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Huelster HL, Mason NT, Davaro F, Naqvi SMH, Kim Y, Gilbert SM. Cost-utility of Initial Management of High-grade T1 Bladder Cancer With Intravesical BCG vs Immediate Radical Cystectomy. Urology 2024; 187:106-113. [PMID: 38467285 DOI: 10.1016/j.urology.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/27/2024] [Accepted: 02/21/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE To compare the cost-utility of initial management of high-grade T1 non-muscle invasive bladder cancer (HGT1 NMIBC) with intravesical BCG vs immediate radical cystectomy. High-risk NMIBC patients may climb a costly ladder of treatments, culminating in radical cystectomy for oncologic or symptomatic benefit in up to one-third. This high healthcare resource utilization presents a challenging dilemma in balancing sufficiently aggressive management with cost, toxicity, and quality-of-life. METHODS Cost-utility of initially managing HGT1 with intravesical BCG and early radical cystectomy with ileal conduit urinary diversion was compared using decision-analytic Markov models. Five-year oncologic outcomes, adverse event rates, and published utility values were extracted from literature. Costs were calculated from a US Medicare perspective in 2021 US dollars. Sensitivity analysis identified drivers of cost and break-even points for recurrence and progression. RESULTS Mean costs were $26,093 for intravesical BCG and $39,720 for immediate radical cystectomy, though cystectomy generated a gain of 2.2 quality-adjusted life years (QALYs) compared to intravesical BCG. Immediate cystectomy was a more cost-effective management strategy for HGT1 NMIBC with an incremental CE ratios (ICER) of $7120/QALY. The costs associated with cystectomy, TURBT, and BCG toxicity had the greatest impact on ICER. One-way sensitivity analysis demonstrated that intravesical BCG became a cost-effective management strategy if the 5-year recurrence rate of HG T1 was less than 56% or the 5-year progression rate to MIBC was less than 4%. CONCLUSION At current prices, treatment of high-grade T1 NMIBC with early radical cystectomy is more cost-effective management strategy than initial treatment with intravesical BCG.
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Affiliation(s)
- Heather L Huelster
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Department of Urology, Indiana University Health, Indianapolis, IN.
| | - Neil T Mason
- Department of Individualized Cancer Medicine, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Facundo Davaro
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Youngchul Kim
- Department of Biostatistics, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL
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2
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You C, Li Q, Qing L, Li R, Wang Y, Cheng L, Dong Z. Device-assisted intravesical chemotherapy versus bacillus Calmette-Guerin for intermediate or high-risk non-muscle invasive bladder cancer: a systematic reviewer and meta-analysis. Int Urol Nephrol 2024; 56:103-120. [PMID: 37659995 DOI: 10.1007/s11255-023-03765-0] [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: 07/09/2023] [Accepted: 08/19/2023] [Indexed: 09/04/2023]
Abstract
PURPOSE To investigate the effectiveness and safety of device-assisted intravesical chemotherapy compared to Bacillus Calmette-Guerin (BCG) in the treatment of patients with intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC). METHODS In February 2023, a systematic search was conducted on the PubMed, Cochrane, and Embase databases. Following the PRISMA guidelines, a systematic review and meta-analysis of the primary outcomes of interest were performed. The review was prospectively registered on PROSPERO under the registration number CRD42023398559. RESULTS A total of 10 studies involving 1160 patients were included. The results of the meta-analysis showed that compared to BCG, device-assisted chemotherapy had a lower recurrence rate (OR: 0.63, 95% CI: 0.48-0.84, p = 0.001), longer recurrence-free survival (OR: 0.64, 95% CI: 0.47-0.88, p = 0.006), and lower incidence of fever (OR: 0.18, 95% CI: 0.08-0.44, p = 0.0002). However, no significant differences were observed between the two groups in terms of progression, overall survival, progression-free survival, disease-free survival, overall adverse events, serious adverse events, hematuria, allergy, and general discomfort. Subgroup analysis revealed that neither chemohyperthermia (CHT) nor electromotive drug administration (EMDA) showed statistically significant differences in oncological outcomes compared to BCG. Regarding adverse events, both CHT and EMDA groups showed lower rates of fever compared to the BCG group (OR: 0.26, 95% CI: 0.10-0.67, p = 0.005, and OR: 0.14, 95% CI: 0.05-0.37, p < 0.0001, respectively). No significant differences were observed in the remaining adverse events between either the CHT or EMDA group and the BCG group. CONCLUSION Device-assisted intravesical chemotherapy appears to be a safe and viable alternative to BCG for patients with intermediate and high-risk NMIBC, showing comparable oncological outcomes and adverse events.
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Affiliation(s)
- Chengyu You
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Qingchao Li
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Liangliang Qing
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Rongxin Li
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Yanan Wang
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Long Cheng
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Zhilong Dong
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China.
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China.
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China.
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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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Grabe-Heyne K, Henne C, Odeyemi I, Pöhlmann J, Ahmed W, Pollock RF. Evaluating the cost-utility of intravesical Bacillus Calmette-Guérin versus radical cystectomy in patients with high-risk non-muscle-invasive bladder cancer in the UK. J Med Econ 2023; 26:411-421. [PMID: 36897006 DOI: 10.1080/13696998.2023.2189860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
AIMS Approximately 75% of bladder cancer (BC) cases present as non-muscle-invasive BC (NMIBC). In patients with high-risk NMIBC, the mainstay treatment is intravesical Bacillus Calmette-Guérin (BCG), with immediate radical cystectomy (RC) as an alternative treatment option. The aim of the present study was to evaluate the cost-utility of BCG versus RC in patients with high-risk NMIBC from the UK healthcare payer perspective. MATERIALS AND METHODS A six-state Markov model was developed that covered controlled disease, recurrence, progression to muscle-invasive BC, metastatic disease, and death. The model included adverse events of BCG and RC and monitoring and palliative care. Drug costs were obtained from the British National Formulary. Intravesical delivery, RC, and monitoring costs were sourced from the National Tariff Payment System and the literature. Utility data were obtained from the literature. Analyses were run over a 30-year time horizon, with future costs and effects discounted at 3.5% per annum. One-way and probabilistic sensitivity analyses were performed. RESULTS The base case analysis comparing BCG with RC showed that BCG would increase life expectancy by 0.88 years versus RC, from 7.74 to 8.62 years. BCG resulted in an increase of 0.76 quality-adjusted life years (QALYs) versus RC, from 5.63 to 6.39 QALYs. Patients incurred lower lifetime costs if treated with BCG (£47,753) than with RC (£64,264). Cost savings were mainly driven by the lower cost of BCG versus RC, and palliative care costs. Sensitivity analyses showed that results were robust to assumptions. LIMITATIONS The evidence base informing efficacy estimates of BCG is heterogeneous as different BCG administration schedules were reported in the literature, while incidence and cost data on some BCG-associated adverse events were sparse. CONCLUSIONS Intravesical BCG led to increased QALYs and reduced costs versus RC for patients with high-risk NMIBC from the UK healthcare payer perspective.
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Affiliation(s)
| | | | - Isaac Odeyemi
- Department of Health Professions, Health Economics and Outcomes Research, Manchester Metropolitan University, Manchester, UK
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Joshi M, Atlas SJ, Beinfeld M, Chapman RH, Rind DM, Pearson SD, Touchette DR. Cost-Effectiveness of Nadofaragene Firadenovec and Pembrolizumab in Bacillus Calmette-Guérin Immunotherapy Unresponsive Non-Muscle Invasive Bladder Cancer. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022:S1098-3015(22)04779-9. [PMID: 36529422 DOI: 10.1016/j.jval.2022.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/29/2022] [Accepted: 12/03/2022] [Indexed: 05/09/2023]
Abstract
OBJECTIVES Nadofaragene firadenovec is a gene therapy for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) undergoing Food and Drug Administration review. Pembrolizumab is approved for treating patients with BCG-unresponsive NMIBC with carcinoma in situ (CIS). We evaluated the cost-effectiveness of these treatments compared with a hypothetical therapeutic alternative, at a willingness-to-pay threshold of $150 000 per quality-adjusted life-year (QALY) gained, in CIS and non-CIS BCG-unresponsive NMIBC populations. METHODS We developed a Markov cohort simulation model with a 3-month cycle length and lifetime horizon to estimate the total costs, QALYs, and cost per additional QALY from the health sector perspective. Clinical inputs were informed by results of single-arm clinical trials evaluating the treatments, and systematic literature reviews were conducted to obtain other model inputs. Sensitivity analyses were conducted to assess uncertainty in model results. RESULTS Nadofaragene firadenovec, at a placeholder price 10% higher than the price of pembrolizumab, had an incremental cost-effectiveness ratio of $263 000 and $145 000 per QALY gained in CIS and non-CIS populations, respectively. Pembrolizumab had an incremental cost-effectiveness ratio of $168 000 per QALY gained for CIS. A 5.4% reduction in pembrolizumab's price would make it cost-effective. The model was sensitive to many inputs, especially to the probabilities of disease progression, initial treatment response and durability, and drug price. CONCLUSIONS The cost-effectiveness of nadofaragene firadenovec will depend upon its price. Pembrolizumab, although not cost-effective in our base-case analysis, is an important alternative in this population with an unmet medical need. Comparative trials of these treatments are warranted to better estimate cost-effectiveness.
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Affiliation(s)
- Mrinmayee Joshi
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Steven J Atlas
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Molly Beinfeld
- Center for Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | | | - David M Rind
- Institute for Clinical and Economic Review, Boston, MA, USA
| | | | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA.
