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Ben-David R, Tillu N, Alerasool P, Bieber C, Ranti D, Tolani S, Eisenhauer J, Chung R, Lavallée E, Waingankar N, Attalla K, Wiklund P, Mehrazin R, Anderson CB, Sfakianos JP. Induction and maintenance of sequential intravesical gemcitabine/docetaxel for intermediate and high-risk non-muscle invasive bladder cancer with different dosage protocols. World J Urol 2024; 42:315. [PMID: 38734774 DOI: 10.1007/s00345-024-04992-5] [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: 10/25/2023] [Accepted: 04/11/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION The combination of sequential intravesical gemcitabine and docetaxel (Gem/Doce) chemotherapy has been considered a feasible option for BCG (Bacillus Calmette-Guérin) treatment in non-muscle invasive bladder cancer (NMIBC), gaining popularity during BCG shortage period. We seek to determine the efficacy of the treatment by comparing Gem/Doce induction alone vs induction with maintenance, and to evaluate the treatment outcomes of two different dosage protocols. METHODS A bi-center retrospective analysis of consecutive patients treated with Gem/Doce for NMIBC between 2018 and 2023 was performed. Baseline characteristics, risk group stratification (AUA 2020 guidelines), pathological, and surveillance reports were collected. Kaplan-Meier survival analysis was performed to detect Recurrence-free survival (RFS). RESULTS Overall, 83 patients (68 males, 15 females) with a median age of 73 (IQR 66-79), and a median follow-up time of 18 months (IQR 9-25), were included. Forty-one had an intermediate-risk disease (49%) and 42 had a high-risk disease (51%). Thirty-seven patients (45%) had a recurrence; 19 (23%) had a high-grade recurrence. RFS of Gem/Doce induction-only vs induction + maintenance was at 6 months 88% vs 100%, at 12 months 71% vs 97%, at 18 months 57% vs 91%, and at 24 months 31% vs 87%, respectively (log-rank, p < 0.0001). Patients who received 2 g Gemcitabine with Docetaxel had better RFS for all-grade recurrences (log-rank, p = 0.017). However, no difference was found for high-grade recurrences. CONCLUSION Gem/Doce induction with maintenance resulted in significantly better RFS than induction-only. Combining 2 g gemcitabine with docetaxel resulted in better RFS for all-grade but not for high-grade recurrences. Further prospective trials are necessary to validate our results.
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Affiliation(s)
- Reuben Ben-David
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA.
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA.
| | - Neeraja Tillu
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
| | - Parissa Alerasool
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Christine Bieber
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
| | - Daniel Ranti
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
| | - Serena Tolani
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
| | - Justin Eisenhauer
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
| | - Rainjade Chung
- Department of Urology, Columbia University Irving Medical Center, New York, NY, USA
| | - Etienne Lavallée
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
| | - Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
| | | | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
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Ben-David R, Galsky MD, Sfakianos JP. Novel bladder-sparing approaches in patients with muscle-invasive bladder cancer. Trends Mol Med 2024:S1471-4914(24)00092-3. [PMID: 38692938 DOI: 10.1016/j.molmed.2024.04.004] [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: 01/17/2024] [Revised: 03/02/2024] [Accepted: 04/04/2024] [Indexed: 05/03/2024]
Abstract
The pursuit of surgeons and oncologists in fulfilling the inherent desire of patients to retain their urinary bladder despite having muscle-invasive bladder cancer (MIBC) has sparked years of research and multiple debates, given its aggressive nature and the high risk of fatal metastatic recurrence. Historically, several approaches to bladder-sparing treatment have been explored, ranging from radical transurethral resection to concurrent chemoradiation. A less well-established approach involves a risk-adapted approach with local therapy deferred based on the clinical response to transurethral resection followed by systemic therapy. Each approach is associated with potential risks, benefits, and trade-offs. In this review, we aim to understand, navigate, and suggest future perspectives on bladder-sparing approaches in patients with MIBC.
