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Tempo JA, Sii S, Ischia J, Bolton DM, D'Onise K, Meng R, Watson DI, O'Callaghan M. Lessons from a population-based bladder cancer registry: exploring why survival is not improving. BJU Int 2024; 133:699-708. [PMID: 38409928 DOI: 10.1111/bju.16286] [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] [Indexed: 02/28/2024]
Abstract
OBJECTIVE To explore the causes of the decrease in bladder cancer survival that has occurred over the past four decades. METHODS We extracted data from the South Australian Cancer Registry. Data from the period 1 January 1977 to 31 December 2020 were extracted to explore changes in incidence and survival among a total of 8356 patients diagnosed with ≥pT1 disease. Invasive bladder cancer was defined as ≥pT1 in this study. RESULTS Invasive bladder cancer age-standardized incidence decreased from 7.20 cases per 100 000 people in 1977 to 5.85 cases per 100 000 in 2020. The mean age at diagnosis increased from 68 years to 76 years. The crude incidence for patients aged 80 years and over increased by 3.3% per year (95% confidence interval [CI] 2.1 to 4.6). Overall survival decreased over the study period (hazard ratio [HR] 1.22 [95% CI 1.09 to 1.35]), however, survival increased after adjusting for age at diagnosis (HR 0.80 [95% CI 0.76 to 0.94]). Despite a decrease in non-bladder cancer-specific deaths in older people, there was no change in the bladder cancer-specific death rate in older people (HR 0.94 [95% CI 0.70 to 1.26]). Male sex was associated with higher survival (HR 0.87 [95% CI 0.83 to 0.92]), whereas socioeconomic advantage was not. CONCLUSIONS Invasive bladder cancer survival has decreased over the past 40 years, with the age structure of the population being a significant contributing factor. PATIENT SUMMARY We looked at why bladder cancer survival is decreasing using a large cancer registry with information from 1977 to 2020. We found that people are now more likely to be diagnosed at an older age. Older people often live for a shorter time with bladder cancer compared to younger people. Bladder cancer survival has decreased because there are more older people with the disease than previously.
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Affiliation(s)
- Jake A Tempo
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Urology Unit, Austin Health, Melbourne, VIC, Australia
| | - Samuel Sii
- Urology Unit, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Joseph Ischia
- Urology Unit, Austin Health, Melbourne, VIC, Australia
| | | | - Katina D'Onise
- Prevention and Population Health, Wellbeing SA, Adelaide, SA, Australia
| | - Rosie Meng
- Prevention and Population Health, Wellbeing SA, Adelaide, SA, Australia
| | - David I Watson
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Michael O'Callaghan
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
- Urology Unit, Flinders Medical Centre, Bedford Park, SA, Australia
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2
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Serretta V. BCG and bladder cancer. Forty-eight years after Morales report. Urologia 2024:3915603241252909. [PMID: 38757638 DOI: 10.1177/03915603241252909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Although BCG use as an anticancer drug was nearly abandoned due to the poor results in most tumors, in 1976 Morales reported a relevant reduction in recurrence with intravesical BCG in few patients affected by NMIBC. Since then BCG was globally accepted as an empirical and effective therapy in treating Tis and preventing recurrence of intermediate and high risk NMIBC. Forty-eight years after Morales' report, although some open questions remain object of debate, we have been able to find answers to many doubts improving BCG activity and toxicity. We better select patients undergoing BCG and many trials have indicated the best dosage and schedule. Moreover, we are able to better identify the patient unresponsive to BCG who might benefit of a timely radical cystectomy. We are also aware of the difficulties and toxicities that can be encountered with BCG use in every-day clinical practice. Research is ongoing to obtain genetically modified BCG to increase its efficacy and reduce toxicity. Moreover, the combination of BCG with other immunotherapeutic drugs given intravesically or systemically, first immune checkpoint inhibitors, is under study to obtain a response in patients unresponsive or intolerant to BCG. Almost 50 years after Morales publication, intravesical BCG remains an inalienable tool against NMIBC.
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Affiliation(s)
- Vincenzo Serretta
- Urology Unit, Candela Clinic, Palermo, Italy
- III Level Oncologic Department "La Maddalena" Palermo, Italy
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3
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Lobo N, Duan Z, Sood A, Tan WS, Grajales V, Contieri R, Lindskrog SV, Dyrskjøt L, Zhao H, Giordano SH, Williams SB, Bree KK, Kamat AM. Association of Age with Non-muscle-invasive Bladder Cancer: Unearthing a Biological Basis for Epidemiological Disparities? Eur Urol Oncol 2024:S2588-9311(24)00036-1. [PMID: 38302322 DOI: 10.1016/j.euo.2024.01.011] [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: 10/28/2023] [Revised: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Age disparity in patients with non-muscle-invasive bladder cancer (NMIBC) exists. Whether this is due to differences in adequate cancer care or tumour biology is unclear. OBJECTIVE To investigate age disparities in NMIBC using the Surveillance, Epidemiology, and End Results (SEER)-Medicare and UROMOL datasets. DESIGN, SETTING, AND PARTICIPANTS The SEER-Medicare data were used to identify patients with clinical stage Ta, Tis, and T1 NMIBC between 2005 and 2017 (n = 32 225). Using the UROMOL cohort (n = 834), age disparities across transcriptomic, genomic, and spatial proteomic domains were assessed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS For the SEER-Medicare data, multivariable competing-risk regression was used to examine the association between age and recurrence, progression, and bladder cancer-specific mortality (BCSM). For the UROMOL cohort, multivariable general linear model and multinomial logistic regression were performed to evaluate the association between age and tumour biology. RESULTS AND LIMITATIONS An analysis of the SEER-Medicare cohort revealed 5-yr recurrence rates of 55.2%, 57.4%, and 58.9%; 5-yr progression rates of 25.6%, 29.2%, and 36.9%; and 5-yr BCSM rates of 3.9%, 5.8%, and 11.8% in patients aged 66-70, 71-80, and ≥81 yr, respectively. After multivariable adjustment, age ≥81 yr was associated with a higher risk of recurrence (hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.03-1.12; p = 0.001), progression (HR 1.32, p < 0.001), and BCSM (HR 2.58, p < 0.001). UROMOL2021 transcriptomic class 2a was most frequently observed in patients with advanced age (34.0% in ≥76 yr vs 21.6% in ≤65 yr; p = 0.004), a finding confirmed on multivariable analysis (risk ratio [RR] 3.86, p = 0.002). UROMOL2021 genomic class 3 was observed more frequently in patients aged ≥76 yr (4.9% vs 24.2%; p = 0.001). Limitations include the definitions used for recurrence and progression, which may lead to under- or overestimation of true rates. CONCLUSIONS Among SEER-Medicare patients with NMIBC, advanced age is associated with inferior oncological outcomes. These results reflect age-related molecular biological differences observed across transcriptomic and genomic domains, providing further evidence that innate tumour biology contributes to observed disparities in NMIBC outcomes. PATIENT SUMMARY Older patients with non-muscle-invasive bladder cancer have worse oncological outcomes than younger patients. Some of this age disparity may be due to differences in tumour biology.
