

CONCLUSION

The expression of miR-182 was increased and the expression of Foxo3a was decreased in bladder cancer, which is related to prognosis. Downregulation of the expression of miR-182 can increase the expression of Foxo3a, inhibiting the proliferation of bladder cancer cells and inducing apoptosis.

Quality of life in men after total cystoprostatectomy: Perceptions of Tunisian patients

INTRODUCTION

Total cystoprostatectomy (TCP) causes many changes in the postoperative quality of life leading to psychological, physical, social and sexual repercussions that are difficult to manage. This study aims to describe the postoperative quality of life of elderly Tunisian men who had a TCP as a result of a bladder cancer.

METHODS

A descriptive quantitative study was conducted with 40 cystoprostatectomized men. Data collection tools were the Stoma-quality of life (QOL) questionnaire of Prieto, Thorsen, and Juul (2005) translated and validated to the Arabic language, and the Arabic version of the International Index of Erectile Function (IIEF5) questionnaire validated by Shamloul, Ghanem and Abou-Zeid (2004).

RESULTS

77.5% of participants had a very low quality-of-life score. All dimensions of quality of life-body image, physical, psychological, family and social life, and sexuality-were affected. In addition, all participants have suffered from severe sexual impotence after surgery.

CONCLUSION

Counselling pre and postoperatively needed to facilitate the postoperative transition and ensure a better quality of life related to the health of men with bladder cancer.

La qualité de vie à la suite à d’une cystoprostatectomie totale chez les hommes: perception des patients tunisiens

Introduction

La cystoprostatectomie totale (CPT) entraîne souvent des changements dans la qualité de vie postopératoire et, par le fait même, des répercussions psychologiques, physiques, sociales et sexuelles difficiles à assumer. La présente étude vise à décrire la qualité de vie postopératoire d’hommes tunisiens âgés ayant subi une CPT à cause d’un cancer de la vessie.

Méthodologie

Il s’agit d’une étude descriptive quantitative, menée auprès de 40 hommes cystoprostatectomisés. Les instruments de mesure utilisés sont: le questionnaire Stoma-Qualité de vie (Stoma-QOL) de Prieto, Thorsen et Juul (2005) , traduit et validé en arabe, ainsi que la version arabe du questionnaire de l’index international de la fonction érectile (IIEF5), validée par Shamloul, Ghanem et Abou-Zeid (2004) .

Résultats

77,5 % des participants obtiennent un score de qualité de vie médiocre. Toutes les dimensions de la qualité de vie sont touchées, à savoir l’image corporelle, physique et psychologique, la vie familiale et sociale, et enfin, la sexualité. En outre, tous les participants ont souffert d’impuissance sexuelle grave après l’intervention.

Conclusion

Le counseling pré et postopératoire s’avère nécessaire pour faciliter la transition après l’opération et assurer aux hommes ayant subi une CPT à cause d’un cancer de la vessie une meilleure qualité de vie liée à la santé.

Organ preservation in bladder cancer: an opportunity for truly personalized treatment

Radical treatment of many solid tumours has moved from surgery to multimodal organ preservation strategies combining systemic and local treatments. Trimodality bladder-preserving treatment (TMT) comprises maximal transurethral resection of the bladder tumour followed by radiotherapy and concurrent radiosensitizing treatment, thereby sparing the urinary bladder. From the patient's perspective, the choice of maintaining quality of life without a negative effect on the chances of cure and long-term survival is attractive. In muscle-invasive bladder cancer (MIBC), the evidence shows comparable clinical outcomes between patients undergoing radical cystectomy and TMT. Despite this evidence, many patients continue to be offered radical surgery as the standard-of-care treatment. Improvements in radiotherapy techniques with adaptive radiotherapy and advances in imaging translate to increases in the accuracy of treatment delivery and reductions in long-term toxicities. With the advent of novel biomarkers promising improved prediction of treatment response, stratification of patients for different treatments on the basis of tumour biology could soon be a reality. The future of oncological treatment lies in personalized medicine with the combination of technological and biological advances leading to truly bespoke management for patients with MIBC.

Life quality evaluation in patients with bladder cancer: A systematic review

OBJECTIVE

To identify scale validation studies for life quality evaluation in patients with bladder cancer.

METHODS

Bibliographic search was performed on MEDLINE® via ovid, EMBASE, CENTRAL and LILACS. Subsequently, each of the articles was evaluated, identifying eligibility criteria. This information was confirmed and verified by the researchers, and in cases of missing information, the authors were contacted to complete the data. Due to the nature of the study, no statistical analysis was performed.