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Affiliation(s)
- Reuben Ben-David
- Department of Urology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA; Tisch Cancer Institute, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA.
| | - Matthew D Galsky
- Tisch Cancer Institute, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA; Tisch Cancer Institute, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
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Kikuchi E, Ng CF, Kitamura H, Ku JH, Lee LS, Lin TP, Ng JYS, Nishiyama H, Poon DMC, Kanesvaran R, Seo HK, Spiteri C, Tan EM, Tsai YS, Tran B. Controversies in terminology associated with management of BCG-unresponsive NMIBC in Asia-Pacific. Int J Urol 2024; 31:32-38. [PMID: 37795933 DOI: 10.1111/iju.15298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/06/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES Examine the understanding of terminologies and management patterns of bacillus Calmette-Guérin (BCG)-unresponsive nonmuscle invasive bladder cancer (NMIBC) in six territories in Asia-Pacific. METHODS This study involved two phases: (1) a survey with 32 urologists and 7 medical oncologists (MOs) and (2) a factorial experiment and in-depth interviews with 23 urologists and 2 MOs. All clinicians had ≥8 years' experience managing NMIBC patients in Australia, Hong Kong, Japan, South Korea, Singapore, and Taiwan. Data from Phase 1 were summarized using descriptive statistics; content and thematic analyses applied in Phase 2. RESULTS In phase 1, 35% of clinicians defined BCG-unresponsive as BCG-refractory, -relapse and -resistant, 6% defined it as BCG-refractory and -relapse; 22% classified BCG-failure as BCG-refractory, -relapse, -resistant, and when muscle-invasive bladder cancer is detected. If eligible and willing, 50% (interquartile range [IQR], 50%-80%) of BCG-unresponsive patients would undergo radical cystectomy (RC), and 50% (IQR 20%-50%) of RC-eligible patients would receive bladder-sparing treatment or surveillance. In phase 2, we found that 32%, 88%, and 48% of clinicians, respectively, used "BCG-unresponsive," "BCG-refractory," and "BCG-relapse" in clinical practice but with no consistent interpretation of the terms. Compared with EAU definitions, 8%-60% of clinicians appropriately classified 9 tumor types that are persistent or recurrent after adequate BCG. Fifty percent of clinicians mentioned a lack of bladder-preserving treatment that outperforms RC in quality of life as a reason to retreat BCG-unresponsive patients with BCG. CONCLUSIONS Our study revealed varied understanding and application of BCG-unresponsive terminologies in practice. There is a need for a uniform and simple definition of BCG-unresponsive disease in Asia-Pacific.
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Affiliation(s)
- Eiji Kikuchi
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Chi-Fai Ng
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | - Ja Hyeon Ku
- Department of Urology, Seoul National University, Seoul, South Korea
| | - Lui Shiong Lee
- Department of Urology, Seng Kang General Hospital, Singapore, Singapore
| | - Tzu-Ping Lin
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Junice Yi Siu Ng
- Health Economics and Outcomes Research, IQVIA Asia-Pacific, Singapore, Singapore
| | | | - Darren Ming-Chun Poon
- Comprehensive Oncology Center, Hong Kong Sanatorium & Hospital, Hong Kong, Hong Kong
| | - Ravindran Kanesvaran
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Ho Kyung Seo
- Department of Urology, National Cancer Center, Goyang-si, South Korea
| | - Carmel Spiteri
- Market Access Asia Pacific, MSD Macquarie Park, NSW, Macquarie Park, Australia
| | - Ee Min Tan
- Health Economics and Outcomes Research, IQVIA Asia-Pacific, Singapore, Singapore
| | - Yuh-Shyan Tsai
