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Huelster HL, Mason NT, Davaro F, Naqvi SMH, Kim Y, Gilbert SM. Cost-utility of Initial Management of High-grade T1 Bladder Cancer With Intravesical BCG vs Immediate Radical Cystectomy. Urology 2024; 187:106-113. [PMID: 38467285 DOI: 10.1016/j.urology.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/27/2024] [Accepted: 02/21/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE To compare the cost-utility of initial management of high-grade T1 non-muscle invasive bladder cancer (HGT1 NMIBC) with intravesical BCG vs immediate radical cystectomy. High-risk NMIBC patients may climb a costly ladder of treatments, culminating in radical cystectomy for oncologic or symptomatic benefit in up to one-third. This high healthcare resource utilization presents a challenging dilemma in balancing sufficiently aggressive management with cost, toxicity, and quality-of-life. METHODS Cost-utility of initially managing HGT1 with intravesical BCG and early radical cystectomy with ileal conduit urinary diversion was compared using decision-analytic Markov models. Five-year oncologic outcomes, adverse event rates, and published utility values were extracted from literature. Costs were calculated from a US Medicare perspective in 2021 US dollars. Sensitivity analysis identified drivers of cost and break-even points for recurrence and progression. RESULTS Mean costs were $26,093 for intravesical BCG and $39,720 for immediate radical cystectomy, though cystectomy generated a gain of 2.2 quality-adjusted life years (QALYs) compared to intravesical BCG. Immediate cystectomy was a more cost-effective management strategy for HGT1 NMIBC with an incremental CE ratios (ICER) of $7120/QALY. The costs associated with cystectomy, TURBT, and BCG toxicity had the greatest impact on ICER. One-way sensitivity analysis demonstrated that intravesical BCG became a cost-effective management strategy if the 5-year recurrence rate of HG T1 was less than 56% or the 5-year progression rate to MIBC was less than 4%. CONCLUSION At current prices, treatment of high-grade T1 NMIBC with early radical cystectomy is more cost-effective management strategy than initial treatment with intravesical BCG.
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Affiliation(s)
- Heather L Huelster
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Department of Urology, Indiana University Health, Indianapolis, IN.
| | - Neil T Mason
- Department of Individualized Cancer Medicine, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Facundo Davaro
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Youngchul Kim
- Department of Biostatistics, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL
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Llano A, Chan A, Kuk C, Kassouf W, Zlotta AR. Carcinoma In Situ (CIS): Is There a Difference in Efficacy between Various BCG Strains? A Comprehensive Review of the Literature. Cancers (Basel) 2024; 16:245. [PMID: 38254736 PMCID: PMC10813486 DOI: 10.3390/cancers16020245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Introduction: Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy is the standard of care for high-risk and intermediate-risk non-muscle-invasive bladder cancer (NMIBC) as well as for Carcinoma in situ (CIS). Evidence supports that the different BCG strains, despite genetic variability, are equally effective clinically for preventing the recurrence and progression of papillary NMIBC. The available evidence regarding possible differences in clinical efficacy between various BCG strains in CIS is lacking. Methods: We reviewed the literature on the efficacy of different BCG strains in patients with CIS (whether primary, secondary, concomitant, or unifocal/multifocal), including randomized clinical trials (RCTs), phase II/prospective trials, and retrospective studies with complete response rates (CRR), recurrence-free survival (RFS), or progression-free survival (PFS) as endpoints. Results: In most studies, being RCTs, phase II prospective trials, or retrospective studies, genetic differences between BCG strains did not translate into meaningful differences in clinical efficacy against CIS, regardless of the CIS subset (primary, secondary, or concurrent) or CIS focality (unifocal or multifocal). CRR, RFS, and PFS were not statistically different between various BCG strains. None of these trials were designed as head-to-head comparisons between BCG strains focusing specifically on CIS. Limitations include the small sample size of many studies and most comparisons between strains being indirect rather than head-to-head. Conclusions: This review suggests that the clinical efficacy of the various BCG strains appears similar, irrespective of CIS characteristics. However, based on the weak level of evidence available and underpowered studies, randomized studies in this space should be encouraged as no definitive conclusion can be drawn at this stage.