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Clarke CS, Melnychuk M, Ramsay AIG, Vindrola-Padros C, Levermore C, Barod R, Bex A, Hines J, Mughal MM, Pritchard-Jones K, Tran M, Shackley DC, Morris S, Fulop NJ, Hunter RM. Cost-Utility Analysis of Major System Change in Specialist Cancer Surgery in London, England, Using Linked Patient-Level Electronic Health Records and Difference-in-Differences Analysis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:905-917. [PMID: 35869355 PMCID: PMC9307119 DOI: 10.1007/s40258-022-00745-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Studies have shown that centralising surgical treatment for some cancers can improve patient outcomes, but there is limited evidence of the impact on costs or health-related quality of life. OBJECTIVES We report the results of a cost-utility analysis of the RESPECT-21 study using difference-in-differences, which investigated the reconfiguration of specialist surgery services for four cancers in an area of London, compared to the Rest of England (ROE). METHODS Electronic health records data were obtained from the National Cancer Registration and Analysis Service for patients diagnosed with one of the four cancers of interest between 2012 and 2017. The analysis for each tumour type used a short-term decision tree followed by a 10-year Markov model with 6-monthly cycles. Costs were calculated by applying National Health Service (NHS) Reference Costs to patient-level hospital resource use and supplemented with published data. Cancer-specific preference-based health-related quality-of-life values were obtained from the literature to calculate quality-adjusted life-years (QALYs). Total costs and QALYs were calculated before and after the reconfiguration, in the London Cancer (LC) area and in ROE, and probabilistic sensitivity analysis was performed to illustrate the uncertainty in the results. RESULTS At a threshold of £30,000/QALY gained, LC reconfiguration of prostate cancer surgery services had a 79% probability of having been cost-effective compared to non-reconfigured services using difference-in-differences. The oesophago-gastric, bladder and renal reconfigurations had probabilities of 62%, 49% and 12%, respectively, of being cost-effective at the same threshold. Costs and QALYs per surgical patient increased over time for all cancers across both regions to varying degrees. Bladder cancer surgery had the smallest patient numbers and changes in costs, and QALYs were not significant. The largest improvement in outcomes was in renal cancer surgery in ROE, making the relative renal improvements in LC appear modest, and the probability of the LC reconfiguration having been cost-effective low. CONCLUSIONS Prostate cancer reconfigurations had the highest probability of being cost-effective. It is not clear, however, whether the prostate results can be considered in isolation, given the reconfigurations occurred simultaneously with other system changes, and healthcare delivery in the NHS is highly networked and collaborative. Routine collection of quality-of-life measures such as the EQ-5D-5L would have improved the analysis.
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Affiliation(s)
- Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK.
| | - Mariya Melnychuk
- Department of Applied Health Research, University College London, London, UK
| | - Angus I G Ramsay
- Department of Applied Health Research, University College London, London, UK
| | | | | | - Ravi Barod
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Axel Bex
- Division of Surgery and Interventional Science, Royal Free London NHS Foundation Trust, University College London, London, UK
| | - John Hines
- University College London Hospitals NHS Foundation Trust, London, UK
- London Cancer, University College London, Cancer Collaborative, London, UK
- Bart's Health, NHS Trust, London, UK
| | - Muntzer M Mughal
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Kathy Pritchard-Jones
- University College London Hospitals NHS Foundation Trust, London, UK
- UCL Partners Academic Health Science Network, London, UK
| | - Maxine Tran
- Specialist Centre for Kidney Cancer, Royal Free Hospital, London, UK
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, UK
| | - David C Shackley
- Greater Manchester Cancer, (hosted by) Christie NHS Foundation Trust, Manchester, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Rachael M Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
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Smith AB, McCabe S, Deal AM, Guo A, Gessner KH, Lipman R, Chisolm S, Ahlschlager L, Gore JL. Quality of Life and Health State Utilities in Bladder Cancer. Bladder Cancer 2022; 8:55-70. [PMID: 38994519 PMCID: PMC11181821 DOI: 10.3233/blc-211615] [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: 09/30/2021] [Accepted: 11/17/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Bladder cancer treatments may variably impact health-related quality of life (QOL). OBJECTIVE To characterize the quality of life of patients with bladder cancer at various time points across the continuum of bladder cancer care from non-muscle-invasive disease to metastatic bladder cancer and develop utility scores to inform cost-effective analyses. METHODS We performed a cross-sectional survey of bladder cancer patients in the Bladder Cancer Advocacy Network Patient Survey Network. Participants were classified into mutually exclusive health states based upon non-muscle invasive (NMIBC), muscle-invasive (MIBC), or metastatic bladder cancer and completed surveys of generic cancer and bladder cancer-specific quality of life, financial toxicity, and work impairment. We constructed generalized linear mixed models to identify patient, clinical, and treatment factors associated with quality of life over time and derived health state utilities. RESULTS Among 911 self-identified patients with bladder cancer, overall QOL scores and function domains were worse among those with advanced cancer. Financial toxicity was similar among non-metastatic disease states. Work and activity impairment increased with advancing disease (13%and 12%among non-recurrent NMIBC to 63%and 31%for metastatic disease respectively; p < 0.01). On multivariable analysis, bowel-related QOL was diminished among patients with MIBC, with urinary symptoms and physical function most diminished among patients with metastatic disease. Patients with metastatic and MIBC experienced worse emotional functioning (p = 0.04; p = 0.048). Health state utilities were calculated, highest among those with non-recurrent NMIBC and lowest among those with metastatic disease. CONCLUSION Generic and bladder cancer-specific QOL diminishes with advancing disease. Health state utility estimates derived from this study can inform shared decision making with patients and may be used to inform future cost-effective analyses.
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Affiliation(s)
- Angela B. Smith
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean McCabe
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allison M. Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Kathryn H. Gessner
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert Lipman
- Bladder Cancer Advocacy Network, Research Patient Advocate, Bethesda, MD, USA
| | - Stephanie Chisolm
- Bladder Cancer Advocacy Network, Director of Education & Research, Bethesda, MD, USA
| | - Lauren Ahlschlager
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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You C, Li X, Du Y, Wang H, Zhang X, Wei T, Wang A. Application of intra-arterial chemotherapy in high-risk non-muscle invasive bladder cancer: a systematic review and meta-analysis. PeerJ 2021; 9:e12248. [PMID: 34692255 PMCID: PMC8485834 DOI: 10.7717/peerj.12248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/13/2021] [Indexed: 12/09/2022] Open
Abstract
Background To summarize the current evidence on the effects of intra-arterial chemotherapy (IAC) on high-risk non-muscle invasive bladder cancer (NMIBC) and compare oncology results with intravesical chemotherapy (IVC). Methods We performed a systematic review and cumulative meta-analysis of the primary outcomes of interest by a systematical search of multiple scientific databases in February 2021. The mean difference (MD) and odds ratio (OR) were calculated for continuous and dichotomous variables respectively, with 95% confidence intervals (CIs). The hazard radio (HR) with 95% CIs was used for overall survival (OS), recurrence-free survival (RFS) and progression-free survival (PFS). Results A total of six studies with 866 patients were included. For IAC combined with IVC versus IVC alone, statistically significant differences were found regarding tumor recurrence rate (OR: 0.51, 95% CI [0.36∼0.72], p = 0.0001), tumor progression rate (OR: 0.47, 95% CI [0.30∼0.72], p = 0.0006), tumor-specific death rate (OR: 0.49, 95% CI [0.25∼0.99], p = 0.05), PFS (HR: 0.47, 95% CI [0.23∼0.96], p = 0.04) and RFS (HR: 0.60, 95% CI [0.41∼0.87], p = 0.007). No significant difference between two groups was found for time to first recurrence (MD: 3.27, 95% CI [−2.37∼8.92], p = 0.26) and OS (HR: 1.20, 95% CI [0.44∼3.32], p = 0.72). For IAC alone versus IVC, There was no statistical difference in the terms of tumor-specific death rate (OR: 0.67, 95% CI [0.29∼1.53], p = 0.34), RFS (HR: 0.90, 95% CI [0.56∼1.46], p = 0.68) and PFS (HR: 0.71, 95% CI [0.32∼1.55], p = 0.39). Adverse events mainly included nausea/vomiting (36.3%), hypoleukemia (19.4%), neutropenia (16.0%), increased creatinine (9.9%), increased alanine aminotransferase (18.7%), and thrombocytopenia (9.9%). Conclusion The IAC combined with IVC is a safe and effective treatment for high risk NMIBC, with lower rates of recurrence, progression, tumor-specific death, PFS and RFS, and with minor and tolerable events. The effectiveness of the IAC alone is parallel to the IVC alone.