- Department of Urology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ben Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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Ślusarczyk A, Zapała P, Zapała Ł, Borkowski T, Radziszewski P. Cancer-Specific Survival of Patients with Non-Muscle-Invasive Bladder Cancer: A Population-Based Analysis. Ann Surg Oncol 2023; 30:7892-7902. [PMID: 37578604 PMCID: PMC10562346 DOI: 10.1245/s10434-023-14051-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/06/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND AND PURPOSE Non-muscle-invasive bladder cancer (NMIBC) constitutes a heterogeneous group of tumors with different prognoses. This population-based study aimed to report real-world cancer-specific survival (CSS) of NMIBC and create a prognostic nomogram based on the identified risk factors. METHODS The Surveillance, Epidemiology, and End Results database was searched for patients diagnosed with NMIBC from 2004 to 2015, who underwent transurethral resection of the bladder tumor. The dataset was divided into development and validation cohorts. Factors associated with CSS were identified using Cox proportional hazards and used to develop a prognostic nomogram. RESULTS In total, 98,238 patients with NMIBC were included. At the median follow-up of 124 months (IQR 81-157 months), cancer-specific mortality (CSM) was highest for T1HG (19.52%), followed by Tis (15.56%), similar for T1LG and TaHG (10.88% and 9.23%, respectively), and lowest for TaLG (3.76%). Multivariable Cox regression for CSS prediction was utilized to develop a nomogram including the following risk factors: tumor T category and grade, age, tumor size and location, histology type, primary character, race, income, and marital status. In the validation cohort, the model was characterized by an AUC of 0.824 and C-index that reached 0.795. CONCLUSIONS To conclude, NMIBC is associated with a significant risk of long-term CSM especially, but not only, in patients with T1HG. Rarely diagnosed TaHG and T1LG tumors should be regarded as high-risk due to approximately 10% CSM. T category, grading, and age remain the most powerful determinants of CSS in NMIBC, but sociodemographic factors might also influence its prognosis.
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Affiliation(s)
- Aleksander Ślusarczyk
- Department of General, Oncological, and Functional Urology, Medical University of Warsaw, Warsaw, Poland.
| | - Piotr Zapała
- Department of General, Oncological, and Functional Urology, Medical University of Warsaw, Warsaw, Poland
| | - Łukasz Zapała
- Department of General, Oncological, and Functional Urology, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Borkowski
- Department of General, Oncological, and Functional Urology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Radziszewski
- Department of General, Oncological, and Functional Urology, Medical University of Warsaw, Warsaw, Poland
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Castaneda PR, Theodorescu D, Rosser CJ, Ahdoot M. Identifying novel biomarkers associated with bladder cancer treatment outcomes. Front Oncol 2023; 13:1114203. [PMID: 37064102 PMCID: PMC10090444 DOI: 10.3389/fonc.2023.1114203] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/08/2023] [Indexed: 03/31/2023] Open
Abstract
Bladder cancer is a complex disease with variable prognosis. Recent investigations into the molecular landscape of bladder cancer have revealed frequent genetic alterations and molecular subtypes with therapeutic implications. Consequently, a shift toward personalized treatment of bladder cancer is underway. To this end, several biomarkers have been developed and tested in their ability to predict response to treatment in patients with bladder cancer and potentially help direct therapy. We performed a search of recently published PubMed articles using terms "biomarker," "bladder cancer," and the respective treatment discussed (i.e., "neoadjuvant" or "BCG"). In this review, we summarize the latest studies on novel biomarkers in bladder cancer with a focus on those intended to improve risk stratification and treatment selection.