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Affiliation(s)
- Niyati Lobo
- Department of Urology, Royal Free London NHS Trust, London, UK; Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhigang Duan
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Akshay Sood
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wei Shen Tan
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Valentina Grajales
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roberto Contieri
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sia V Lindskrog
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars Dyrskjøt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hui Zhao
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen B Williams
- Department of Urology, University of Texas Medical Branch, Galveston, TX, USA
| | - Kelly K Bree
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Noel OD, Stewart E, Cress R, Dall'Era MA, Shrestha A. Underutilization of intravesical chemotherapy and immunotherapy for high grade non-muscle invasive bladder cancer in California between 2006-2018: Effect of race, age and socioeconomic status on treatment disparities. Urol Oncol 2023; 41:431.e7-431.e14. [PMID: 37295979 DOI: 10.1016/j.urolonc.2023.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/26/2023] [Accepted: 05/21/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Among patients diagnosed with non-muscle invasive bladder cancer (NMIBC), those with high risk disease have the greatest risk of recurrence and disease progression. The underutilization of intravesical immunotherapy with Bacillus Calmette-Guérin (BCG) has been a longstanding concern in clinical practice. This study aimed to determine the disparities present in receipt of adjuvant intravesical chemotherapy and immunotherapy in treatment of patients with high grade NMIBC following initial transurethral resection of a bladder tumor (TURBT). METHODS The California Cancer Registry data was used to identify 19,237 patients diagnosed with high grade NMIBC who underwent TURBT. Treatment variables include re-TURBT, re-TURBT and intravesical chemotherapy (IVC) and/or BCG. Independent variables include age, sex, race/ethnicity, neighborhood socioeconomic status (nSES), primary insurance payer and marital status at diagnosis. Multiple logistic regression and multinomial regression models were used to examine variation in the treatments received following TURBT. RESULTS The proportion of patients receiving TURBT followed by BCG was similar across all racial and ethnic groups (28%-32%). BCG therapy was higher in patients belonging to the highest nSES quintile (37% for highest vs. 23%-26% for the 2 lowest quintiles). In multiple variable analyses, receipt of any intravesical therapy (IVT) was influenced by nSES, age, marital status, race/ethnicity, and insurance type. Patients in the lowest nSES quintile had a 45% less likelihood of receiving IVT compared to the highest nSES group (OR [95%CI]: 0.55[0.49, 0.61]). Race/ethnicity differences in receipt of any adjuvant therapy were noted in the middle to lowest nSES quintile for Hispanic and Asian/Pacific Islander patients when compared to non-Hispanic White patients. When comparing variation in treatment by insurance type at diagnosis, those with Medicare or other insurance were 24% and 30% less likely to receive BCG after TURBT compared to those with private insurance, (OR [95%CI]: 0.76 [0.70, 0.82] and 0.70[0.62, 0.79]) respectively. CONCLUSION In patients with a diagnosis of high risk NMIBC, disparities in utilization of BCG are seen based on SES, age, and insurance type.
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Affiliation(s)
- Onika Dv Noel
- Department of Urology, University of California Davis, Sacramento, CA
| | - Eric Stewart
- Public Health Institute, Cancer Registry of Greater California, Sacramento, CA
| | - Rosemary Cress
- Public Health Institute, Cancer Registry of Greater California, Sacramento, CA; Department of Public Health Sciences, University of California Davis, Davis, CA
| | - Marc A Dall'Era
- Department of Urology, University of California Davis, Sacramento, CA
| | - Anshu Shrestha
- Public Health Institute, Cancer Registry of Greater California, Sacramento, CA.
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5
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Tosh JM, Panwar VK, Mittal A, Mandal AK. Interruption of BCG Therapy for NMIBC During COVID-19 Crisis, Dilemma in Its Continuation: a Review of Available Evidence and Suggested Management Strategies. Indian J Surg Oncol 2023:1-8. [PMID: 37363711 PMCID: PMC10068698 DOI: 10.1007/s13193-023-01742-8] [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: 10/06/2021] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
The COVID-19 disease, caused by SARS-CoV-2 virus, has been one of the worst pandemics ever to hit the human mankind. Undoubtedly the start of the second wave of COVID-19 has literally ripped apart the hearts of millions of people. Cancer patients have been left of the beaten track to their fate, with no access to treatments. Intravesical BCG instillation is the standard of care for patients with non-muscle invasive bladder cancer (NMIBC). Several patients were in the middle of their treatment regimen when this pandemic struck. As slowly the word is recuperating from concussion effect of this pandemic and routine health services are being restored, uro-oncologist will face a unique scenario with respect to intravesical BCG therapy i.e., whether to restart the course of BCG therapy or to continue course from where it was interrupted. There are no studies in literature to directly answer this peculiar question and to resolve this dilemma. So, we in this review article propose to explore the literature for the most appropriate therapeutic regimen for these patients with interruption of intravesical BCG therapy. We plan to divide the patients with interruption to BCG therapy into the following three groups:Group 1: Patients who had interruption during the induction period.Group 2: Patients who completed the induction course but maintenance course could not be started.Group 3: Patients who had interruption during maintenance phase of BCG therapy. We will compile the recent recommendations by NCCN, AUA, and EAU for the administration of intravesical BCG in non-muscle invasive bladder cancer. We herein want to review the literature to propose the most appropriate strategy, its safety profile for these subsets of patients. Supplementary Information The online version contains supplementary material available at 10.1007/s13193-023-01742-8.
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6
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Tempo J, Yiu TW, Ischia J, Bolton D, O'Callaghan M. Global changes in bladder cancer mortality in the elderly. Cancer Epidemiol 2023; 82:102294. [PMID: 36470068 DOI: 10.1016/j.canep.2022.102294] [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: 09/13/2022] [Revised: 10/28/2022] [Accepted: 11/07/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Bladder cancer is the 14th most common cause of cancer deaths worldwide and has a mean age of diagnosis of 73 years. Elderly people have fewer curative treatment options for muscle invasive bladder cancer. The aim of this study is to investigate how bladder cancer mortality has changed over the past forty years in different world regions to assess discrepancies between elderly and younger patients with bladder cancer. METHODS Bladder cancer mortality data were extracted from the World Health Organisation's GLOBOCAN database. Age-standardised mortality rates (ASMR) for bladder cancer were computed by year, sex, region and Human Development Index (HDI) using the world standard population. RESULTS Overall ASMR in all available countries with data between 1986 and 2014 for men aged ≥ 75 has decreased from 101.2 to 89.9 per 100,000 (-11.2%). The decrease in ASMR for men < 75 has been 0.3-2.0 per 100,000 (-39.4%). In women aged ≥ 75 ASMR has decreased from 26.9 to 22.5 per 100,000 (-16.4%) and in women < 75 the ASMR has decreased from 0.76 to 0.56 per 100,000 (-26.4%). Correlation analysis showed a positive linear relationship between Human Development Index (HDI) and improvement in age-standardised mortality rate in all ages. Pearson's coefficient showed that correlation was strongest in the 60-74 age group (r = -0.61, p < 0.001) and weakest in those aged ≥ 75 (r = -0.39, p = 0.01). CONCLUSION Bladder cancer mortality is not improving in the elderly at the same rate as the rest of the population. Particular focus should be applied in future research to enhance and expand treatment options for bladder cancer that are appropriate for elderly patients.