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Affiliation(s)
- Chengyu You
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Xianhui Li
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Yuelin Du
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Hui Wang
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Xiaojun Zhang
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Tangqiang Wei
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Anguo Wang
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
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Enhanced Visualization Methods for First Transurethral Resection of Bladder Tumour in Suspected Non-muscle-invasive Bladder Cancer: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2021; 21:1-123. [PMID: 34484486 PMCID: PMC8382283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Bladder cancer begins in the innermost lining of the bladder wall and, on histological examination, is classified as one of two types: non-muscle-invasive bladder cancer (NMIBC) or muscle-invasive bladder cancer. Transurethral resection of bladder tumour (TURBT) is the standard treatment for people with NMIBC, but the high rate of cancer recurrence after first TURBT is a challenge that physicians and patients face. Tumours seen during follow-up may have been missed or incompletely resected during first TURBT. TURBT is conventionally performed using white light to see the tumours. However, small papillary or flat tumours may be missed with the use of white light alone. With the emergence of new technologies to improve visualization during TURBT, better diagnostic and patient outcomes may be expected. We conducted a health technology assessment of two enhanced visualization methods, both as an adjunct to white light to guide first TURBT for people with suspected NMIBC-hexaminolevulinate hydrochloride (HAL), a solution that is instilled into the bladder to make tumours fluoresce under blue-violet light, and narrow band imaging (NBI), a technology that filters light into wavelengths that can be absorbed by hemoglobin in the tumours, making them appear darker. Our assessment included an evaluation of effectiveness, safety, cost-effectiveness, and the budget impact of publicly funding these new technologies to improve patient outcomes following first TURBT. The use of NBI in diagnostic cystoscopy was out of scope for this health technology assessment. METHODS We performed a systematic literature search of the clinical evidence from inception to April 15, 2020. We searched for randomized controlled trials (RCTs) that compared the outcomes of first TURBT with the use of HAL or NBI, both as an adjunct to white light, with the outcomes of first TURBT using white light alone, or studies that made such comparison between HAL and NBI. We conducted pairwise meta-analyses using a fixed effects model where head-to-head comparisons were available. In the absence of any published RCT for comparison between HAL and NBI, we indirectly compared the two technologies through indirect treatment comparison (ITC) analysis. We assessed the risk of bias of each included study using the Cochrane risk-of-bias tool. We assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-utility analysis with a 15-year time horizon from a public payer perspective. We also analyzed the budget impact of publicly funding HAL and NBI as an adjunct to white light in people undergoing their first TURBT for suspected non-muscle-invasive bladder cancer in Ontario. RESULTS In the clinical evidence review, we identified 8 RCTs that used HAL or NBI as an adjunct to white light during first TURBT. Pairwise meta-analysis of HAL studies showed that HAL-guided TURBT as an adjunct to white light significantly reduces recurrence rate at 12 months compared with TURBT using white light alone (risk ratio 0.70, 95% confidence interval [CI] 0.51-0.95) (GRADE: Moderate). Five-year recurrence-free survival was significantly higher when HAL was used as an adjunct to white light than when white light was used alone (GRADE: Moderate). There was little to no difference in the tumour progression rate (GRADE: Moderate).Meta-analysis of NBI studies did not show a significant difference between NBI-guided TURBT as an adjunct to white light and TURBT using white light alone in reducing the rate of recurrence at 12 months (risk ratio 0.94, 95% CI 0.75-1.19) (GRADE: Moderate). No evidence on the effect on recurrence-free survival or tumour progression rate was identified for NBI-guided TURBT. The indirect estimate from the network analysis showed a trend toward a lower rate of recurrence after HAL-guided TURBT than after NBI-guided TURBT but the difference was not statistically significant (risk ratio 0.76, 95% CI 0.51-1.11) (GRADE: Low). Studies showed that use of HAL or NBI during TURBT was generally safe.The incremental cost-effectiveness ratio of HAL-guided TURBT compared with NBI-guided TURBT, both as an adjunct to white light, is $12,618 per quality-adjusted life-year (QALY) gained. Compared with TURBT using white light alone and using adjunct NBI, the probability of HAL-guided TURBT being cost-effective is 69.1% at a willingness-to-pay value of $50,000 per QALY gained and 74.6% at a willingness-to-pay of $100,000 per QALY gained. The annual budget impact of publicly funding HAL-guided TURBT in Ontario over the next 5 years ranges from an additional $0.6 million in year 1 to $2.5 million in year 5. CONCLUSIONS First TURBT guided by HAL as an adjunct to white light likely reduces the rate of recurrence at 12 months and increases 5-year recurrence-free survival when compared with first TURBT using white light alone. There is likely little to no difference in the tumour progression rate. First TURBT guided by NBI as an adjunct to white light likely results in little to no difference in the rate of recurrence at 12 months when compared with first TURBT using white light alone. Based on an indirect comparison, there may be little to no difference in cancer recurrence rate between HAL-guided and NBI-guided first TURBT. Use of HAL or NBI during first TURBT is generally safe. For people undergoing their first TURBT for suspected non-muscle-invasive bladder cancer, using HAL as an adjunct to white light is likely to be cost-effective compared with using white light alone or with using NBI as an adjunct to white light. We estimate that publicly funding HAL as an adjunct to white light to guide first TURBT for people in Ontario with suspected NMIBC would result in additional costs of between $0.6 million and $2.5 million per year over the next 5 years.
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Beinfeld M, Atlas SJ, Touchette D, McKenna A, Rind D, Pearson SD. The effectiveness and value of nadofaragene firadenovec, oportuzumab monatox, and pembrolizumab for BCG-unresponsive non-muscle-invasive bladder cancer. J Manag Care Spec Pharm 2021; 27:797-804. [PMID: 34057394 PMCID: PMC10391138 DOI: 10.18553/jmcp.2021.27.6.797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES: Funding for this summary was contributed by Arnold Ventures, California Health Care Foundation, The Donaghue Foundation, Harvard Pilgrim Health Care, and Kaiser Foundation Health Plan to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from AbbVie, Aetna, America's Health Insurance Plans, Anthem, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Boehringer-Ingelheim, Cambia Health Services, CVS, Editas, Evolve Pharmacy, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, HealthFirst, Health Partners, Humana, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Pfizer, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, uniQure, and United Healthcare. Beinfeld, McKenna, Rind, and Pearson are employed by ICER. Touchette received funding from ICER for work on this report and has also received fees from Monument Analytics and AstraZeneca, unrelated to this work. The University of Illinois at Chicago (UIC) and Touchette hold a patent for the model described in this report. The model is included in ICER's Interactive Modeler, for which a fee is paid to UIC and Touchette. Atlas also received funding from ICER for work on this report.
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Affiliation(s)
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Daniel Touchette
- University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Avery McKenna
- Institute for Clinical and Economic Review, Boston, MA
| | - David Rind
- Institute for Clinical and Economic Review, Boston, MA
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11
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Zhou Z, Cui Y, Huang S, Chen Z, Zhang Y. The Efficacy of Intra-Arterial Plus Intravesical Chemotherapy Versus Intravesical Chemotherapy Alone After Bladder-Sparing Surgery in High-Risk Bladder Cancer: A Systematic Review and Meta-Analysis of Comparative Study. Front Oncol 2021; 11:651657. [PMID: 34123803 PMCID: PMC8190377 DOI: 10.3389/fonc.2021.651657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 05/04/2021] [Indexed: 01/11/2023] Open
Abstract
Background Due to the poor prognosis, the treatment of high-risk bladder cancer (HRBC) remains controversial. This meta-analysis aims to access the efficacy of intra-arterial chemotherapy (IAC) combined with intravesical chemotherapy (IC) versus IC alone after bladder-sparing surgery in HRBC. Methods A systematic search of PubMed, Cochrane Library databases, EMBASE (until June 2020) was conducted. PRISMA checklist was followed. The data were analyzed by RevMan v5.3.0. Results A total of five articles including 843 patients were studied. The analysis demonstrated that the IAC + IC group had a greater improvement of overall survival (P = 0.02) and significant reduction in terms of tumor recurrence rate (P = 0.0006) and tumor progression rate (P = 0.008) compared with the IC group. The recurrence-free survival in the IAC + IC group was significantly higher than that in the IC group (P = 0.004), but there was no significant difference in progression-free survival between the two groups (P = 0.32). In addition, the combination of IAC and IC significantly extended tumor recurrence interval (P = 0.0001) and reduced tumor-specific death rate (P = 0.01) for patients with HRBC compared with IC alone. For side effects related with IAC, although about half of the patients experienced some toxicities, most of them were mild and reversible (grades 1-2, 22.3% vs. grade 3-4, 2.7%), mainly including nausea/vomiting (P = 0.0001), neutropenia (P = 0.002), and alanine aminotransferase (P = 0.0001). Conclusion Patients with HRBC treated with IAC + IC after bladder-sparing surgery had a marked improvement in the overall survival, recurrence-free survival, time interval to first recurrence, tumor recurrence rate, tumor progression rate, and tumor-specific death rate than patients treated with IC alone. However, progression-free survival was not significantly correlated with treatment strategy. In addition, patients seemed to tolerate well the toxicities related with IAC. Systematic Review Registration PROSPERO, identifier CRD42021232679.
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Affiliation(s)
- Zhongbao Zhou
- Department of Urology, Beijing TianTan Hospital, Capital Medical University, Beijing, China
| | - Yuanshan Cui
- Department of Urology, Beijing TianTan Hospital, Capital Medical University, Beijing, China.,Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Shuangfeng Huang
- Second Clinical Medical College, Binzhou Medical University, Yantai, China
| | - Zhipeng Chen
- Department of Urology, Weifang People's Hospital, Weifang, China
| | - Yong Zhang
- Department of Urology, Beijing TianTan Hospital, Capital Medical University, Beijing, China
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12
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Froehner M, Koch R, Heberling U, Borkowetz A, Hübler M, Novotny V, Wirth MP, Thomas C. Decreasing Non-bladder-cancer Mortality After Radical Cystectomy. EUR UROL SUPPL 2021; 29:15-18. [PMID: 34337529 PMCID: PMC8317886 DOI: 10.1016/j.euros.2021.04.007] [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] [Accepted: 04/22/2021] [Indexed: 12/01/2022] Open
Abstract
Life expectancy is increasing in many parts of the world. Using proportional hazard models for competing risks, we investigated whether this increase has changed outcomes after radical cystectomy in a sample of 1419 consecutive patients treated between 1993 and 2018. During the observation period, the mean age and the proportion of patients with American Society of Anesthesiologists physical status class 3 or 4 increased, whereas the proportion of patients with heart disease decreased. Competing mortality (causes other than bladder cancer) decreased in all subgroups (hazard ratios [HRs] per year ranged from 0.931 to 0.963) and after controlling for increasing age (HRs ranged from 1.018 to 1.081). In an optimal model resulting from an analysis including age (HR per year 1.048, 95% confidence interval [CI] 1.027–1.070; p < 0.0001), comorbidity, tumor-related variables, body mass index, (neoadjuvant and adjuvant) chemotherapy and smoking status, the HR per increment for year of surgery was 0.928 (95% CI 0.886–0.973; p = 0.0019). The effect of year of surgery was greater than the decrease in competing mortality that may be expected with increasing life expectancy (4 yr for females, 6 yr for males). Patient summary In a review of data for 1993–2018, we found that death from other causes after removal of the bladder (radical cystectomy) for bladder cancer decreased over time. This decreasing trend might increase the age limit at which bladder cancer patients can benefit from radical cystectomy in the future.