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Affiliation(s)
- Peris R. Castaneda
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Dan Theodorescu
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA, United States
| | - Charles J. Rosser
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA, United States
| | - Michael Ahdoot
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Elsawy AA, Laymon M, Mansour I, Elghareeb A, Harraz A. Can we offer additional BCG therapy for three-month BCG refractory high grade/T1, Tis bladder cancer patients? Arab J Urol 2023; 21:142-149. [PMID: 37521452 PMCID: PMC10373613 DOI: 10.1080/2090598x.2023.2190687] [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: 01/20/2023] [Accepted: 03/08/2023] [Indexed: 08/01/2023] Open
Abstract
Background We lack tools to predict treatment and survival outcomes in patients receiving additional BCG therapy as a bladder-preserving therapy in high grade/T1, Tis NMIBC patients who showed persistent/recurrent tumors at three-month follow-up. Objectives To assess the predictors of additional BCG response in patients who experienced persistent/recurrent tumors at three-month follow-up after BCG induction. Patients and methods We retrospectively analyzed database for NMIBC. Between 2000 and 2019, 231 patients with high-grade T1/Tis NMIBC showed persistent/recurrent tumors at 3-month after BCG-induction, refused or were unfit to radical cystectomy (RC) and were offered additional intravesical BCG as bladder-preserving treatment. Predictors of the outcome after additional BCG were studied using univariate and multivariate logistic regression analysis. Kaplan Meier curve was utilized to estimate the recurrence-free survival (RFS) and progression-free survival (PFS). COX regression analysis was performed to identify independent predictors or RFS and PFS. Results During a median (range) of 148 (24-224) months, poor response to additional BCG (tumor recurrence and/or progression) was noted in 112 (48.5%) patients. On multivariate logistic regression analysis, 3-month tumor features (persistent T stage, persistent grade and persistent/new CIS) significantly predicted poor response to additional BCG (OR: 3.4, 95%CI: 1.3-10.8, p = 0.021, OR: 2.1, 95%CI: 1.1-4.1, p = 0.02 and OR: 16.6, 95%CI: 4.5-109, p=<0.001, respectively). The mean RFS was 26 (9-152) months with identified 3-month tumor features (persistent T stage and persistent/new CIS) as independent predictors of RFS (HR = 11.5, 95%CI = 2.7-48.3, p = 0.001 and HR = 2.5, 95%CI = 1.5-4.1, p=<0.001, respectively) on multivariate COX regression analysis. In addition, 3-month tumor features (persistent/new CIS, non-papillary shape and bladder neck involvement) were identified to significantly predict PFS (HR = 6.2, 95%CI = 3.4-11.5, p=<0.001 and HR = 2.3, 95%CI = 1.3-4.3 p = 0.001 and HR = 2.1, 95%CI = 1.2-3.8, p=<0.005, respectively). Conclusions Three-month tumor features could be utilized as a tool to predict treatment outcomes and survival benefits when additional intravesical BCG is utilized as a bladder-preserving treatment in patients with recurrent/persistent tumors at three-month follow-up.
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Affiliation(s)
- Amr A. Elsawy
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Mahmoud Laymon
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Islam Mansour
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed Elghareeb
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed Harraz
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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Sun X, Dai T, Xu L. Transurethral resection of bladder tumor-based bladder preservation therapy for refractory high risk non-muscle invasive bladder cancer: Current landscape and future directions. Front Surg 2023; 10:1143219. [PMID: 37123545 PMCID: PMC10130525 DOI: 10.3389/fsurg.2023.1143219] [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: 01/12/2023] [Accepted: 03/06/2023] [Indexed: 05/02/2023] Open
Abstract
Bladder cancer is the most common malignant tumor of urinary system worldwide. Approximately 75% of patients with bladder cancer present with non-muscle-invasive bladder cancer (NMIBC), which is effectively managed with transurethral resection of bladder tumor (TURBT). For refractory high risk NMIBC, patients are typically treated by radical cystectomy (RC). TURBT deserves further evaluation. Growing evidence suggests that repeated TURBT-based bladder-sparing approaches may improve oncological outcomes and quality of life in highly selected patients. Novel imaging techniques and biomarkers may aid in patients selection and postoperative surveillance. With growing interest in adding immunotherapy to refractory bladder cancer, TURBT based approaches enable the bladder preservation therapy for high risk NMIBC. Here we summarize the current landscape, biomarkers for surveillance, and future directions for applying TURBT-based bladder preservation therapy.