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Affiliation(s)
- Andres Llano
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
| | - Amy Chan
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
| | - Cynthia Kuk
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
| | - Wassim Kassouf
- Division of Urology, McGill University Health Center, Montreal, QU H4A 3J1, Canada;
| | - Alexandre R. Zlotta
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON M5G 2N2, Canada; (A.L.)
- Division of Urology, Department of Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre, University Heath Network, University of Toronto, Toronto, ON M5G 2C4, Canada
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Ślusarczyk A, Zapała P, Zapała Ł, Radziszewski P. The impact of smoking on recurrence and progression of non-muscle invasive bladder cancer: a systematic review and meta-analysis. J Cancer Res Clin Oncol 2023; 149:2673-2691. [PMID: 36404390 PMCID: PMC10129946 DOI: 10.1007/s00432-022-04464-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/02/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Although smoking is a well-recognized causative factor of urothelial bladder cancer and accounts for 50% of cases, less is known about the prognostic significance of smoking on non-muscle invasive bladder cancer (NMIBC) prognosis. This systematic review and meta-analysis aimed to evaluate the effect of smoking on the risk of NMIBC recurrence and progression. MATERIALS AND METHODS We systematically searched Medline, Web of Science and Scopus databases for original articles published before October 2021 regarding the effect of smoking on NMIBC recurrence and progression. Information about smoking status and the number of events or odds ratio or hazard ratio for event-free survival must have been reported to include the study in the analysis. Quality In Prognosis Studies tool was utilized for the risk of bias assessment. RESULTS We selected 64 eligible studies, including 28 617 patients with NMIBC with available data on smoking status. In a meta-analysis of 28 studies with 7885 patients, we found that smokers (current/former) were at higher risk for recurrence (OR = 1.68; 95% CI 1.34-2.09; P < 0.0001) compared to never smokers. Subgroup analysis of 2967 patients revealed that current smokers were at a 1.24 higher risk of recurrence (OR = 1.24; 95% CI 1.02-1.50; P = 0.03) compared to former smokers. A meta-analysis of the hazard ratio revealed that smokers are at higher risk of recurrence (HR = 1.31; 95%CI 1.15-1.48; P < 0.0001) and progression (HR = 1.18; 95%CI 1.08-1.29; P < 0.001) compared to never smokers. Detrimental prognostic effect of smoking on progression, but not for recurrence risk was also noted in the subgroup analysis of high-risk patients (HR = 1.30; 95%CI 1.09-1.55; P = 0.004) and BCG-treated ones (HR = 1.15; 95%CI 1.06-1.25; P < 0.001). CONCLUSION In conclusion, patients with non-muscle invasive bladder cancer and a history of smoking have a worse prognosis regarding recurrence-free and progression-free survival compared to non-smokers.
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Affiliation(s)
- Aleksander Ślusarczyk
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland.
| | - Piotr Zapała
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland.