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Affiliation(s)
- Jake Tempo
- Department of Surgery, Flinders University, Adelaide, Australia; Department of Urology, Austin Health, Melbourne, Australia.
| | - Ting Wai Yiu
- Department of Urology, Austin Health, Melbourne, Australia.
| | - Joseph Ischia
- Department of Urology, Austin Health, Melbourne, Australia.
| | - Damien Bolton
- Department of Urology, Austin Health, Melbourne, Australia.
| | - Michael O'Callaghan
- Urology Unit, Flinders Medical Centre, Adelaide, Australia; Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia; Discipline of Medicine, University of Adelaide, Adelaide, Australia.
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7
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Aghamir SMK, Khatami F, Farrokhpour H, Oliveira Reis L, Ahmadi Pishkuhi M, Mohammadi A. Oncologic outcomes of Bacillus Calmette-Guérin therapy in elderly patients with non-muscle-invasive bladder cancer: A meta-analysis. PLoS One 2022; 17:e0267934. [PMID: 35587916 PMCID: PMC9119482 DOI: 10.1371/journal.pone.0267934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 04/19/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction
There is a challenge on the medical efficacy of intravesical Bacillus Calmette-Guérin (BCG) therapy and the power of the immune system boosting, which can be influenced by the age of the non-muscle-invasive bladder cancer (NMIBC) patients. This meta-analysis evaluates the efficacy of BCG therapy among aged (>70) and younger patients with non-muscle-invasive bladder cancer (NMIBC).
Methods
The central database of PubMed, Scopus, and Web of Science were queried until August 4, 2021, by using "BCG," "Bladder Cancer," "AGE," and "efficacy" keywords. After excluding duplicated results, titles and abstracts were evaluated by two independent reviewers. The exclusion criteria included non-English studies, conference abstracts, reviews, editorials, letters, and comments. Three main outcomes, disease-free survival (DFS), progression-free survival (PFS), and cancer-specific survival (CSS), were considered. The statistical analysis was performed using STATA (version 14; Stata Corp, College Station, Texas, USA).
Results
From 1115 found documents, the 24 research articles were recruited in the systematic review, and 10 were the candidate for meta-analysis. The overall estimate of H.R. revealed that BCG therapy in those over age 70 is significantly associated with an improved risk of progression and cancer-specific death in studied patients. However, this association was not statistically significant for DFS (1.04 (95% CI: 0.85,1.26)).
Conclusion
The BCG maintenance therapy improved CSS and PFS oncological outcomes in elderly patients with NMIBC. BCG therapy did not significantly change the DSF.
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Affiliation(s)
| | - Fatemeh Khatami
- Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Leonardo Oliveira Reis
- UroScience and Department of Surgery (Urology), School of Medical Sciences, University of Campinas, Unicamp, and Pontifical Catholic University of Campinas, PUC-Campinas, Campinas, São Paulo, Brazil
| | - Mahin Ahmadi Pishkuhi
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Abdolreza Mohammadi
- Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran
- * E-mail:
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8
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Lamm DL, Morales A. A BCG success story: From prevention of tuberculosis to optimal bladder cancer treatment. Vaccine 2021; 39:7308-7318. [PMID: 34417051 DOI: 10.1016/j.vaccine.2021.08.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/13/2021] [Accepted: 08/06/2021] [Indexed: 01/22/2023]
Abstract
BCG remains the most important vaccine for tuberculosis 100 years after its first use, and over the past 4 decades it has become the most widely accepted, effective drug used in the treatment of aggressive localized bladder cancer. This review chronicles the narrow path that led to approval and world-wide acceptance of BCG immunotherapy for bladder cancer while immunotherapy trials in other malignancies were abandoned. Six intravesical instillations of 5x10^8 CFU of BCG weekly after bladder tumor resection, first reported in 1976, is superior to resection alone and resection plus intravesical chemotherapy. Maintenance of effective immune stimulation is surprisingly difficult, but 3 weekly treatments 3, 6, and 12, 18, 24, 30 and 36 months after induction produces further significant reduction in tumor recurrence. This 3 week BCG maintenance schedule alone has reduced disease progression and mortality in multicenter randomized clinical trials. In the new age of immuno-oncology patients with many types of cancer now benefit from immunotherapy, but currently these modern agents are prohibitively expensive for most of the world. In contrast, the low cost and therefore low profitability of BCG has resulted in recurrent shortages that threaten both bladder cancer patients and children at risk for tuberculosis and other serious infections. Humanity has greatly benefited from early 20th century science that developed BCG and the benevolence of doctors Calmette and Guerin who put people over profit and widely shared cultures of the vaccine. The 21st century is bringing new immunotherapies and greatly expanding the types of malignancies that can be treated. Recombinant technology is expected to improve both the efficacy and production of BCG, hopefully expanding the availability of BCG and relieving the recurring supply shortage for both vaccination and cancer therapy.
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Affiliation(s)
- Donald L Lamm
- Department of Surgery, University of Arizona, Phoenix, AZ, USA.
| | - Alvaro Morales
- Department of Urology, Queen's University. Kingston. Ontario, Canada
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9
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Garg T, Johns A, Young AJ, Nielsen ME, Tan HJ, McMullen CK, Kirchner HL, Cohen HJ, Murphy TE. Geriatric conditions and treatment burden following diagnosis of non-muscle- invasive bladder cancer in older adults: A population-based analysis. J Geriatr Oncol 2021; 12:1022-1030. [PMID: 33972184 DOI: 10.1016/j.jgo.2021.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/23/2021] [Accepted: 04/27/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Treatment burden is emerging as an important patient-centered outcome for older adults with cancer who concurrently manage geriatric conditions. Our objective was to evaluate the contribution of geriatric conditions to treatment burden in older adults with non-muscle invasive bladder cancer (NMIBC). METHODS We identified 73,395 Medicare beneficiaries age 66+ diagnosed with NMIBC (Stage <II) in SEER-Medicare (2001-2014). The primary outcome was treatment burden, defined as health system contact days in the year following NMIBC diagnosis. Explanatory variables were the following geriatric conditions: multimorbidity (≥ 2 chronic conditions), functional dependency, falls, depression, cognitive impairment, weight loss, and urinary incontinence. We used negative binomial regression to model the association between individual geriatric conditions and treatment burden while adjusting for covariates. RESULTS At baseline, 64% had multimorbidity and median 3 conditions (IQR 0-5). Prevalence of other geriatric conditions ranged from 5.9%-15.2%. Adjusted mean health system contact was 8.9 days (95% CI 8.6-9.2). Multimorbidity had the largest effect size (adjusted mean 11.8 contact days (95% CI 8.3-8.8)). Each additional chronic condition conferred a 13% increased average number of health system contact (adjusted IRR 1.132, 95% CI 1.129-1.135). Regardless of number of chronic conditions, rural patients consistently had more treatment burden than urban counterparts. DISCUSSION In this population-based cohort of older NMIBC patients, multimorbidity and rurality were strongly associated with treatment burden in the year following NMIBC diagnosis. These findings highlight the need for interventions that reduce treatment burden due to geriatric conditions among the growing population of older adults with cancer, particularly in rural areas.