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Affiliation(s)
- Xinghui Sun
- Department of Urology, Mengchao Hepatobiliary Hospital, Fuzhou, China
- Correspondence: Xinghui Sun
| | - Tianzeng Dai
- Department of Urology, Mengchao Hepatobiliary Hospital, Fuzhou, China
| | - Lihui Xu
- Department of Urology, Mengchao Hepatobiliary Hospital, Fuzhou, China
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Kombathula SH, Hoskin P. Pushing the Envelope: The Role of Radiation Therapy in Non-muscle-Invasive Bladder Cancer. Semin Radiat Oncol 2023; 33:21-25. [PMID: 36517190 DOI: 10.1016/j.semradonc.2022.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The standard of care for non-muscle-invasive bladder cancer (NMIBC) is transurethral resection followed by risk stratified use of intravesical immune- or chemotherapy and for multifocal, recurrent and high grade disease, radical cystectomy with high rates of cure. Bladder preservation analogous to the trimodality therapy approach in muscle-invasive bladder cancer (MIBC) has not been adequately explored but the available data suggests that NMIBC is a radioresponsive malignancy and that in a proportion of patients bladder preservation would be possible. Combination modality with chemotherapy, hypoxia sensitisation, hyperthermia and immunotherapy are all approaches which have been shown effective. Unfortunately the quality of the available data is poor. Although there are many putative prognostic biomarkers for progression in NMIBC none have emerged in clinical use and there are none predictive for response to non-surgical treatment. This would be an important component of future large scale studies to evaluate the precise role of radiotherapy within a multimodality schedule for bladder reservation in NMIBC.
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Affiliation(s)
| | - Peter Hoskin
- Christie Hospital, Manchester; Division of Cancer Sciences, University of Manchester, Manchester; Mount Vernon Cancer Centre, Northwood.
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Han JH, Jeong SH, Yuk HD, Jeong CW, Kwak C, Ku JH. Acidic urine is associated with poor prognosis in patients with bladder cancer undergoing radical cystectomy. Front Oncol 2022; 12:964571. [PMID: 36091123 PMCID: PMC9459327 DOI: 10.3389/fonc.2022.964571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/22/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose To assess the prognostic value of acidic urine (low urine pH) in patients with bladder cancer undergoing radical cystectomy. Materials and methods We reviewed patients enrolled in the Seoul National University Prospectively Enrolled Registry for Urothelial Cancer-Cystectomy (SUPER-UC-Cx) who underwent radical cystectomy for bladder cancer between March 2016 and December 2020 at the Seoul National University Hospital. During this period, 368 patients were registered in our database. To eliminate confounding factors, we excluded patients diagnosed with non-urothelial cancer and end-stage renal disease. Results A total of 351 patients with a mean age of 69.8 ± 10.5 years and median follow-up of 16.0 months were eligible for the analysis. The mean preoperative urine pH was 6.0. The patients were divided into low (pH ≤ 5.5) and high (pH≥6.0) urine pH groups for comparison. All clinicopathological features, including the tumor size, grade, and stage were comparable between the low and high urine pH groups. A Cox regression analysis was performed to assess the independent effect of acidic urine on patient survival. A multivariate analysis showed that high T stage (T3-4) (hazard ratio (HR) 5.18, P<0.001), decreased renal function (estimated glomerular filtration rate <60 mL/min/1.73 m2) (HR 2.29, P=0.003), and low urine pH (≤5.5) (HR 1.69, P=0.05) were associated with shortened recurrence-free survival (RFS). Regarding the overall survival (OS), high T stage (T3-4) (HR 7.15, P<0.001) and low urine pH (≤5.5) (HR 2.66, P=0.029) were significantly associated with shortened survival. A Kaplan–Meier analysis demonstrated that the acidic urine group showed shorter RFS (P=0.04) and OS (P=0.028) than the other groups. Conclusions Acidic urine was independently associated with reduced RFS and OS in patients with bladder cancer undergoing radical cystectomy. Acidic urine contributing to an acidic tumor environment may promote aggressive behavior in bladder cancer.