RESULTS

From 1760 articles found, only 5were included in the qualitative analysis. Five validated questionnaires for quality of life in patients with bladder cancer (BCI, EORTC QLQ-NMIBC24, FACT-VCI, BUSS, FACT-BL). The BCI; most frequently used instrument in bladder cancer studies published to date. The FACT-VCI, instrument of application limited to unique therapeutic options within the spectrum of the disease. The EORTC QLQ-NMIBC24, widely acceptable questionnaire in the European community due to its psychometric characteristics. The BUSS evaluates the patient regardless the stage of the disease. The FACT-BL evaluates life quality in patients with non-muscle invasive bladder cancer.

CONCLUSION

The use of validated instruments such as: BCI, EORTC QLQ-NMIBC24, FACT-VI, BUSS and FACT-BL which allow evaluating the impact of disease and the established therapies, is recommended.

Expression of miR-195 and MEK1 in patients with bladder cancer and their relationship to prognosis

OBJECTIVE

MAPK kinase 1 (MEK1) plays an important role in regulating cell proliferation and apoptosis through activation of the ERK/MAPK signaling pathway. It was found that the expression of miR-195 in bladder cancer was abnormally decreased, suggesting that miR-195 may affect the development of bladder cancer. In this study, we examined the expression of miR-195 and MEK1 in bladder cancer tissues and analyzed the relationship between miR-195 and MEK1 in cell proliferation and apoptosis in bladder cancer cells.

PATIENTS AND METHODS

The expression of MEK1 in bladder cancer tissues was detected by western blot, and the expression levels of miR-195 and MEK1 mRNA were detected by qRT-PCR. Log Rank test was used to compare the survival and prognosis of patients with low and high expression of miR-195 and MEK1 by using the median expression of miR-195 and MEK1. Bioinformatics analysis and double luciferase reporter gene test were used to verify the relationship between miR-195 and MEK1. Bladder cancer BIU-87 and 5637 cells were cultured in vitro and divided into two groups: miR-NC group and miR-195 mimic group. The expression of MEK1 and p-MEK1 protein was detected by western blot, apoptosis was detected by flow cytometry, and cell proliferation was detected by EdU staining.

RESULTS

Compared with normal bladder tissue, expression of miR-195 in bladder cancer tissue was significantly decreased, while the expression of MEK1 mRNA and protein was significantly increased. The prognosis of patients with low expression of miR-195 was worse than those with high expression of miR-195. The prognosis of patients with low expression of MEK1 was better than those with high expression of MEK1. Bioinformatics analysis showed that there was a target complementary binding site between miR-195 and MEK1. Double luciferase reporter gene experiments confirmed that there was a target regulatory relationship between miR-195 and MEK1. miR-195 mimic transfection could significantly down-regulate the expression of MEK1 and p-MEK1 proteins in BIU-87 and 5637 cells, weaken cell proliferation, and increase cell apoptosis.

CONCLUSION

Overexpression of miR-195 can inhibit the proliferation of bladder cancer cells by inhibiting MEK1, which provides further evidence for developing therapy against bladder cancer.

Quality of life in bladder cancer patients receiving medical oncological treatment; a systematic review of the literature

Background

Previous quality of life (QoL) literature in bladder cancer (BC) patients has focused on finding the preferred urinary diversion while little is known about the QoL of patients in medical oncological treatment (MOT). We performed a systematic review to assess the existing literature on QoL in patients with muscle-invasive BC (MIBC) undergoing MOT.

Methods

A systematic search of Pubmed and Embase was performed. Inclusion criteria were studies containing QoL data for patients undergoing chemo- and/or radiotherapy. We extracted all QoL scorings at different time intervals and on the six most prevalent domains: overall QoL, urinary, bowel sexual symptoms, pain and fatigue. The study was carried out according to PRISMA guidelines for systematic reviews and GRADE was used to rate the quality of evidence from the included studies.

Results

Of 208 papers reviewed, 21 papers were included. Twenty-one different QoL instruments were applied. The only data on QoL during chemotherapy was from patients in clinical trials investigating new treatments. No studies were found for patients in neoadjuvant treatment. The level of evidence at each time point was graded as very low to moderate. From the studies included the overall QoL seemed inversely related to the organ-specific impairment from sexual and urinary symptoms and increased with decreasing organ-specific symptoms for long term survivors > 6 months after treatment.

Conclusions

Collection of data on QoL from patients with MIBC disease undergoing MOT has been sparse and diverse. The present data can act as a summary but prompts for more prospective collection of QoL data from BC patients.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-1077-6) contains supplementary material, which is available to authorized users.