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Affiliation(s)
- Michael Froehner
- Department of Urology, Zeisigwaldkliniken Bethanien Chemnitz, Chemnitz, Germany
- Corresponding author. Current address: Department of Urology, Zeisigwaldkliniken Bethanien Chemnitz, Zeisigwaldstrasse 101, D-09130 Chemnitz, Germany. Tel.: +49 371 4301701; Fax: +49 351 4301704.
| | - Rainer Koch
- Department of Urology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ulrike Heberling
- Department of Urology, Zeisigwaldkliniken Bethanien Chemnitz, Chemnitz, Germany
| | - Angelika Borkowetz
- Department of Urology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Matthias Hübler
- Department of Anesthesiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Vladimir Novotny
- Department of Urology, Städtisches Klinikum Görlitz, Görlitz, Germany
| | - Manfred P. Wirth
- Department of Urology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christian Thomas
- Department of Urology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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13
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Hird AE, Magee DE, Cheung DC, Sander B, Sridhar S, Nam RK, Kulkarni GS. Neoadjuvant Versus Adjuvant Chemotherapy for Upper Tract Urothelial Carcinoma: A Microsimulation Model. Clin Genitourin Cancer 2020; 19:e135-e147. [PMID: 33168398 DOI: 10.1016/j.clgc.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/04/2020] [Accepted: 10/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Upper tract urothelial carcinoma (UTUC) is clinically understudied, and there are no definitive recommendations regarding timing of perioperative chemotherapy. The objective of this study was to compare 3 treatment pathways in UTUC: nephroureterectomy (NU) alone, neoadjuvant chemotherapy (NAC), and adjuvant chemotherapy (AC) using a microsimulation model. PATIENTS AND METHODS An individual-level state transition model was constructed using TreeAgePro software to compare treatment strategies for patients with newly diagnosed UTUC. The base case was that of a 70-year-old patient with a radiographically localized upper tract tumor. Primary outcome was quality-adjusted life expectancy. Secondary outcomes included crude overall survival, rates of adverse events, and bladder cancer diagnoses. RESULTS A total of 100,000 patients were simulated. NAC was preferred, with an estimated quality-adjusted life expectancy of 7.50 years versus 6.79 years with NU alone and 7.23 years with AC. Median crude overall survival was 123 months with NAC, 96 months with NU only, and 111 months with AC. Overall, 40.0% of patients in the AC group with invasive pathology completed chemotherapy. In the NAC group, 83.3% of patients completed chemotherapy. In the NAC group, 37.5% of patients experienced an adverse chemotherapy event compared to 15.1% of patients in the AC group. Bladder cancer recurrence rates were 64.9%, 65.9%, and 67.4% over the patient's lifetime for the NU, NAC, and AC strategies, respectively. CONCLUSION This study supports the increased use of NAC in UTUC until robust randomized trials are completed. The ultimate choice should be based on patient and tumor factors.
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Affiliation(s)
- Amanda E Hird
- Division of Urology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Diana E Magee
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Douglas C Cheung
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Srikala Sridhar
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Girish S Kulkarni
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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14
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Hird AE, Magee DE, Cheung DC, Matta R, Kulkarni GS, Nam RK. Abiraterone vs. docetaxel for metastatic hormone-sensitive prostate cancer: A microsimulation model. Can Urol Assoc J 2020; 14:E418-E427. [PMID: 32223875 PMCID: PMC7492043 DOI: 10.5489/cuaj.6234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Our aim was to determine whether androgen deprivation therapy (ADT) with abiraterone acetate (AA) or ADT with docetaxel chemotherapy (DC) resulted in improved quality-adjusted life years (QALYs) among men with de novo metastatic castration-sensitive prostate cancer (mCSPC) and the cost effectiveness of the preferred strategy using decision analytic techniques. METHODS A microsimulation model with a lifetime time horizon was constructed. Our primary outcome was QALYs. Secondary outcomes included cost, incremental cost effectiveness ratio (ICER), unadjusted overall survival (OS), rates of second- and third-line therapy, and adverse events. A systematic literature review was used to generate probabilities and utilities to populate the model. The base case was a 65-year-old patient with de novo mCSPC. RESULTS A total of 100 000 microsimulations were generated. Initial AA resulted in a gain of 0.45 QALYs compared to DC (3.36 vs. 2.91 QALYs) with an ICER of $276 251.82 per QALY gained with initial AA therapy. Median crude OS was 51 months with AA and 48 months with DC. Overall, 46.6% and 42.6% of patients received second-line therapy and 8.7% and 7.9% patients received third-line therapy in the AA and DC groups, respectively. Grade 3/4 adverse events were experienced in 17.6% of patients receiving initial AA and 22.3% of patients receiving initial DC. CONCLUSIONS Although ADT with AA results in a gain in QALYs and crude OS compared to DC, AA therapy is not a cost-effective treatment strategy to apply uniformly to all patients. The availability of AA as a generic medication may help to close this gap. The ultimate choice should be based on patient and tumor factors.
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Affiliation(s)
- Amanda E. Hird
- Division of Urology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Diana E. Magee
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Urology, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada
| | - Douglas C. Cheung
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Urology, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada
| | - Rano Matta
- Division of Urology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Girish S. Kulkarni
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Urology, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada
| | - Robert K. Nam
- Division of Urology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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15
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Tully KH, Cole AP, Krimphove MJ, Friedlander DF, Mossanen M, Herzog P, Noldus J, Sonpavde GP, Trinh QD. Contemporary Treatment Patterns for Non-muscle-invasive Bladder Cancer: Has the Use of Radical Cystectomy Changed in the BCG Shortage Era? Urology 2020; 147:199-204. [PMID: 32805294 DOI: 10.1016/j.urology.2020.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To examine recent treatment trends for non-muscle-invasive bladder cancer (NMIBC), and specifically, to assess whether there was a change in use radical cystectomy (RC) between 2008 and 2015 using data from the Surveillance, Epidemiology, and End Results database. METHODS We identified patients presenting with high-grade T1 (T1HG) NMIBC at diagnosis during the study period. Treatment was dichotomized into "RC" and "local treatment" (which included transurethral resection and intravesical therapies). We then employed multivariable logistic regression models to assess the odds of undergoing RC across the study period. Additionally we examined the rates of RC for T1HG NMIBC during the period of BCG-shortage, defined as 2012-2015. RESULTS We identified 21,817 individuals diagnosed with T1HG bladder cancer during the study period. The majority of patients underwent local treatment (94.5%). During the shortage period, the rate of RC for T1HG NMIBC was significantly lower compared to the preshortage era (5.1% vs 5.9%, P = .007). Across the study period, the utilization of RC for T1HG NMIBC decreased significantly (odds ratio 0.99 per quarter, 95% confidence interval 0.98-0.99, P = .017). CONCLUSION In our cohort of patients diagnosed with T1HG bladder cancer, we found a significant decrease in the use of radical cystectomy across the study period. Contrary to the hypothesis of increasing rates of RC in the face of BCG shortage, the rate of RC was significantly higher in the pre-shortage era. Further examination of NMIBC treatment patterns will be necessary to assess the impact of BCG availability on therapeutic pathways and oncologic outcomes in patients with high-grade NMIBC.
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Affiliation(s)
- Karl H Tully
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Alexander P Cole
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marieke J Krimphove
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - David F Friedlander
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Matthew Mossanen
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Peter Herzog
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joachim Noldus
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Guru P Sonpavde
- Lank Center for Genitourinary Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard, Medical School, Boston, MA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Cox E, Saramago P, Kelly J, Porta N, Hall E, Tan WS, Sculpher M, Soares M. Effects of Bladder Cancer on UK Healthcare Costs and Patient Health-Related Quality of Life: Evidence From the BOXIT Trial. Clin Genitourin Cancer 2020; 18:e418-e442. [PMID: 32144049 PMCID: PMC7427321 DOI: 10.1016/j.clgc.2019.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/01/2019] [Accepted: 12/09/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Limited evidence exists regarding the cost and health-related quality of life (HRQoL) effects of non-muscle-invasive bladder cancer (NMIBC) recurrence and progression to muscle-invasive bladder cancer (MIBC). We examined these effects using evidence from a recent randomized control trial. MATERIAL AND METHODS The costs and HRQoL associated with bladder cancer were assessed using data from the BOXIT trial (bladder COX-2 inhibition trial; n = 472). The cost and HRQoL effects from clinical events were estimated using generalized estimating equations. The costs were derived from the recorded resource usage and UK unit costs. HRQoL was assessed using the EQ-5D-3L and reported UK preference tariffs. The events were categorized using the TMN classification. RESULTS Cases of grade 3 recurrence and progression were associated with statistically significant HRQoL decrements (-0.08; 95% confidence interval [CI], -0.13 to -0.03; and -0.10; 95% CI, -0.17 to -0.03, respectively). The 3-year average cost per NMIBC patient was estimated at £8735 (95% CI, 8325-9145). Cases of grade 1, 2, and 3 recurrence were associated with annual cost effects of £1218 (95% CI, 403-2033), £1677 (95% CI, 920-2433), and £3957 (95% CI, 2332-5583), respectively. Progression to MIBC was associated with an average increase in costs of £5407 (95% CI, 2663-8152). CONCLUSION Evidence from the BOXIT trial suggests that patients with NMIBC will both experience decrements in HRQoL and incur significant costs, especially in the event of a grade 3 recurrence or a progression to MIBC.