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Affiliation(s)
- Jang Hee Han
- Department of Urology, Seoul National University Hospital, Seoul, South Korea
| | - Seung-hwan Jeong
- Department of Urology, Seoul National University Hospital, Seoul, South Korea
| | - Hyeong Dong Yuk
- Department of Urology, Seoul National University Hospital, Seoul, South Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
| | - Chang Wook Jeong
- Department of Urology, Seoul National University Hospital, Seoul, South Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
| | - Cheol Kwak
- Department of Urology, Seoul National University Hospital, Seoul, South Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
| | - Ja Hyeon Ku
- Department of Urology, Seoul National University Hospital, Seoul, South Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Ja Hyeon Ku,
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Effectiveness of Early Radical Cystectomy for High-Risk Non-Muscle Invasive Bladder Cancer. Cancers (Basel) 2022; 14:cancers14153797. [PMID: 35954460 PMCID: PMC9367342 DOI: 10.3390/cancers14153797] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/24/2022] [Accepted: 08/01/2022] [Indexed: 02/04/2023] Open
Abstract
Purpose: The purpose of this study is to compare perioperative and oncological outcomes of upfront vs. delayed early radical cystectomy (eRC) for high-risk non-muscle-invasive bladder cancer (HR-NMIBC). Methods: All consecutive HR-NMIBC patients who underwent eRC between 2001 and 2020 were retrospectively included and divided into upfront and delayed groups, according to the receipt or not of BCG. Perioperative outcomes were evaluated and the impact of upfront vs. delayed eRC on pathological upstaging, defined as ≥pT2N0 disease at final pathology, was assessed using multivariable logistic regression. Recurrence-free (RFS), cancer-specific (CSS) and overall survival (OS) were compared between upfront and delayed eRC groups using inverse probability of treatment weighting (IPTW)-adjusted Cox model. Results: Overall, 184 patients received either upfront (n = 87; 47%) or delayed (n = 97; 53%) eRC. No difference was observed in perioperative outcomes between the two treatment groups (all p > 0.05). Pathological upstaging occurred in 55 (30%) patients and upfront eRC was an independent predictor (HR = 2.65; 95% CI = (1.23−5.67); p = 0.012). In the IPTW-adjusted Cox analysis, there was no significant difference between upfront and delayed eRC in terms of RFS (HR = 1.31; 95% CI = (0.72−2.39); p = 0.38), CSS (HR = 1.09; 95% CI = (0.51−2.34); p = 0.82) and OS (HR = 1.19; 95% CI = (0.62−2.78); p = 0.60). Conclusion: our results suggest similar perioperative outcomes between upfront and delayed eRC, with an increased risk of upstaging after upfront eRC that did impact survival, as compared to delayed eRC.
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Han JH, Yuk HD, Choi JW, Ku JH. NBCA-Lipiodol Mixture Embolization of Persistent Urine Leakage After Orthotopic Neobladder Formation: Techniques and Outcomes. Front Surg 2022; 9:844588. [PMID: 35574556 PMCID: PMC9091345 DOI: 10.3389/fsurg.2022.844588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo show the effective and successful technical approach of percutaneous embolization for persistent urine leakage that occurred after orthotopic neobladder formation.Materials and MethodsWe retrospectively reviewed patients who underwent percutaneous embolization of N-butyl cyanoacrylate (NBCA) and lipiodol mixture after orthotopic neobladder formation at the Seoul National University Hospital (Seoul, Korea) from 1 January 2018 to 31 December 2020.ResultsAmong total of 182 patients of neobladder formation, five patients (four males and one female) were enrolled in this study, and their median age was 61.0 years (interquartile range (IQR): 42.5–69.5 years). All the patients showed persistent urine leakage at the neobladder-urethral anastomosis site and percutaneous drainage was primarily performed. The median time to perform percutaneous embolization was 40 days (IQR: 31.5–71.5 days) postoperatively. Elective two-staged embolization was performed in three cases for large diameter with a large fluid-filled cavity, while re-embolization was needed for delayed recurrence of urine leakage in two cases. Complete resolution of urine leakage was seen in all the cases and the median time to leakage closure was 55 days (IQR: 27.5–82.5 days). The median follow-up period after leakage closure was 26 months (IQR: 15.5–36.4 months), and embolization material-related bladder stone was a noticeable complication (two cases) during follow-up, which was removed endoscopically within 1 year after embolization. All patients' quality of life (EQ-5D-5L score) was well-maintained during the entire period.ConclusionsPersistent urine leakage after neobladder formation can be effectively managed with percutaneous embolization of “dumbbell technique” by reinforcing the closure of leakage tract from inner opening to the outer opening even for large diameter (>1 cm).