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Affiliation(s)
- Tullika Garg
- Department of Urology, Geisinger, Danville, PA, United States of America; Department of Population Health Sciences, Geisinger, Danville, PA, United States of America.
| | - Alicia Johns
- Department of Population Health Sciences, Geisinger, Danville, PA, United States of America; Biostatistics Core, Geisinger, Danville, PA, United States of America
| | - Amanda J Young
- Department of Population Health Sciences, Geisinger, Danville, PA, United States of America; Biostatistics Core, Geisinger, Danville, PA, United States of America
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America; Departments of Epidemiology and Health Policy & Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, United States of America; Center for Health Research, Kaiser Permanente Northwest, Portland, OR, United States of America
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Carmit K McMullen
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, United States of America
| | - H Lester Kirchner
- Department of Population Health Sciences, Geisinger, Danville, PA, United States of America; Biostatistics Core, Geisinger, Danville, PA, United States of America
| | - Harvey J Cohen
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, United States of America
| | - Terrence E Murphy
- Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
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10
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Jaber TM, Samiullah M, Surti A. Vertebral Osteomyelitis Secondary to Bacillus Calmette-Guérin Instillation Therapy for Transitional Cell Carcinoma In Situ. Cureus 2021; 13:e14589. [PMID: 34036007 PMCID: PMC8136454 DOI: 10.7759/cureus.14589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Transitional cell carcinoma is the sixth most common cancer among men and the 17th most common cancer in women. The treatment methods for the condition range from noninvasive chemotherapy to more invasive procedures like cystectomy and complete transurethral resection of bladder tumor (TURBT) followed by intravesical Bacillus Calmette-Guérin (BCG) therapy (BCG). Intravesical BCG treatment is known to be effective as it is associated with increased survivability and long-term benefits, especially in early-stage, minimally-invasive disease. It is generally considered to be safe, even though some adverse reactions have been described. Vertebral osteomyelitis secondary to intravesical BCG therapy is a rare complication but one that has been reported in the literature. Although our patient had multiple comorbidities, including a previous vertebral compression fracture prior to treatment, complications from intravesical BCG treatment should always be considered in the differential. Further multi-center retrospective studies are needed to better ascertain its true risk given its increasing use as a treatment modality for transitional cell carcinoma.
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Affiliation(s)
- Tariq M Jaber
- Infectious Diseases, Allegheny Health Network, Pittsburgh, USA
| | | | - Amy Surti
- Critical Care Medicine, University of Massachusetts Medical School-Baystate, Springfield, USA
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11
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Caputo JM, Moran G, Muller B, Keller AT, Li G, Anderson CB. The Management of Newly-Diagnosed Non-muscle Invasive Bladder Cancer in Veterans Integrated Services Network 02 of the Veterans Health Administration. Mil Med 2021; 185:276-281. [PMID: 31294791 DOI: 10.1093/milmed/usz166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/04/2019] [Accepted: 06/12/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Over 1,500 bladder cancers were diagnosed among US Veterans in 2010, the majority of which were non-muscle invasive bladder cancer (NMIBC). Little is known about NMIBC treatment within the Veterans Health Administration. The objective of the study was to assess the quality of care for Veterans with newly-diagnosed NMIBC within Veterans Integrated Service Network (VISN) 02. MATERIALS AND METHODS We used ICD-9 and ICD-10 codes to identify patients with newly-diagnosed bladder cancer from 1/2016-8/2017. We risk-stratified the patients into low, intermediate, and high-risk based on the 2016 American Urological Association Guidelines on NMIBC. Our primary objectives were percentages of transurethral resection of bladder tumors (TURBTs) with detrusor, repeat TURBT in high-risk and T1 disease, high-risk NMIBC treated with induction intravesical therapy (IVT), and responders treated with maintenance IVT. We performed logistic regression for association between distance to diagnosing hospital and receipt of induction IVT in high-risk patients. RESULTS There were 121 newly-diagnosed NMIBC patients; 16% low-risk, 28% intermediate-risk, and 56% high-risk. Detrusor was present in 80% of all initial TURBTs and 84% of high-risk patients. Repeat TURBT was performed in 56% of high-risk NMIBC and 60% of T1. Induction IVT was given to 66% of high-risk patients and maintenance IVT was given to 59% of responders. On multivariate logistic regression, distance to medical center was not associated with receipt of induction IVT (OR = 0.99, 95% CI [0.97,1.01], p = 0.52). CONCLUSIONS We observed high rates of sampling of detrusor in the first TURBT specimen, utilization of repeat TURBT, and administration of induction and maintenance intravesical BCG for high-risk patients among a regional cohort of US Veterans with NMIBC. While not a comparative study, our findings suggest high quality NMIBC care in VA VISN 02.
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Affiliation(s)
- Joseph M Caputo
- Department of Urology, NewYork-Presbyterian/Columbia University Medical Center, 161 Fort Washington Avenue 11th Floor, New York, NY 10032.,James J. Peters Veterans Affairs Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468
| | - George Moran
- Department of Urology, NewYork-Presbyterian/Columbia University Medical Center, 161 Fort Washington Avenue 11th Floor, New York, NY 10032
| | - Benjamin Muller
- Department of Urology, NewYork-Presbyterian/Columbia University Medical Center, 161 Fort Washington Avenue 11th Floor, New York, NY 10032
| | - Alison T Keller
- James J. Peters Veterans Affairs Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468
| | - Gen Li
- Department of Biostatistics, Mailman School of Public Health, Columbia University, 722 West 168th St, New York, NY 10032
| | - Christopher B Anderson
- Department of Urology, NewYork-Presbyterian/Columbia University Medical Center, 161 Fort Washington Avenue 11th Floor, New York, NY 10032.,James J. Peters Veterans Affairs Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468
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12
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Williams SB, Howard LE, Foster ML, Klaassen Z, Sieluk J, De Hoedt AM, Freedland SJ. Estimated Costs and Long-term Outcomes of Patients With High-Risk Non-Muscle-Invasive Bladder Cancer Treated With Bacillus Calmette-Guérin in the Veterans Affairs Health System. JAMA Netw Open 2021; 4:e213800. [PMID: 33787908 PMCID: PMC8013821 DOI: 10.1001/jamanetworkopen.2021.3800] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Management of high-risk non-muscle-invasive bladder cancer (NMIBC) represents a clinical challenge due to high failure rates despite prior bacillus Calmette-Guérin (BCG) therapy. OBJECTIVE To describe real-world patient characteristics, long-term outcomes, and the economic burden in a population with high-risk NMIBC treated with BCG therapy. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study identified 412 patients with high-risk NMIBC from 63 139 patients diagnosed with bladder cancer who received at least 1 dose of BCG within Department of Veterans Affairs (VA) centers across the US from January 1, 2000, to December 31, 2015. Adequate induction BCG therapy was defined as at least 5 installations, and adequate maintenance BCG therapy was defined as at least 7 installations. Data were analyzed from January 2, 2020, to January 20, 2021. EXPOSURES Intravesical BCG therapy, including adequate induction BCG therapy, was defined as at least 5 intravesical instillations of BCG within 70 days from BCG therapy start date. Adequate maintenance BCG therapy was defined as at least 7 installations of BCG within 274 days of the start (the first instillation) of adequate induction BCG therapy (ie, adequate induction BCG plus some form of additional BCG). MAIN OUTCOMES AND MEASURES The Kaplan-Meier method was used to estimate outcomes, including event-free survival. All-cause expenditures were summarized as medians with corresponding interquartile ranges (IQRs) and adjusted to 2019 USD. RESULTS Of the 412 patients who met inclusion criteria, 335 (81%) were male and 77 (19%) were female, with a median age of 67 (IQR, 61-74) years. Follow-up was 2694 person-years. A total of 392 patients (95%) received adequate induction BCG therapy, and 152 (37%) received adequate BCG therapy. For all patients with high-risk NMIBC, the 10-year progression-free survival rate and disease-specific death rate were 78% and 92%, respectively. Patients with carcinoma in situ (Cis) had worse disease-free survival than those without Cis (hazard ratio [HR], 1.85; 95% CI, 1.34-2.56). Total median costs at 1 year were $29 459 (IQR, $14 991-$52 060); at 2 years, $55 267 (IQR, $28 667-$99 846); and at 5 years, $117 361 (IQR, $59 680-$211 298). Patients with progressive disease had significantly higher median 5-year costs ($232 729 [IQR, $151 321-$341 195] vs $94 879 [IQR, $52 498-$172 631]; P < .001), with outpatient care, pharmacy, and surgery-related costs contributing. CONCLUSIONS AND RELEVANCE Despite adequate induction BCG therapy, only 37% of patients received adequate BCG therapy. Patients with Cis had increased risk of progression, and progression regardless of Cis was associated with significantly increased costs relative to patients without progression. Extrapolating cost figures, regardless of progression, resulted in nationwide costs at 1 year of $373 million for patients diagnosed with high-risk NMIBC in 2019.