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Affiliation(s)
- Edward Cox
- Centre for Health Economics, University of York, York, United Kingdom.
| | - Pedro Saramago
- Centre for Health Economics, University of York, York, United Kingdom
| | - John Kelly
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Urology, University College London Hospital, London, United Kingdom
| | - Nuria Porta
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Wei Shen Tan
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Urology, Imperial College Healthcare, London, United Kingdom
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, United Kingdom
| | - Marta Soares
- Centre for Health Economics, University of York, York, United Kingdom
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Koch GE, Luckenbaugh AN, Chang SS. High-Risk Nonmuscle Invasive Bladder Cancer: Selecting the Appropriate Patient for Timely Cystectomy. Urology 2020; 147:7-13. [PMID: 32445767 DOI: 10.1016/j.urology.2020.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/18/2020] [Accepted: 05/10/2020] [Indexed: 11/26/2022]
Abstract
The heterogenous nature of high-risk nonmuscle invasive bladder cancer encompasses a wide range of tumor biologies with varying recurrence and progression risks. Radical cystectomy provides excellent oncologic outcomes but is often underutilized. Timing for these patients is critical, however, to its effectiveness. Certain unfavorable tumor characteristics predict worse outcomes and may help select the most appropriate patients for more aggressive initial therapy. This manuscript aims to outline factors that predict worse outcomes in high-risk nonmuscle invasive bladder cancer and proposes which patients may benefit most from a timely radical cystectomy.
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Affiliation(s)
- George E Koch
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Amy N Luckenbaugh
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN.
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18
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[Cost-effectiveness analysis of blue light cystoscopy with hexylaminolevulinate in transurethral resection of the bladder]. Urologe A 2019; 58:34-40. [PMID: 29637215 DOI: 10.1007/s00120-018-0624-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Photodynamic diagnosis using the optical imaging agent hexaminolevulinate (HAL, Hexvix®, Ipsen Pharma GmbH, Ettlingen, Germany) as an adjunct to white light cystoscopy (WLC) during the initial transurethral resection of bladder tumours (TURB) improves the detection rate of bladder cancer and leads to fewer recurrences. OBJECTIVES A cost-effectiveness analysis was carried out in order to calculate the consequences for the German healthcare system. METHODS We combined a short-term decision tree and a Markov model to evaluate outcomes over a long period of time. The alternatives investigated were HAL-assisted blue light cystoscopy (BLC) as adjunct to WLC (HAL + BLC/WLC) compared with WLC alone in patients undergoing TURB. RESULTS HAL + BLC/WLC compared to WLC alone was associated with 0.07 incremental quality-adjusted life years (QALYs) and cost savings of 537 € per patient. CONCLUSION HAL + BLC/WLC compared with WLC alone resulted in both cost savings and improved patient outcome rendering it the "dominant" strategy.
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19
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Froehner M, Koch R, Heberling U, Hübler M, Novotny V, Borkowetz A, Wirth MP, Thomas C. Which comorbidity classification is best suited to identify patients at risk for 90-day and long-term non-bladder cancer mortality after radical cystectomy? World J Urol 2019; 38:695-702. [PMID: 31267181 DOI: 10.1007/s00345-019-02860-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/24/2019] [Indexed: 12/19/2022] Open
Abstract
PURPOSE There is no consensus on the best comorbidity measure in candidates for radical cystectomy. The aim of this study was to identify tool best suited to identify patients at risk for 90-day or premature long-term non-bladder cancer mortality. METHODS We studied 1268 patients who underwent radical cystectomy to identify patients at risk for 90-day and later-than-90-day mortality, respectively. Six classifications were investigated as possible predictors of both types of mortality. Multivariable models including age as continuous variable and each classification separately were calculated. A heuristic ranking was based on the evaluation of the hazard ratios, p values, Akaike's information criteria, and concerning the logit models also the areas under the curve. RESULTS The median follow-up was 5.7 years. Within 90 days after surgery, the mortality rate was 4.2%. The greatest independent contribution concerning the prediction of 90-day mortality was seen with the American Society of Anesthesiologists (ASA) physical status classification (classes 3-4 versus 1-2: hazard ratio 7.98, 95% confidence interval 3.54-18.01, p < 0.0001). In the longer term, countable diseases (Canadian Cardiovascular Society classification of angina pectoris, conditions contributing the Charlson score) were of greater importance. The results of heuristic ranking were confirmed by multivariate analyses including age and all classifications together. CONCLUSIONS Besides to chronological age, clinicians should pay particular attention to the ASA classification to identify patients at risk for 90-day mortality after radical cystectomy, whereas long-term mortality is more determined by countable comorbid diseases.
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Affiliation(s)
- Michael Froehner
- Department of Urology, Zeisigwaldkliniken Bethanien Chemnitz, Zeisigwaldstrasse 101, 09130, Chemnitz, Germany.
- Department of Urology, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Rainer Koch
- Department of Medical Statistics and Biometry, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ulrike Heberling
- Department of Urology, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Matthias Hübler
- Department of Anesthesiology, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Vladimir Novotny
- Department of Urology, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- Department of Urology, Städtisches Klinikum Görlitz, Girbigsdorfer Strasse 1-3, 02828, Görlitz, Germany
| | - Angelika Borkowetz
- Department of Urology, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Manfred P Wirth
- Department of Urology, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Christian Thomas
- Department of Urology, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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The Role and Importance of Timely Radical Cystectomy for High-Risk Non-muscle-Invasive Bladder Cancer. Cancer Treat Res 2019; 175:193-214. [PMID: 30168123 DOI: 10.1007/978-3-319-93339-9_9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Non-muscle-invasive bladder cancer accounts for the majority of incident bladder cancers but is a heterogeneous disease with variation in clinical presentation, course, and outcomes. Risk stratification techniques have attempted to identify those at highest risk of cancer recurrence and progression to help personalize and individualize treatment options. Radical cystectomy during the optimal window of curability could improve cancer outcomes; however, identifying the disease and patient characteristics as well as the correct timing to intervene remains difficult. We review the natural history of non-muscle-invasive bladder cancer, discuss different risk-stratification techniques and how they can help identify those most likely to benefit from radical treatment, and examine the evidence supporting the benefit of timely cystectomy.
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Criss SD, Weaver DT, Sheehan DF, Lee RJ, Pandharipande PV, Kong CY. Effect of PD-L1 testing on the cost-effectiveness and budget impact of pembrolizumab for advanced urothelial carcinoma of the bladder in the United States. Urol Oncol 2019; 37:180.e11-180.e18. [DOI: 10.1016/j.urolonc.2018.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/14/2018] [Accepted: 11/19/2018] [Indexed: 01/07/2023]
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Racioppi M, Di Gianfrancesco L, Ragonese M, Palermo G, Sacco E, Bassi PF. ElectroMotive drug administration (EMDA) of Mitomycin C as first-line salvage therapy in high risk "BCG failure" non muscle invasive bladder cancer: 3 years follow-up outcomes. BMC Cancer 2018; 18:1224. [PMID: 30522445 PMCID: PMC6282335 DOI: 10.1186/s12885-018-5134-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 11/26/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In case of high grade non-muscle invasive bladder cancer (HG-NMIBC), intravesical BCG represents the first-line treatment; despite the "gold" standard therapy, up to 50% of patients relapse, needing radical cystectomy. Hence, alternative therapeutic strategies have been developed. The aim of the study was to evaluate a first-line salvage treatment with EMDA®-MMC in patients with HGNMIBC unresponsive to BCG. METHODS We carried out a prospective, single-center, single-arm Phase II study in order to evaluate the efficacy (in terms of recurrence and progression) and the safety of the EMDA®-MMC treatment in 26 (21 male, 5 female) consecutive patients with "BCG refractory" HGNMIBC on a 3 years follow-up. EMDA®-MMC treatment consisted of 40 mg of MMC diluted in 100 ml of sterile water retained in the bladder for 30 min with 20 mA pulsed electric current. EMDA®-MMC regimen consisted of an induction course of 6 weekly instillations followed by a maintenance course of 6 monthly instillations. Follow-up was performed with systematic mapping biopsies of the bladder (with sampling in the prostatic urethra for men), voiding and washing urinary cytology, radiological study of the upper urinary tract. We performed Survival Kaplan-Meier curves and Log-rank test in order to analyze high grade disease-free survival. RESULTS At the end of follow-up, 16 patients (61.5%) preserved their native bladder; 10 patients (38.4%) underwent radical cystectomy, in 6 patients (23.1%) for recurrent HGNMIBC and in 4 patients (15.4%) for progression to muscle-invasive disease. At the end of follow-up, stratifying patients based on TNM classification (TaG3, T1G3, Cis, TaT1G3 + Cis), disease-free rates were 75, 71.4, 50 and 25%, respectively; survival curves showed statistically significant differences (p value < 0.05). Regarding toxicity, we reported severe adverse systemic event of hypersensitivity to the MMC in 3 patients (11.5%), and local side effects in 6 patients (26.1%). CONCLUSIONS In the field of alternative strategies to radical cystectomy, the EMDA®-MMC could be considered safe and effective in high-risk NMIBC unresponsive to BCG, as a "bladder sparing" therapy in selected patients. Multicenter studies with a larger number of patients and a longer follow-up might confirm our preliminary results. TRIAL REGISTRATION EudraCT2017-002585-43. 17 June 2017 (retrospectively registered).