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Affiliation(s)
- Jang Hee Han
- Department of Urology, Seoul National University Hospital, Seoul, South Korea
| | - Hyeong Dong Yuk
- Department of Urology, Seoul National University Hospital, Seoul, South Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin Woo Choi
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ja Hyeon Ku
- Department of Urology, Seoul National University Hospital, Seoul, South Korea
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Ja Hyeon Ku
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Multi-country clinical practice patterns, including use of biomarkers, among physicians’ treatment of BCG-unresponsive non-muscle invasive bladder cancer (NMIBC). BMC Urol 2022; 22:27. [PMID: 35219307 PMCID: PMC8882282 DOI: 10.1186/s12894-022-00959-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/18/2022] [Indexed: 11/27/2022] Open
Abstract
Background Intravesical bacillus Calmette-Guérin (BCG) fails in a considerable proportion of non-muscle invasive bladder cancer (NMIBC) patients despite treatment per recommended protocol. This real-world study aimed to understand the current patterns of treatment and disease management for the broad BCG-unresponsive NMIBC patient population, alongside collecting sufficient data on patients who do not undergo cystectomy. Methods This was a multicenter, retrospective survey of physicians treating BCG-unresponsive NMIBC patients. Data were collected in eight countries – France, Germany, Spain, Italy, United Kingdom, United States, China, and Japan – between January and May 2019. The study consisted of a short online physician survey and a retrospective chart review of eligible BCG-unresponsive NMIBC patients. Physicians abstracted chart data for the last 10 (five patients in Japan) eligible BCG-unresponsive NMIBC patients meeting the inclusion criteria, and the data were analysed for all countries combined using descriptive statistics. Country-specific analyses were also carried out, as appropriate. Results Overall, 508 physicians participated in the study. Almost one-quarter (22.9%) of physicians’ current NMIBC patient caseload was BCG-unresponsive, whereby BCG therapy was no longer considered an option. Half of physicians (49.4%) did not regularly use biomarker tests in their practice, with particularly few physicians undertaking biomarker testing in Spain and Japan. Biomarker testing varied considerably, with the proportions of physicians selecting ‘none’ ranging from 11.4% in China to 70.3% in Japan. Physicians reported transurethral resection of the bladder tumor (TURBT) and BCG as the most common current treatments received by their patients. Chemotherapy and anti-PD-L1 treatment options were considered impactful new therapies by 94.7% and 90.0% of physicians surveyed in this study, respectively. Conclusions The most common treatments received by patients in this study were TURBT and BCG. Emerging new treatments are driven by exploring biomarkers, but in real-world clinical practice only half of physicians or fewer regularly tested their NMIBC patients for biomarkers; PD-1/PD-L1 was the most common biomarker test used. Most physicians reported that, in addition to chemotherapy, anti-PD-L1 was an impactful new therapy. Supplementary Information The online version contains supplementary material available at 10.1186/s12894-022-00959-z.
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Tan WS, Kelly JD. Is delay to radical cystectomy following BCG failure oncologically safe? Nat Rev Urol 2021; 18:323-324. [PMID: 33772157 DOI: 10.1038/s41585-021-00457-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Wei Shen Tan
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Urology, Royal Free Hospital, London, UK.,Department of Urology, University College London Hospital, London, UK
| | - John D Kelly
- Division of Surgery and Interventional Science, University College London, London, UK. .,Department of Urology, University College London Hospital, London, UK.