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Affiliation(s)
- Stephen B. Williams
- Division of Urology, Department of Surgery, University of Texas Medical Branch, Galveston
| | - Lauren E. Howard
- Durham Veterans Affairs Health Care System, Durham, North Carolina
- Biostatistics Shared Resource, Duke Cancer Institute, Durham, North Carolina
| | - Meagan L. Foster
- Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Zachary Klaassen
- Section of Urology, Department of Surgery, Augusta University, Medical College of Georgia, Augusta
| | | | | | - Stephen J. Freedland
- Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, California
- Center for Integrated Research on Cancer and Lifestyle, Cedars-Sinai Medical Center, Los Angeles, California
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13
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Marcq G, Kassouf W. Adjuvant Intravesical Therapy: Bacillus Calmette-Guerin. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Richards KA, Lin SW, Chuo CY, Derleth CL, Yi J, Zivkovic M, Ogale S, Prasad S, Decastro GJ, Steinberg GD. Increased Bacillus Calmette-Guérin Treatment Intensity Associated With Improved Outcomes in Elderly Patients With Non–Muscle-invasive Bladder Cancer in United States Clinical Practice. Urology 2020; 145:172-180. [DOI: 10.1016/j.urology.2020.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/22/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
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15
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Alshyarba MH, Alamri A, Assiri AA. Economic impacts of the Bacillus Calmette-Guérin (BCG) therapy shortage and the proposed solutions for patients with non-muscle invasive bladder Cancer in Aseer Province, Saudi Arabia. J Family Med Prim Care 2020; 9:2758-2762. [PMID: 32984121 PMCID: PMC7491787 DOI: 10.4103/jfmpc.jfmpc_171_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/13/2020] [Accepted: 03/30/2020] [Indexed: 11/04/2022] Open
Abstract
Objective To report the magnitude, the financial and the economic impact of Bacillus Calmette-Guérin (BCG) shortage in our institute and transfer of non-muscle invasive bladder cancer (NMIBC) patients to higher centers to receive the treatment. Methods This is a retrospective study, between January 2015 and December 2017, the cases of NMIBC diagnosed at Aseer Central Hospital, Abha, Saudi Arabia were studied. Demographic features, clinical presentations, histopathological features, and the BCG therapy shortage and its economic impact were addressed. Results Over a three years study review of 62 urothelial bladder cancer, NMIBC was diagnosed in 55 (89%) patients. Forty-three (78%) patients were males and 12 (22%) patients were females. The mean age ± standard deviation (SD) (range) in this cohort was 59 ± 12 years (38-87). Gross hematuria was the main presentation in 51 (92%) patients of this cohort. Dysuria and other lower urinary tract symptoms were the presentations in 18 (32%) patients. Smoking history was positive in 33 (60%) patients and the rest 22 (40%) patients denied any form of tobacco consumptions. The BCG eligible were 46 (84%) patients of all NMIBC patients in this study. Twenty-seven (59%) patients of them received BCG in our institute. The rest 19 (41%) patients were opted to be transferred to a higher medical center to receive the BCG because of the BCG shortage in our center. The financial cost of traveling to receive the six-weeks induction BCG therapy was on average of 7200 Saudi riyals (1.745 €) for every patient. Conclusions The BCG shortage in our institute is almost approaching half of eligible BCG cases. This has had an economic impact on the health budget. Such health catastrophe could be mitigated with proper health plans of a provision of the BCG to all tertiary care centers. Alternative therapies for such cases should be considered in cases of global BCG shortage.
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Affiliation(s)
- Mishari Hm Alshyarba
- Department of Surgery (Urology Division), College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Kingdom of Saud Arabia
| | - Abdulaziz Alamri
- Department of Surgery (Urology Division), College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Kingdom of Saud Arabia
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Plouvier SD, Bonnal JL, Machuron F, Colin P, Vankemmel O, Leroy X, Duhamel A, Villers A, Saint F, Pasquier D. Impact of age on bladder cancer management practices: a general population study. Acta Oncol 2020; 59:462-466. [PMID: 32043407 DOI: 10.1080/0284186x.2020.1723164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Jean-Louis Bonnal
- Service d’Urologie, Groupement des hôpitaux de l’Institut Catholique de Lille, Université nord de France
| | - François Machuron
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | - Pierre Colin
- Service d'urologie, Hôpital privé La Louvière, Lille, France
| | | | - Xavier Leroy
- Department of Pathology, University of Lille, CHU Lille, Lille, France
| | - Alain Duhamel
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | - Arnauld Villers
- Department of Urology, University of Lille, CHU Lille, Lille, France
| | - Fabien Saint
- Department of Urology, University of Lille, CHU Lille, Lille, France
| | - David Pasquier
- Academic department of radiation oncology, Centre Oscar Lambret, Lille, France
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17
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Gofrit ON, Klein BY, Cohen IR, Ben-Hur T, Greenblatt CL, Bercovier H. Bacillus Calmette-Guérin (BCG) therapy lowers the incidence of Alzheimer's disease in bladder cancer patients. PLoS One 2019; 14:e0224433. [PMID: 31697701 PMCID: PMC6837488 DOI: 10.1371/journal.pone.0224433] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/14/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Alzheimer's disease (AD) affects one in ten people older than 65 years. Thus far, there is no cure or even disease-modifying treatment for this disease. The immune system is a major player in the pathogenesis of AD. Bacillus Calmette-Guérin (BCG), developed as a vaccine against tuberculosis, modulates the immune system and reduces recurrence of non-muscle invasive bladder cancer. Theoretical considerations suggested that treatment with BCG may decrease the risk of AD. We tested this hypothesis on a natural population of bladder cancer patients. METHODS AND FINDINGS After removing all bladder cancer patients presenting with AD or developing AD within one-year following diagnosis of bladder cancer, we collected data on a total of 1371 patients (1134 males and 237 females) who were followed for at least one year after the diagnosis of bladder cancer. The mean age at diagnosis of bladder cancer was 68.1 years (SD 13.0). Adjuvant post-operative intra-vesical treatment with BCG was given to 878 (64%) of these patients. The median period post-operative follow-up was 8 years. During follow-up, 65 patients developed AD at a mean age of 84 years (SD 5.9), including 21 patients (2.4%) who had been treated with BCG and 44 patients (8.9%) who had not received BCG. Patients who had been treated with BCG manifested more than 4-fold less risk for AD than those not treated with BCG. The Cox proportional hazards regression model and the Kaplan-Meier analysis of AD free survival both indicated high significance: patients not treated with BCG had a significantly higher risk of developing AD compared to BCG treated patients (HR 4.778, 95%CI: 2.837-8.046, p = 4.08x10-9 and Log Rank Chi-square 42.438, df = 1, p = 7.30x10-11, respectively). Exposure to BCG did not modify the prevalence of Parkinson's disease, 1.9% in BCG treated patients and 1.6% in untreated (Fisher's Exact Test, p = 1). CONCLUSIONS Bladder cancer patients treated with BCG were significantly less likely to develop AD at any age than patients who were not so treated. This finding of a retrospective study suggests that BCG treatment might also reduce the incidence of AD in the general population. Confirmation of such effects of BCG in other retrospective studies would support prospective studies of BCG in AD.