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Affiliation(s)
- Marco Racioppi
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Luca Di Gianfrancesco
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Mauro Ragonese
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Giuseppe Palermo
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Emilio Sacco
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Pier Francesco Bassi
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
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Mossanen M, Wang Y, Szymaniak J, Tan WS, Huynh MJ, Preston MA, Trinh QD, Sonpavde G, Kibel AS, Chang SL. Evaluating the cost of surveillance for non-muscle-invasive bladder cancer: an analysis based on risk categories. World J Urol 2018; 37:2059-2065. [PMID: 30446799 DOI: 10.1007/s00345-018-2550-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 10/29/2018] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Non-muscle-invasive bladder cancer (NMIBC) is a biologically heterogeneous disease and is one of the most expensive malignancies to treat on a per patient basis. In part, this high cost is attributed to the need for long-term surveillance. We sought to perform an economic analysis of surveillance strategies to elucidate cumulative costs for the management of NMIBC. METHODS A Markov model was constructed to determine the average 5-year costs for the surveillance of patients with NMIBC. Patients were stratified into low, intermediate, and high-risk groups based on the EORTC risk calculator to determine recurrence and progression rates according to each category. The index patient was a compliant 65-year-old male. A total of four health states were utilized in the Markov model: no evidence of disease, recurrence, progression and cystectomy, and death. RESULTS Cumulative costs of care over a 5-year period were $52,125 for low-risk, $146,250 for intermediate-risk, and $366,143 for high-risk NMIBC. The primary driver of cost was progression to muscle-invasive disease requiring definitive therapy, contributing to 81% and 92% of overall cost for intermediate- and high-risk disease. Although low-risk tumors have a high likelihood of 5-year recurrence, the overall cost contribution of recurrence was 8%, whereas disease progression accounted for 71%. CONCLUSION Although protracted surveillance cystoscopy contributes to the expenditures associated with NMIBC, progression increases the overall cost of care across all three patient risk groups and most notably for intermediate- and high-risk disease patients.
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Affiliation(s)
- Matthew Mossanen
- Division of Urology, Harvard Medical School, Brigham and Women's Hospital, 45 Francis Street, Boston, MA, 02115, USA. .,Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Ye Wang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Julie Szymaniak
- Division of Urology, Harvard Medical School, Brigham and Women's Hospital, 45 Francis Street, Boston, MA, 02115, USA
| | - Wei Shen Tan
- University College of London, London, England, UK
| | - Melissa J Huynh
- Division of Urology, Harvard Medical School, Brigham and Women's Hospital, 45 Francis Street, Boston, MA, 02115, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mark A Preston
- Division of Urology, Harvard Medical School, Brigham and Women's Hospital, 45 Francis Street, Boston, MA, 02115, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Quoc-Dien Trinh
- Division of Urology, Harvard Medical School, Brigham and Women's Hospital, 45 Francis Street, Boston, MA, 02115, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Adam S Kibel
- Division of Urology, Harvard Medical School, Brigham and Women's Hospital, 45 Francis Street, Boston, MA, 02115, USA.,Dana-Farber Cancer Institute, Boston, MA, USA
| | - Steven L Chang
- Division of Urology, Harvard Medical School, Brigham and Women's Hospital, 45 Francis Street, Boston, MA, 02115, USA.,Dana-Farber Cancer Institute, Boston, MA, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
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Wang Z, Xiao H, Wei G, Zhang N, Wei M, Chen Z, Peng Z, Peng S, Qiu S, Li H, Long J. Low-dose Bacillus Calmette-Guerin versus full-dose for intermediate and high-risk of non-muscle invasive bladder cancer: a Markov model. BMC Cancer 2018; 18:1108. [PMID: 30419836 PMCID: PMC6233591 DOI: 10.1186/s12885-018-4988-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 10/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the efficacy of low dose (27 mg) Bacillus Calmette-Guérin (BCG) and a full dose (81 mg) BCG immunotherapy for patients with intermediate and high-risk non-muscle invasive bladder cancer (NMIBC) after a typical transurethral bladder resection. METHODS We constructed a Markov model for a 20-year simulation of the disease to compare the overall survival of patients with intermediate and high-risk of NMIBC between the full-dose therapy (FD group) and the low-dose therapy (LD group). Base case analysis, one-way and two-way sensitivity analysis and a second-order Monte Carlo analysis were performed based on data from 15 published articles. RESULTS The expected overall survivals were 9.56 (9.55-9.57) years for FD group and 9.63 (9.61-9.64) years for LD group(P < 0.001). The estimated mortality in the FD group at 5, 10, and 20 years were 34.23%, 57.51% and 83.14%, respectively. The corresponding values in the LD group were 34.11%, 57.17%, 82.16%, respectively. Age-specific mortality and metastatic rate after undergoing radical cystectomy (RC) were the most two sensitive parameters in both groups. The rate of disease recurrence with disease worsening is the determining factor when choosing the optimal dose of BCG treatment. CONCLUSIONS A low-dose BCG treatment may act slightly better than a full-dose BCG treatment for patients with intermediate and high-risk of NMIBC. This finding will require further high-quality studies to validate.
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Affiliation(s)
- Zongren Wang
- Department of Urology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Han Xiao
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Guangyan Wei
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ning Zhang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Mengchao Wei
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zebin Chen
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhenwei Peng
- Department of Clinical Trials Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
- Department of Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Sui Peng
- Department of Clinical Trials Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Shaopeng Qiu
- Department of Urology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Heping Li
- Department of Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Jianting Long
- Department of Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
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Klaassen Z, Kamat AM, Kassouf W, Gontero P, Villavicencio H, Bellmunt J, van Rhijn BW, Hartmann A, Catto JW, Kulkarni GS. Treatment Strategy for Newly Diagnosed T1 High-grade Bladder Urothelial Carcinoma: New Insights and Updated Recommendations. Eur Urol 2018; 74:597-608. [DOI: 10.1016/j.eururo.2018.06.024] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/20/2018] [Indexed: 10/28/2022]
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26
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Shen PL, lin ME, Hong YK, He XJ. Bladder preservation approach versus radical cystectomy for high-grade non-muscle-invasive bladder cancer: a meta-analysis of cohort studies. World J Surg Oncol 2018; 16:197. [PMID: 30285788 PMCID: PMC6169022 DOI: 10.1186/s12957-018-1497-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 09/20/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND High-grade non-muscle-invasive bladder cancer is superficial; nonetheless, it is an aggressive cancer. Proper management strategy selection following transurethral resection between bladder preservation (BP) and radical cystectomy (RC) could result in delayed or excessive treatment. Hence, selecting the optimal treatment modality remains controversial to date. METHODS We searched MEDLINE, The Cochrane Library, EMBASE, China National Knowledge Infrastructure, and Wanfang database through 12 April 2018. Quality and publication bias were assessed using the Newcastle-Ottawa Scale and Begg's/Egger's test. We collected 2-year, 5-year, 10-year, and 15-year survival rate and hazard ratio (HR) for overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS). Using the Review Manager 5.2 software, we used the odds ratio (OR) of specific years and HR for meta-analysis. Subgroup analysis was performed by the original tumor state, radical cystectomy timing, bladder preservation modality, and age. RESULTS In total, 11 cohorts with 1735 patients were selected for the meta-analysis. All OR of OS supported BP as a better treatment option; however, all OR of PFS had no significant differences. As for CSS, only the 15-year OR reflected a statistical significance preferring RC. Subgroup analysis showed that BP is more appropriate for patients older than 65 and G3 tumor. Limited data demonstrated that late RC (> 3 months) is more effective compared to early RC (< 3 months) and intravesical Bacillus Calmette-Guerin was not statistically different from that of RC. The mixed BP modalities were significantly better compared to RC in OS and worse in CSS, with both having a very low evidence strength. CONCLUSIONS BP is a superior treatment modality compare to RC, especially for older patients and T1G3 or lower grade tumors. However, the superior BP modality was unclear. Conversely, RC could be a better option for younger patients. More specifically, late RC may be more beneficial but had a very-low-level of evidence. Quality of life should be considered equal to survival outcome; hence, post-treatment follow-up needs to be performed. Prospective randomized studies should be performed to overcome the limitations of this meta-analysis study. REGISTRATION Registration ID is CRD42018093491 .