| | - Łukasz Zapała
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
| | - Piotr Radziszewski
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, Lindleya 4, 02-005, Warsaw, Poland
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Del Giudice F, Asero V, Bologna E, Scornajenghi CM, Carino D, Dolci V, Viscuso P, Salciccia S, Sciarra A, D'Andrea D, Pradere B, Moschini M, Mari A, Albisinni S, Krajewski W, Szydełko T, Małkiewicz B, Nowak Ł, Laukhtina E, Gallioli A, Mertens LS, Marcq G, Cimadamore A, Afferi L, Soria F, Mori K, Tully KH, Pichler R, Ferro M, Tataru OS, Autorino R, Crivellaro S, Crocetto F, Busetto GM, Basran S, Eisenberg ML, Chung BI, De Berardinis E. Efficacy of Different Bacillus of Calmette-Guérin (BCG) Strains on Recurrence Rates among Intermediate/High-Risk Non-Muscle Invasive Bladder Cancers (NMIBCs): Single-Arm Study Systematic Review, Cumulative and Network Meta-Analysis. Cancers (Basel) 2023; 15:cancers15071937. [PMID: 37046598 PMCID: PMC10093360 DOI: 10.3390/cancers15071937] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND In an era of Bacillus of Calmette-Guérin (BCG) shortages, the comparative efficacy from different adjuvant intravesical BCG strains in non-muscle invasive bladder cancer (NMIBC) has not been clearly elucidated. We aim to compare, through a systematic review and meta-analysis, the cumulative BC recurrence rates and the best efficacy profile of worldwide available BCG strains over the last forty years. METHODS PubMed, Scopus, Web of Science, Embase, and Cochrane databases were searched from 1982 up to 2022. A meta-analysis of pooled BC recurrence rates was stratified for studies with ≤3-y vs. >3-y recurrence-free survival (RFS) endpoints and the strain of BCG. Sensitivity analysis, sub-group analysis, and meta-regression were implemented to investigate the contribution of moderators to heterogeneity. A random-effect network meta-analysis was performed to compare BCG strains on a multi-treatment level. RESULTS In total, n = 62 series with n = 15,412 patients in n = 100 study arms and n = 10 different BCG strains were reviewed. BCG Tokyo 172 exhibited the lowest pooled BC recurrence rate among studies with ≤3-y RFS (0.22 (95%CI 0.16-0.28). No clinically relevant difference was noted among strains at >3-y RFS outcomes. Sub-group and meta-regression analyses highlighted the influence of NMIBC risk-group classification and previous intravesical treated categories. Out of the n = 11 studies with n = 7 BCG strains included in the network, BCG RIVM, Tice, and Tokyo 172 presented with the best-predicted probability for efficacy, yet no single strain was significantly superior to another in preventing BC recurrence risk. CONCLUSION We did not identify a BCG stain providing a clinically significant lower BC recurrence rate. While these findings might discourage investment in future head-to-head randomized comparison, we were, however, able to highlight some potential enhanced benefits from the genetically different BCG RIVM, Tice, and Tokyo 172. This evidence would support the use of such strains for future BCG trials in NMIBCs.
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Affiliation(s)
- Francesco Del Giudice
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Vincenzo Asero
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Eugenio Bologna
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Carlo Maria Scornajenghi
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Dalila Carino
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Virginia Dolci
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Pietro Viscuso
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Stefano Salciccia
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Alessandro Sciarra
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1030 Vienna, Austria
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1030 Vienna, Austria
- Department of Urology, La Croix du Sud Hospital, 31130 Quint-Fonsegrives, France
| | - Marco Moschini
- Department of Urology and Division of Experimental Oncology, Urological Research Institute, Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Andrea Mari
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, 50134 Florence, Italy
| | - Simone Albisinni
- Urology Unit, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Tomasz Szydełko
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Bartosz Małkiewicz
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Łukasz Nowak
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1030 Vienna, Austria
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
| | - Andrea Gallioli
- Department of Urology, Fundacio Puigvert, 16444 Barcelona, Spain
| | - Laura S Mertens
- Department of Urology, The Netherlands Cancer Institute, 1066 Amsterdam, The Netherlands
| | - Gautier Marcq
- Urology Department, Claude Huriez Hospital, CHU Lille, 59000 Lille, France
- Cancer Heterogeneity Plasticity and Resistance to Therapies, UMR9020-U1277-CANTHER, Institut Pasteur de LilleCHU Lille, Inserm, CNRS University of Lille, 59000 Lille, France