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Affiliation(s)
- Ofer N. Gofrit
- Department of Urology, Hadassah- Hebrew University Medical Center, Jerusalem, Israel
- * E-mail: (HB); (ONG)
| | - Benjamin Y. Klein
- Department of Microbiology and Molecular Genetics, Hebrew University Jerusalem, Israel
| | - Irun R. Cohen
- Department of Immunology, Weizmann Institute, Rehovot, Israel
| | - Tamir Ben-Hur
- Department of Neurology Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Charles L. Greenblatt
- Department of Microbiology and Molecular Genetics, Hebrew University Jerusalem, Israel
| | - Hervé Bercovier
- Department of Microbiology and Molecular Genetics, Hebrew University Jerusalem, Israel
- * E-mail: (HB); (ONG)
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18
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Wang H, Wang D, Feng Y, Zhai J, Lu C. Improved antitumor efficacy of neutrophils stimulated by bacillus Calmette‑Guérin. Mol Med Rep 2019; 20:2909-2915. [PMID: 31524238 DOI: 10.3892/mmr.2019.10532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 05/31/2019] [Indexed: 11/05/2022] Open
Abstract
Bacillus Calmette‑Guérin (BCG) has become a significant treatment for bladder cancer, and neutrophils are reported to be associated with the antitumor effect of BCG. The aim of the present study was to clarify the antitumor function of neutrophils stimulated by BCG. Initially, the killing effect and cytotoxic activity of neutrophils treated with BCG was detected. Subsequently, the effectiveness of BCG‑treated neutrophils extracted from tumor‑bearing mice was analyzed. The results revealed that the cytotoxic effect of neutrophils was stronger in the BCG‑treated group compared with that in the normal saline (NS)‑treated and control groups (P<0.05). A significantly higher concentration of cytokines tumor necrosis factor (TNF)‑α, interleukin (IL)‑1β, IL‑6 and TNF‑related apoptosis‑inducing ligand occurred in the BCG‑treated neutrophil group compared with the NS and control groups (P<0.01), which was also associated with the BCG dose (P<0.01). The gross tumor volume percentage in BCG‑treated neutrophils from tumor‑bearing mice (BCGT group) was significantly lower in comparison with that in the NS‑treated neutrophils from tumor‑bearing mice (NST group; P<0.05). In addition, the survival rate of tumor‑bearing mice was higher in the BCGT group compared with the NST group (P<0.05), while more BCG‑treated neutrophils from tumor‑bearing mice were infiltrated in the MethA tumor (P<0.01). In conclusion, BCG‑treated neutrophils were observed to enhance the antitumor efficacy and extend the life span of mice.
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Affiliation(s)
- Huan Wang
- Department of Immunology, School of Basic Medical Science, China Medical University, Shenyang, Liaoning 110122, P.R. China
| | - Danan Wang
- Department of Immunology, School of Basic Medical Science, China Medical University, Shenyang, Liaoning 110122, P.R. China
| | - Yonghui Feng
- Department of Immunology, School of Basic Medical Science, China Medical University, Shenyang, Liaoning 110122, P.R. China
| | - Jingbo Zhai
- Department of Immunology, School of Basic Medical Science, China Medical University, Shenyang, Liaoning 110122, P.R. China
| | - Changlong Lu
- Department of Immunology, School of Basic Medical Science, China Medical University, Shenyang, Liaoning 110122, P.R. China
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Balakrishnan AS, Washington SL, Meng MV, Porten SP. Determinants of Guideline-Based Treatment in Patients With cT1 Bladder Cancer. Clin Genitourin Cancer 2019; 17:e461-e471. [DOI: 10.1016/j.clgc.2019.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 11/25/2022]
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20
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Jahnson S, Gårdmark T, Hosseini A, Jerlström T, Liedberg F, Malmström PU, Rosell J, Sherif A, Ströck V, Häggström C, Holmberg L, Aljabery F. Management and outcome of TaG3 tumours of the urinary bladder in the nationwide, population-based bladder cancer database Sweden (BladderBaSe). Scand J Urol 2019; 53:200-205. [PMID: 31144582 DOI: 10.1080/21681805.2019.1621377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: To investigate the management of TaG3 tumours of the urinary bladder using nationwide population-based data in relation to the prevailing guidelines, patients' characteristics, and outcome.Materials and methods: The Bladder Cancer Data Base Sweden (BladderBaSe), including data from the Swedish National Register for Urinary Bladder Cancer (SNRUBC), was used to study all patients with TaG3 bladder cancer diagnosed from 2008 to 2014. Patients were divided into the following management groups: (1) transurethral resection (TUR) only, (2) TUR and intravesical instillation therapy (IVIT), (3) TUR and second-look resection (SLR), and (4) TUR with both SLR and IVIT. Patient and tumour characteristics and outcome were studied.Results: There were 831 patients (83% males) with a median age of 74 years. SLR was performed more often on younger patients, on men, and less often in the Western and Uppsala/Örebro Healthcare regions. IVIT was performed more often with younger patients, with men, in the Western Healthcare region, and less often in the Uppsala/Örebro Healthcare region. Death from bladder cancer occurred in 6% of cases within a median of 29 months (0-84 months) and was lower in the TUR/IVIT and TUR/SLR/IVIT groups compared to the other two groups.Conclusion: In the present study, there was, according to the prevailing treatment guidelines, an under-treatment with SLR for older patients, women, and in some healthcare regions and, similarly, there was an under-treatment with IVIT for older patients. Cancer-specific survival and relative survival were lower in the TUR only group compared to the TUR/IVIT and TUR/SLR/IVIT groups.
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Affiliation(s)
- Staffan Jahnson
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
| | - Truls Gårdmark
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Abolfazl Hosseini
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jerlström
- Department of Urology, Örebro University Hospital, Örebro, Sweden
| | - Fredrik Liedberg
- Department of Urology, Skåne University Hospital, Malmö, Sweden.,Institution of Translational Medicine, Lund University, Malmö, Sweden
| | - Per-Uno Malmström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Johan Rosell
- Regional Cancer Center Southeast Sweden and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Amir Sherif
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University Hospital, Umeå, Sweden
| | - Viveka Ströck
- Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christel Häggström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Department of Biobank Research, Umeå University, Umeå, Sweden
| | - Lars Holmberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,School of Medicine, King's College London, London, UK
| | - Firas Aljabery
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
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D'Andrea D, Gontero P, Shariat SF, Soria F. Intravesical bacillus Calmette-Guérin for bladder cancer: are all the strains equal? Transl Androl Urol 2019; 8:85-93. [PMID: 30976572 PMCID: PMC6414340 DOI: 10.21037/tau.2018.08.19] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Intravesical immunotherapy with bacillus Calmette-Guérin (BCG) is the standard of care for high-risk and intermediate-risk non-muscle-invasive bladder cancer (NMIBC). Several BCG strains are available. Despite originating all from subcultures of the same Mycobacterium, strains are genetically different which may lead to differences in treatment efficacy and adverse events. Identification of a more efficient strain and assessing its optimal administration schedule may improve oncological outcomes in NMIBC, specifically because of the worldwide shortage in BCG availability. This review focused on the antitumor effect of different BCG strains with a particular emphasis on the evidence underlying BCG dose and treatment schedules.