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Affiliation(s)
- Pei-lin Shen
- Department of Urology, The First Affiliated Hospital of Shantou University Medical College, No. 57, Changping Road, Jinping District, Shantou, Guangdong China
- Shantou University Medical College, No. 22, Xinling Road, Jinping District, Shantou, Guangdong China
| | - Ming-en lin
- Department of Urology, The First Affiliated Hospital of Shantou University Medical College, No. 57, Changping Road, Jinping District, Shantou, Guangdong China
| | - Ying-kai Hong
- Department of Urology, The First Affiliated Hospital of Shantou University Medical College, No. 57, Changping Road, Jinping District, Shantou, Guangdong China
| | - Xue-jun He
- Department of Urology, The First Affiliated Hospital of Shantou University Medical College, No. 57, Changping Road, Jinping District, Shantou, Guangdong China
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Huang B, Zheng J, Yao Z, Fan W, Qiu S, Chen L, Chen J. Efficacy of intra-arterial chemotherapy combined with intravesical chemotherapy in T1G3 bladder cancer when compared with intravesical chemotherapy alone after bladder-sparing surgery: a retrospective study. World J Urol 2018; 37:823-829. [PMID: 30191393 DOI: 10.1007/s00345-018-2437-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE To assess the efficacy of intra-arterial chemotherapy (IAC) combined with intravesical chemotherapy (IVC) in T1G3 bladder cancer (Bca) after transurethral resection of bladder tumor (TURBT). METHODS Our study retrospectively reviewed 200 patients with T1G3 BCa who had all undergone TURBT. The patients' medical records were divided into two groups, one group only had IVC with pirarubicin after surgery, and the other group had IAC (cisplatin and epirubicin) combined with IVC after surgery. The patients were monitored regularly by urine cytology and cystoscopy. Survival and recurrence curves were calculated using the Kaplan-Meier method. Tumor recurrence, progression and tumor-specific death rate were compared with Chi-square test. A multivariate analysis was carried out to find out potential confounders. RESULTS A total of 200 medical record was analyzed, 131 patients received IVC, 69 IAC + IVC treatment, tumor-specific death rate between the combined IAC and IVC compared to IVC alone was 7.25 and 17.6%, respectively (p < 0.05); the tumor recurrence rate between the two groups was 31.8% (22/69) and 44.3%, respectively (58/131) (p < 0.05), and tumor recurred later in the IAC + IVC group (p < 0.05), tumor progression rate was 18.8% (13/69) and 28.2% (37/131), respectively, with p < 0.05. Overall survival was longer in IAC + IVC group (p < 0.05). Using the multivariable regression model, IAC was significantly related to disease recurrence (p < 0.05) and overall survival (p < 0.05). CONCLUSION T1G3 BCa post-TURBT surgery patients who underwent IAC combined with IVC had a longer overall survival and increased time interval to first recurrence, lower tumor recurrence rate, progression rate and tumor-specific death rate than compared with those who only underwent IVC alone.
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Affiliation(s)
- Bin Huang
- Department of Urology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhong Shan 2nd Road, Guangzhou, 510080, China
| | - Jiabo Zheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Zhijun Yao
- Department of Urology, The Central Hospital of Hengyang, Hengyang, 421001, China
| | - Wenzhe Fan
- Department of Interventional Oncology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
| | - Shaopeng Qiu
- Department of Urology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhong Shan 2nd Road, Guangzhou, 510080, China
| | - Lingwu Chen
- Department of Urology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhong Shan 2nd Road, Guangzhou, 510080, China.
| | - Junxing Chen
- Department of Urology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhong Shan 2nd Road, Guangzhou, 510080, China.
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Sutton AJ, Lamont JV, Evans RM, Williamson K, O’Rourke D, Duggan B, Sagoo GS, Reid CN, Ruddock MW. An early analysis of the cost-effectiveness of a diagnostic classifier for risk stratification of haematuria patients (DCRSHP) compared to flexible cystoscopy in the diagnosis of bladder cancer. PLoS One 2018; 13:e0202796. [PMID: 30138462 PMCID: PMC6107278 DOI: 10.1371/journal.pone.0202796] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 08/09/2018] [Indexed: 12/20/2022] Open
Abstract
Background Urothelial bladder cancer (UBC) is the 5th most common cancer in Western societies. The most common symptom of UBC is haematuria. Cystoscopy the gold standard for UBC detection, allows direct observation of the bladder, but is expensive, invasive, and uncomfortable. This study examines whether an alternative new urine-based diagnostic test, the DCRSHP, is cost-effective as a triage diagnostic tool compared to flexible cystoscopy in the diagnosis of UBC in haematuria patients. Methods A model-based cost-utility analysis using cost per quality adjusted life year and life year gained, parameterised with secondary data sources. Results If the DCRSHP is targeted at haematuria patients at lower risk of having bladder cancer e.g. younger patients, non-smokers, then it can be priced as high as £620, and be both effective and cost-effective. Sensitivity analysis found that DCRSHP is approximately 80% likely to be cost-effective across all willingness to pay values (for a QALY) and prevalence estimates. Conclusion This analysis shows the potential for a non-invasive test to be added to the diagnostic pathway for haematuria patients suspected of having UBC. If the DCRSHP is applied targeting haematuria patients at low risk of UBC, then it has the potential to be both effective and cost-effective.
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Affiliation(s)
- Andrew J. Sutton
- Test Evaluation Group, Institute of Health Sciences, University of Leeds, NIHR Diagnostic Evidence Cooperative Leeds, Leeds, United Kingdom
- * E-mail:
| | - John V. Lamont
- Randox Laboratories Ltd, Molecular Biology, Crumlin, County Antrim, Northern Ireland
| | - R. Mark Evans
- Department of Urology, Belfast City Hospital, Belfast, Northern Ireland
| | - Kate Williamson
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland
| | - Declan O’Rourke
- Department of Pathology, Belfast City Hospital, Belfast, Northern Ireland
| | - Brian Duggan
- Ulster Hospital Dundonald, South Eastern Trust, Belfast, Northern Ireland
| | - Gurdeep S. Sagoo
- Test Evaluation Group, Institute of Health Sciences, University of Leeds, NIHR Diagnostic Evidence Cooperative Leeds, Leeds, United Kingdom
| | - Cherith N. Reid
- Randox Laboratories Ltd, Molecular Biology, Crumlin, County Antrim, Northern Ireland
| | - Mark W. Ruddock
- Randox Laboratories Ltd, Molecular Biology, Crumlin, County Antrim, Northern Ireland
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Schroeck FR, Smith N, Shelton JB. Implementing risk-aligned bladder cancer surveillance care. Urol Oncol 2018; 36:257-264. [PMID: 29395957 DOI: 10.1016/j.urolonc.2017.12.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/04/2017] [Accepted: 12/24/2017] [Indexed: 11/18/2022]
Abstract
Implementation science is a rapidly developing field dedicated to the scientific investigation of strategies to facilitate improvements in healthcare delivery. These strategies have been shown in several settings to lead to more complete and sustained change. In this essay, we discuss how refined surveillance recommendations for non-muscle-invasive bladder cancer, which involve a complex interplay between providers, healthcare facilities, and patients, could benefit from use of implementation strategies derived from the growing literature of implementation science. These surveillance recommendations are based on international consensus and indicate that the frequency of surveillance cystoscopy should be aligned with each patient's risk for recurrence and progression of disease. Risk-aligned surveillance entails cystoscopy at 3 and 12 months followed by annual surveillance for low-risk cancers, with surveillance every 3 months reserved for high-risk cancers. However, risk-aligned care is not the norm. Implementing risk-aligned surveillance could curtail overuse among low-risk patients, while curbing underuse among high-risk patients. Despite clear direction from respected and readily available clinical guidelines, there are multiple challenges to implementing risk-aligned surveillance in a busy clinical setting. Here, we describe how implementation science methods can be systematically used to understand determinants of care and to develop strategies to improve care. We discuss how the tailored implementation for chronic diseases framework can facilitate systematic assessment and how intervention mapping can be used to develop implementation strategies to improve care. Taken together, these implementation science methods can help facilitate practice transformation to improve risk-aligned surveillance for bladder cancer.
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Affiliation(s)
- Florian R Schroeck
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH.
| | | | - Jeremy B Shelton
- Department of Urology, UCLA, Los Angeles, CA; Greater Los Angeles VA Medical Center, Los Angeles, CA
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Bhatt NR, Davis NF, Breen K, Flood HD, Giri SK. Life expectancy calculation in urology: Are we equitably treating older patients? Cent European J Urol 2018; 70:368-371. [PMID: 29410887 PMCID: PMC5791409 DOI: 10.5173/ceju.2017.1575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 10/05/2017] [Accepted: 10/07/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction The aim of our study was to determine the contemporary practice in the utilization of life expectancy (LE) calculations among urological clinicians. Material and methods Members of the Irish Society of Urology (ISU) and the British Association of Urological Surgeons (BAUS) completed a questionnaire on LE utilization in urological practice. Results The survey was delivered to 1251 clinicians and the response rate was 17% (n = 208/1251). The majority (61%, n = 127) of urologists were aware of methods available for estimated LE calculation.Seventy-one percent (n = 148) had never utilized LE analysis in clinical practice and 81% (n = 170) routinely used 'eyeballing' (empiric prediction) for estimating LE. Life expectancy tables were utilized infrequently (12%, n = 25) in making the decision for treatment in the setting of multi-disciplinary meetings. Conclusions LE is poorly integrated into treatment decision-making; not only for the management of urological patients but also in the multidisciplinary setting. Further education and awareness regarding the importance of LE is vital.
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Affiliation(s)
- Nikita R Bhatt
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - Niall F Davis
- Department of Urology, Tallaght Hospital, Tallaght, Dublin, Ireland
| | - Kieran Breen
- Department of Urology, Limerick Regional Hopsital, Limerick, Ireland
| | - Hugh D Flood
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - Subhasis K Giri
- Department of Urology, University Hospital Limerick, Limerick, Ireland
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Parker WP, Smelser W, Lee EK, Habermann EB, Thapa P, Zaid HB, Frank I, Griebling TL, Tollefson MK, Thompson RH, Holzbeierlein JM, Karnes RJ, Boorjian SA. Utilization and Outcomes of Radical Cystectomy for High-grade Non-muscle-invasive Bladder Cancer in Elderly Patients. Clin Genitourin Cancer 2017; 16:S1558-7673(17)30208-2. [PMID: 28844793 DOI: 10.1016/j.clgc.2017.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 06/27/2017] [Accepted: 07/18/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Radical cystectomy (RC) represents a treatment option for patients with high-grade non-muscle-invasive bladder cancer (HG-NMIBC); however, perioperative morbidity is not insignificant, particularly in elderly patients. We sought to evaluate the associations of age with utilization and outcomes of RC for HG-NMIBC. PATIENTS AND METHODS Patients with HG-NMIBC diagnosed between 2004 and 2013 were identified in the National Cancer Database and stratified by age: ≤ 60, 61-70, 71-80, and > 80 years. Association between age and treatment with RC was assessed by multivariable logistic regression. Associations between age and overall survival were assessed using the Kaplan-Meier method. A multi-institutional analysis was performed to evaluate the associations of age with perioperative outcomes and survival among patients managed with RC for HG-NMIBC. RESULTS On multivariable analysis, age was associated with RC utilization, with the lowest usage in patients > 80 years (2.1%; P < .01). Upstaging at RC occurred in 40% of patients with HG-NMIBC, and no association of age with upstaging risk was noted. Significantly inferior overall survival was observed in the patients who were upstaged across age strata (all P < .01). In the multi-institutional cohort, age was not associated with risks of upstaging, receipt of transfusion, 30-/90-day complications, or recurrence-free or cancer-specific survival (all P > .05), whereas upstaging was associated with inferior recurrence-free and cancer-specific survival regardless of age. CONCLUSION RC for HG-NMIBC is used less frequently in older adults, despite similar risks of pathologic upstaging. As upstaging is associated with inferior survival regardless of age, these data suggest that elderly patients with HG-NMIBC may be at risk for undertreatment.