| | - Alessia Cimadamore
- Department of Medical Area (DAME), Institute of Pathological Anatomy, University of Udine, 33100 Udine, Italy
| | - Luca Afferi
- Department of Urology, Luzerner Kantonsspital, 6004 Luzern, Switzerland
| | - Francesco Soria
- Urology Division, Department of Surgical Sciences, University of Studies of Torino, 10124 Turin, Italy
| | - Keiichiro Mori
- Department of Urology, The Jikei University School of Medicine, Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Karl Heinrich Tully
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, 44780 Herne, Germany
| | - Renate Pichler
- Department of Urology, Comprehensive Cancer Center Innsbruck, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Matteo Ferro
- Division of Urology, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Octavian Sabin Tataru
- Department of Simulation Applied in Medicine, The Institution Organizing University Doctoral Studies (I.O.S.U.D.), George Emil Palade University of Medicine, Pharmacy, Sciences, and Technology, 540142 Târgu Mureș, Romania
| | - Riccardo Autorino
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Simone Crivellaro
- Health Sciences System, Department of Urology, University of Illinois Hospital e Camp, Chicago, IL 60612, USA
| | - Felice Crocetto
- Reproductive Sciences and Odontostomatology, Urology Unit, Department of Neurosciences, University of Naples "Federico II", 80138 Naples, Italy
| | - Gian Maria Busetto
- Department of Urology and Organ Transplantation, University of Foggia, 71122 Foggia, Italy
| | - Satvir Basran
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Michael L Eisenberg
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Benjamin Inbeh Chung
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Ettore De Berardinis
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
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Lemiński A, Michalski W, Masojć B, Kaczmarek K, Małkiewicz B, Kienitz J, Zawisza-Lemińska B, Falco M, Słojewski M. Combined Modality Bladder-Sparing Therapy for Muscle-Invasive Bladder Cancer: How (Should) We Do It? A Narrative Review. J Clin Med 2023; 12:1560. [PMID: 36836093 PMCID: PMC9960746 DOI: 10.3390/jcm12041560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
Organ-sparing combined-modality treatment for muscle-invasive bladder cancer remains underutilized despite high-quality evidence regarding its efficacy, safety, and preservation of quality of life. It may be offered to patients unwilling to undergo radical cystectomy, as well as those unfit for neoadjuvant chemotherapy and surgery. The treatment plan should be tailored to each patient's characteristics, with more intensive protocols offered to patients who are fit for surgery but opt for organ-sparing. After a thorough, debulking transurethral resection of the tumor and neoadjuvant chemotherapy, the response evaluation should trigger further management with either chemoradiation or early cystectomy in non-responders. A hypofractionated, continuous radiotherapy regimen of 55 Gy in 20 fractions with concurrent radiosensitizing chemotherapy with gemcitabine, cisplatin, or 5-fluorouracil and mitomycin C is currently preferred based on clinical trials. The response should be evaluated with repeated transurethral resections of the tumor bed and abdominopelvic-computed tomography after chemoradiation, with quarterly assessments during the first year. Salvage cystectomy should be offered to patients fit for surgery who failed to respond to treatment or developed a muscle-invasive recurrence. Non-muscle-invasive bladder recurrences and upper tract tumors should be treated in line with guidelines for respective primary tumors. Multiparametric magnetic resonance can be used for tumor staging and response monitoring, as it may distinguish disease recurrence from treatment-induced inflammation and fibrosis.
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Affiliation(s)
- Artur Lemiński
- Department of Urology and Urological Oncology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Wojciech Michalski
- Department of Urological Cancer, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Roentgena 5, 02-781 Warsaw, Poland
| | - Bartłomiej Masojć
- Department of Radiotherapy, West-Pomeranian Oncology Center, 71-730 Szczecin, Poland
| | - Krystian Kaczmarek
- Department of Urology and Urological Oncology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Bartosz Małkiewicz
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, Borowska 213, 50-556 Wrocław, Poland
| | - Jakub Kienitz
- Department of Urology and Urological Oncology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | | | - Michał Falco
- Department of Radiotherapy, West-Pomeranian Oncology Center, 71-730 Szczecin, Poland
| | - Marcin Słojewski
- Department of Urology and Urological Oncology, Pomeranian Medical University, 70-111 Szczecin, Poland
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