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Affiliation(s)
- David D'Andrea
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Paolo Gontero
- Department of Urology, Le Molinette Hospital, University of Turin, Turin, Italy
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Francesco Soria
- Department of Urology, Medical University of Vienna, Vienna, Austria
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Khanna A, Yerram N, Zhu H, Kim S, Abouassaly R. Utilization of Bacillus Calmette-Guerin for Nonmuscle Invasive Bladder Cancer in an Era of Bacillus Calmette-Guerin Supply Shortages. Urology 2019; 124:120-126. [DOI: 10.1016/j.urology.2018.07.055] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/15/2018] [Accepted: 07/06/2018] [Indexed: 10/28/2022]
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Grossman HB, Lamm D, Sjödahl G, O’Donnell M, Hahn N, Kamat A. Intravesical Therapy – BCG and Beyond. Bladder Cancer 2019. [DOI: 10.3233/blc-180198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- H. Barton Grossman
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Donald Lamm
- University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Gottfrid Sjödahl
- Department of Urology, Skåne University Hospital, Lund, Sweden
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Michael O’Donnell
- University of Iowa Carver College of Medicine, Department of Urology, Iowa City, IA, USA
| | - Noah Hahn
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
- Johns Hopkins Greenberg Bladder Cancer Institute, Baltimore, MD, USA
| | - Ashish Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Garg T, Young AJ, O’Keeffe‐Rosetti M, McMullen CK, Nielsen ME, Kirchner HL, Murphy TE. Association between treatment of superficial bladder cancer and 10‐year mortality in older adults with multiple chronic conditions. Cancer 2018; 124:4477-4485. [DOI: 10.1002/cncr.31705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/11/2018] [Accepted: 07/09/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Tullika Garg
- Department of Urology Geisinger Danville Pennsylvania
- Department of Epidemiology and Health Services Research Geisinger Danville Pennsylvania
| | - Amanda J. Young
- Biostatistics Core Geisinger Danville Pennsylvania
- Biomedical and Translational Informatics Institute Geisinger, Danville Pennsylvania
| | | | | | - Matthew E. Nielsen
- Center for Health Research, Kaiser Permanente Northwest Portland Oregon
- Department of Urology University of North Carolina at Chapel Hill Chapel Hill North Carolina
- Department of Epidemiology University of North Carolina at Chapel Hill Chapel Hill North Carolina
- Department of Health Policy and Management University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - H. Lester Kirchner
- Biostatistics Core Geisinger Danville Pennsylvania
- Biomedical and Translational Informatics Institute Geisinger, Danville Pennsylvania
| | - Terrence E. Murphy
- Section of Geriatrics, Department of Internal Medicine Yale University School of Medicine New Haven Connecticut
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Racioppi M, Di Gianfrancesco L, Ragonese M, Palermo G, Sacco E, Bassi P. The challenges of Bacillus of Calmette-Guerin (BCG) therapy for high risk non muscle invasive bladder cancer treatment in older patients. J Geriatr Oncol 2018; 9:507-512. [PMID: 29673806 DOI: 10.1016/j.jgo.2018.03.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 02/14/2018] [Accepted: 03/28/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety of a tailored endovesical immunotherapy protocol with biweekly BCG for elderly Patients with high risk non muscle invasive bladder cancer (HG-NMIBC). MATERIALS AND METHODS We retrospectively evaluated data from 200 patients older than 80 years newly diagnosed with HG-NMIBC: 100 (group 1) with multiple comorbidities (WHO PS 2-3, ASA score ≥3, Charlson Comorbidity index ≥3, GFR<60 mL/min) were treated with BCG induction course administered biweekly; 100 (group 2) with statistically significant better conditions were treated with standard weekly BCG therapy. After the induction treatment disease-free patients underwent to at least one year of BCG maintenance therapy. Endpoints were: initial response to BCG, cancer-free survival and rate of progression at 2 years, rate of complications. RESULTS No statistically significant differences were found in terms of initial response to BCG (69% in Group 1 vs 71% in Group 2, P = 0.75), cancer free survival (57% vs 55% respectively, P = 0.77) and rate of progression (20% vs 14% respectively, P = 0.26) at 2 years. The difference in the rate of overall complications was statistically significant (15% in Group 1 vs 27% in Group 2, P = 0.03), in the rate of severe complications was not statistically significant (5% in Group 1 vs 7% in Group 2, P = 0.61). CONCLUSION A tailored regimen of BCG administration is possible and safe in frail elderly patients, limiting side effects and risk of undertreatment but maintaining oncological outcomes. Preliminary results in a small patients group are promising but larger randomized studies are needed to confirm our data.
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Affiliation(s)
- Marco Racioppi
- Department of Urology, "Agostino Gemelli" Academic Hospital Foundation, IRCCS, Catholic University School of Medicine, Rome, Italy
| | - Luca Di Gianfrancesco
- Department of Urology, "Agostino Gemelli" Academic Hospital Foundation, IRCCS, Catholic University School of Medicine, Rome, Italy.
| | - Mauro Ragonese
- Department of Urology, "Agostino Gemelli" Academic Hospital Foundation, IRCCS, Catholic University School of Medicine, Rome, Italy
| | - Giuseppe Palermo
- Department of Urology, "Agostino Gemelli" Academic Hospital Foundation, IRCCS, Catholic University School of Medicine, Rome, Italy
| | - Emilio Sacco
- Department of Urology, "Agostino Gemelli" Academic Hospital Foundation, IRCCS, Catholic University School of Medicine, Rome, Italy
| | - PierFrancesco Bassi
- Department of Urology, "Agostino Gemelli" Academic Hospital Foundation, IRCCS, Catholic University School of Medicine, Rome, Italy
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Clark PE, Spiess PE, Agarwal N, Bangs R, Boorjian SA, Buyyounouski MK, Efstathiou JA, Flaig TW, Friedlander T, Greenberg RE, Guru KA, Hahn N, Herr HW, Hoimes C, Inman BA, Kader AK, Kibel AS, Kuzel TM, Lele SM, Meeks JJ, Michalski J, Montgomery JS, Pagliaro LC, Pal SK, Patterson A, Petrylak D, Plimack ER, Pohar KS, Porter MP, Sexton WJ, Siefker-Radtke AO, Sonpavde G, Tward J, Wile G, Dwyer MA, Smith C. NCCN Guidelines Insights: Bladder Cancer, Version 2.2016. J Natl Compr Canc Netw 2017; 14:1213-1224. [PMID: 27697976 DOI: 10.6004/jnccn.2016.0131] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
These NCCN Guidelines Insights discuss the major recent updates to the NCCN Guidelines for Bladder Cancer based on the review of the evidence in conjunction with the expert opinion of the panel. Recent updates include (1) refining the recommendation of intravesical bacillus Calmette-Guérin, (2) strengthening the recommendations for perioperative systemic chemotherapy, and (3) incorporating immunotherapy into second-line therapy for locally advanced or metastatic disease. These NCCN Guidelines Insights further discuss factors that affect integration of these recommendations into clinical practice.