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Yang M, Georgieva MV, Bocharova I, Vembusubramanian M, Qian K, Guo A, Kamat AM. The Impact of Progression on Healthcare Resource Utilization and Costs Among Patients with High-Grade Non-Muscle Invasive Bladder Cancer After Bacillus Calmette-Guérin Therapy: A Retrospective SEER-Medicare Analysis. Adv Ther 2021; 38:1584-1600. [PMID: 33543424 DOI: 10.1007/s12325-020-01616-3] [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: 11/25/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION We evaluated the real-world healthcare resource utilization (HRU) and costs among patients with high-grade non-muscle invasive bladder cancer (HG-NMIBC) following Bacillus Calmette-Guérin (BCG) therapy. METHODS Patients aged ≥ 65 years diagnosed with HG-NMIBC between 2008 and 2015 who received adequate BCG induction and were identified in the SEER-Medicare database. Those who received intravesical chemotherapy or radical cystectomy within 12 months of the last BCG induction dose, and had ≥ 6 months of data availability after treatment (index date), were included. Annualized HRU and mean medical costs (2020 United States dollars) were estimated and compared between patients with versus without progression. Inverse probability of treatment weighting was used to adjust for differences in baseline characteristics. RESULTS Of 986 patients diagnosed with HG-NMIBC who met the inclusion criteria, 257 (26.1%) progressed; the mean ages were similar between patients who did and did not progress (77.6 vs. 77.0 years). The overall population had a mean of 0.96 [standard deviation (SD): 1.18] inpatient admissions, 6.47 (11.40) hospitalization days, 1.38 (2.19) emergency department (ED) visits, and 48.03 (44.97) outpatient visits per patient-year during the study period; total annualized costs per patient post-BCG were $39,102 ($44,244). Patients experiencing progression had significantly higher mean numbers of inpatient admissions [1.61 (SD 1.40) vs. 0.72 (0.99)], hospitalization days [11.77 (14.96) vs. 4.59 (9.29)], ED visits [2.34 (2.92) vs. 1.03 (1.76)], and outpatient visits [65.97 (44.72) vs. 41.63 (43.09)] per patient-year compared with patients without progression (all p < 0.05). Total mean annualized costs per patient after BCG among those who progressed [$65,668 (SD $53,943)] were more than double compared with patients who did not [$29,780 ($36,425)]. CONCLUSIONS Existing treatments for HG-NMIBC after BCG therapy are associated with substantial HRU and medical costs, particularly after progression. Novel treatments and earlier detection are needed to reduce progression rates and associated costs in this difficult-to-treat population.
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Hugar LA, Gilbert SM, Sexton WJ, Kamat AM, Li R. Immunotherapy in Bacillus Calmette-Guerin (BCG) unresponsive nonmuscle invasive bladder cancer. Curr Opin Urol 2021; 31:160-169. [PMID: 33394766 DOI: 10.1097/mou.0000000000000846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW A number of promising therapies for Bacillus Calmette-Guerin (BCG) unresponsive nonmuscle invasive bladder cancer (NMIBC) are in the pipeline. In this review, we discuss the history of immunotherapy for the treatment of NMIBC and future developments, focusing on novel intravesical treatments. RECENT FINDINGS The term BCG unresponsive NMIBC encompasses patients with both BCG refractory and BCG relapsing disease. This definition was adopted to standardize inclusion criteria for patients enrolling in clinical trials in this setting. A host of intravesical immuno-oncologic therapies that include gene therapies, oncolytic viruses, cell surface molecule delivered immunotoxins, and cytokine driven agonism of cellular immunity, are in various phases of the drug development pipeline. In addition, pembrolizumab, an immune-checkpoint inhibitor, has recently been approved as a treatment option for BCG unresponsive NMIBC. SUMMARY Patients with BCG unresponsive disease face many difficulties. Although radical cystectomy is the most effective treatment option for these patients, it is associated with significant morbidity, difficult recovery challenges, and refusal by many patients. Cancer immunotherapies may provide bladder sparing options for some patients who develop BCG unresponsive disease.
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Affiliation(s)
- Lee A Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
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