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Packiam VT, Johnson SC, Steinberg GD. Non-muscle-invasive bladder cancer: Intravesical treatments beyond Bacille Calmette-Guérin. Cancer 2016; 123:390-400. [PMID: 28112819 DOI: 10.1002/cncr.30392] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 12/15/2022]
Abstract
An unmet need exists for patients with high-risk non-muscle-invasive bladder cancer for whom bacille Calmette-Guérin (BCG) has failed and who seek further bladder-sparing approaches. This shortcoming poses difficult management dilemmas. This review explores previously investigated first-line intravesical therapies and discusses emerging second-line treatments for the heterogeneous group of patients for whom BCG has failed. The myriad of recently published and ongoing trials assessing novel salvage intravesical treatments offer promise to patients who both seek an effective cure and want to avoid radical surgery. However, these trials must carefully be contextualized by specific patient, tumor, and recurrence characteristics. As data continue to accumulate, there will potentially be a role for these agents as second-line or even first-line intravesical therapies. Cancer 2017;123:390-400. © 2016 American Cancer Society.
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Affiliation(s)
- Vignesh T Packiam
- Section of Urology, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Scott C Johnson
- Section of Urology, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Gary D Steinberg
- Section of Urology, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
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Lenis AT, Donin NM, Litwin MS, Saigal CS, Lai J, Hanley JM, Konety BR, Chamie K. Association Between Number of Endoscopic Resections and Utilization of Bacillus Calmette-Guérin Therapy for Patients With High-Grade, Non-Muscle-Invasive Bladder Cancer. Clin Genitourin Cancer 2016; 15:e25-e31. [PMID: 27432529 DOI: 10.1016/j.clgc.2016.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/16/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bacillus Calmette-Guérin (BCG) is the reference standard treatment for patients with high-grade, non-muscle-invasive bladder cancer (NMIBC). We previously described noncompliance with guidelines for BCG use in patients with high-risk disease. In the current study, we sought to characterize how the number of endoscopic resections of bladder tumors affects BCG utilization using population-level data. PATIENTS AND METHODS We queried a Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to evaluate claims records of 4776 patients diagnosed with high-grade NMIBC between 1992 and 2002 and followed until 2007, who survived for at least 2 years and who did not undergo definitive treatment with cystectomy, radiotherapy, or systemic chemotherapy. We stratified patients on the basis of the number of endoscopic resections of bladder tumors. We used chi-square analysis to compare number of resections to BCG utilization and multinomial logistic regression analysis to quantify BCG utilization by patient and tumor characteristics. RESULTS Utilization of BCG increases with increasing endoscopic resections from 40% at diagnosis to 72% after 6 resections. The cumulative rate of at least an induction course of BCG plateaus after 3 resections. Lower BCG utilization was associated with advanced age (≥ 80 years), while increased utilization was associated with being married, higher disease stage (Tis and T1) and grade (undifferentiated), and increasing endoscopic resections. CONCLUSION A significant fraction of patients with NMIBC do not receive induction BCG despite its proven benefit in minimizing recurrences. Most patients receive BCG only after multiple endoscopic resections. Strategies focused on earlier adoption of BCG to prevent recurrences instead of reacting to recurrences may limit progression and improve survival.
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Affiliation(s)
- Andrew T Lenis
- Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Nicholas M Donin
- Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Mark S Litwin
- Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; RAND Corporation, Santa Monica, CA; Department of Health Policy & Management, University of California Los Angeles School of Public Health, Los Angeles, CA
| | - Christopher S Saigal
- Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; RAND Corporation, Santa Monica, CA
| | | | | | | | - Karim Chamie
- Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Lamm DL. Getting the Most Out of bacillus Calmette-Guérin for Treatment of Bladder Cancer. J Urol 2016; 195:7-8. [DOI: 10.1016/j.juro.2015.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 01/11/2023]
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Buchwald ZS, Efstathiou JA. Immunotherapy and Radiation - A New Combined Treatment Approach for Bladder Cancer? Bladder Cancer 2015; 1:15-27. [PMID: 30561443 PMCID: PMC6218185 DOI: 10.3233/blc-150014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Recently, immunotherapy with checkpoint inhibitors has been showing promise in clinical trials for stage IV bladder cancer. Herein, we review the literature regarding the role for radiation therapy, the role for immunotherapy, and the potential synergy of these treatments combined in bladder cancer. There is ample pre-clinical data in a number of different tumor models, coupled with a growing body of clinical evidence in melanoma and other malignancies to suggest combining radiation and immunotherapy could lead to substantial advances in treatment outcomes for bladder cancer. Yet, these data for bladder cancer remain at the pre-clinical stage, and further study is needed.
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Affiliation(s)
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Consensus statement on best practice management regarding the use of intravesical immunotherapy with BCG for bladder cancer. Nat Rev Urol 2015; 12:225-35. [DOI: 10.1038/nrurol.2015.58] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Patschan O, Holmäng S, Hosseini A, Liedberg F, Ljungberg B, Malmström PU, Rosell J, Jahnson S. Use of bacillus Calmette-Guérin in stage T1 bladder cancer: Long-term observation of a population-based cohort. Scand J Urol 2014; 49:127-32. [PMID: 25331368 DOI: 10.3109/21681805.2014.968868] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to analyse the rate of use of bacillus Calmette-Guérin (BCG) at a population-based level, and the overall mortality and bladder cancer mortality due to stage T1 bladder cancer in a national, population-based register. MATERIALS AND METHODS In total, 3758 patients with primary stage T1 bladder cancer, registered in the Swedish Bladder Cancer Register between 1997 and 2006, were included. Age, gender, tumour grade and primary treatment in the first 3-6 months were registered. High-volume hospitals registered 10 or more T1 tumours per year. Date and cause of death were obtained from the National Board of Health and Welfare Cause of Death Register. RESULTS BCG was given to 896 patients (24%). The use of BCG increased from 18% between 1997 and 2000, to 24% between 2001 and 2003, and to 31% between 2004 and 2006. BCG was given more often to patients with G3 tumours, patients younger than 75 years and patients attending high-volume hospitals. BCG treatment, grade 2 tumours and patient age younger than 75 years were associated with lower mortality due to bladder cancer. Hospital volume, gender and year of diagnosis were not related to bladder cancer mortality. However, selection factors might have affected the results since comorbidity, number of tumours and tumour size were unknown. CONCLUSIONS Intravesical BCG is underused at a population-based level in stage T1 bladder cancer in Sweden, particularly in patients 75 years or older, and in those treated at low-volume hospitals. BCG should be offered more frequently to patients with stage T1 bladder cancer in Sweden.
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Affiliation(s)
- Oliver Patschan
- Department of Urology, Skåne University Hospital , Malmö , Sweden
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Kamat AM, Lamm DL. Predicting response to bacillus Calmette-Guérin: time to look beyond the ages. Eur Urol 2014; 66:702-3. [PMID: 24968969 DOI: 10.1016/j.eururo.2014.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 06/06/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Ashish M Kamat
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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