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Affiliation(s)
- William P Parker
- Department of Urology, Mayo Clinic, Rochester, MN; Department of Urology, University of Kansas Medical Center, Kansas City, KS
| | - Woodson Smelser
- Department of Urology, University of Kansas Medical Center, Kansas City, KS
| | - Eugene K Lee
- Department of Urology, University of Kansas Medical Center, Kansas City, KS
| | | | - Prabin Thapa
- Department of Health Services Research, Mayo Clinic, Rochester, MN
| | | | - Igor Frank
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Tomas L Griebling
- Department of Urology, University of Kansas Medical Center, Kansas City, KS; The Landon Center on Aging, University of Kansas Medical Center, Kansas City, KS
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Yang GL, Zhang LH, Liu Q, Wang ZL, Duan XH, Huang YR, Bo JJ. A novel treatment strategy for newly diagnosed high-grade T1 bladder cancer: Gemcitabine and cisplatin adjuvant chemotherapy-A single-institution experience. Urol Oncol 2016; 35:38.e9-38.e15. [PMID: 28040419 DOI: 10.1016/j.urolonc.2016.08.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 08/10/2016] [Accepted: 08/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Management of high-grade T1 (formerly T1G3) bladder cancer continues to be controversial. Should patients with T1G3 bladder cancer have an immediate radical cystectomy or should they receive intravesical bacillus Calmette-Guérin-preserving bladder? Gemcitabine and cisplatin (GC) adjuvant chemotherapy may help to strike a balance between intravesical and early cystectomy. For purposes of this study, we continue to refer high-grade T1 lesion as "T1G3." OBJECTIVE To evaluate the characteristics and the long-term outcome of GC adjuvant chemotherapy in T1G3 bladder cancer after transurethral resection of bladder tumor (TURBT). MATERIALS AND METHODS We retrospectively reviewed 48 patients who were newly diagnosed with T1G3 bladder cancer between January 2009 and December 2012. A total of 48 patients received 4 cycles of GC adjuvant chemotherapy after TURBT. One month after 4 cycles of GC adjuvant chemotherapy, response was evaluated by re-TURBT. Median follow-up was 59.5 (range: 18-70) months, all patients have been observed for more than 3 years. Salvage cystectomy was recommended for patients with persistent disease and for tumor progression after initial complete response. RESULT Complete response was achieved in 44 (91.7%) patients. Of complete responders, 5 patients experienced recurrence and 5 patients showed progression. The progression rate and disease-specific survival rate were 10.4% and 91.7% at 3 years, respectively. More than 80% of survivors preserved their bladder. Kaplan-Meier curves showed that concomitant carcinoma in situ (CIS) was the only factor that had an influence on progression-free survival (P = 0.022) and disease-specific survival (P = 0.017). Concomitant CIS was the prognostic factor for progression rate and disease-specific survival rate at 3 years (P = 0.008 and P = 0.035). CONCLUSION GC adjuvant chemotherapy is a safe conservative treatment for T1G3 bladder cancer, but effective is really a phase II study. Patients with T1G3 bladder cancer with concomitant CIS should be treated more aggressively because of the high risk of progression.
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Affiliation(s)
- Guo-Liang Yang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lian-Hua Zhang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Liu
- Department of Pathology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhao-Liang Wang
- Department of Pathology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xue-Hui Duan
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi-Ran Huang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Juan-Jie Bo
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Kassouf W, Aprikian A, Black P, Kulkarni G, Izawa J, Eapen L, Fairey A, So A, North S, Rendon R, Sridhar SS, Alam T, Brimo F, Blais N, Booth C, Chin J, Chung P, Drachenberg D, Fradet Y, Jewett M, Moore R, Morash C, Shayegan B, Gotto G, Fleshner N, Saad F, Siemens DR. Recommendations for the improvement of bladder cancer quality of care in Canada: A consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015. Can Urol Assoc J 2016; 10:E46-80. [PMID: 26977213 DOI: 10.5489/cuaj.3583] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This initiative was undertaken in response to concerns regarding the variation in management and in outcomes of patients with bladder cancer throughout centres and geographical areas in Canada. Population-based data have also revealed that real-life survival is lower than expected based on data from clinical trials and/or academic centres. To address these perceived shortcomings and attempt to streamline and unify treatment approaches to bladder cancer in Canada, a multidisciplinary panel of expert clinicians was convened last fall for a two-day working group consensus meeting. The panelists included urologic oncologists, medical oncologists, radiation oncologists, patient representatives, a genitourinary pathologist, and an enterostomal therapy nurse. The following recommendations and summaries of supporting evidence represent the results of the presentations, debates, and discussions. Methodology
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Affiliation(s)
- Wassim Kassouf
- Department of urology, McGill University Health Centre, Montreal, QC, Canada
| | - Armen Aprikian
- Department of urology, McGill University Health Centre, Montreal, QC, Canada
| | - Peter Black
- Department of urology, University of British Columbia, Vancouver, BC, Canada
| | - Girish Kulkarni
- Department of surgery (urology) and surgical oncology, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jonathan Izawa
- Division of urology, Western University, London, ON, Canada
| | - Libni Eapen
- Division of radiation oncology, University of Ottawa, Ottawa, ON, Canada
| | - Adrian Fairey
- Division of urology, University of Alberta, Edmonton, AB, Canada
| | - Alan So
- Department of urology, University of British Columbia, Vancouver, BC, Canada
| | - Scott North
- Medical oncology, University of Alberta, Edmonton, AB, Canada
| | - Ricardo Rendon
- Division of urology, Dalhousie University, Halifax, NS, Canada
| | - Srikala S Sridhar
- Medical oncology, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tarik Alam
- School of nursing, Dawson College, Montreal, QC, Canada
| | - Fadi Brimo
- Pathology, McGill University Health Centre, Montreal, QC, Canada
| | - Normand Blais
- Division of medical oncology, University of Montreal, Montreal, QC, Canada
| | - Chris Booth
- Departments of oncology, Queen's University, Kingston, ON, Canada
| | - Joseph Chin
- Division of urology, Western University, London, ON, Canada
| | - Peter Chung
- Radiation oncology, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada
| | | | - Yves Fradet
- Division of urology, Laval University, Quebec City, QC, Canada
| | - Michael Jewett
- Department of surgery (urology) and surgical oncology, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ron Moore
- Division of urology, University of Alberta, Edmonton, AB, Canada
| | - Chris Morash
- Urology, University of Ottawa, Ottawa, ON, Canada
| | - Bobby Shayegan
- Division of urology, McMaster University, Hamilton, ON, Canada
| | - Geoffrey Gotto
- Division of urology, University of Calgary, Calgary, AB, Canada
| | - Neil Fleshner
- Department of surgery (urology) and surgical oncology, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada
| | - Fred Saad
- Urology, University of Montreal, Montreal, QC, Canada
| | - D Robert Siemens
- Departments of oncology, Queen's University, Kingston, ON, Canada;; Urology, Queen's University, Kingston, ON, Canada
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Zhang Y, Xie L, Chen T, Xie W, Wu Z, Xu H, Xing C, Sha N, Shen Z, Qie Y, Liu X, Hu H, Wu C. Intravenous chemotherapy combined with intravesical chemotherapy to treat T1G3 bladder urothelial carcinoma after transurethral resection of bladder tumor: results of a retrospective study. Onco Targets Ther 2016; 9:605-11. [PMID: 26869805 PMCID: PMC4734785 DOI: 10.2147/ott.s99866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective The management of stage 1 and grade 3 (T1G3) bladder cancer continues to be controversial. Although the transurethral resection of bladder tumor (TURBT) followed by intravesical chemotherapy is a conservative strategy for treatment of T1G3 bladder cancer, a relatively high risk of tumor recurrence and progression remains regarding the therapy. This study aimed to compare the efficacy of intravenous chemotherapy combined with intravesical chemotherapy versus intravesical chemotherapy alone for T1G3 bladder cancer after TURBT surgery. Methods We retrospectively reviewed the cases of 457 patients who were newly diagnosed with T1G3 bladder urothelial carcinoma between January 2009 and March 2014. After TURBT, 281 patients received intravesical chemotherapy alone, whereas 176 patients underwent intravesical chemotherapy in combination with intravenous chemotherapy. Tumor recurrence and progression were monitored periodically by urine cytology and cystoscopy in follow-up. Recurrence-free survival and progression-free survival of the two chemotherapy strategies following TURBT were analyzed. Univariable and multivariable Cox hazards analyses were performed to predict the prognostic factors for tumor recurrence and progression. Results The tumor recurrence rate was 36.7% for patients who received intravesical chemotherapy alone after TURBT, compared with 19.9% for patients who received intravenous chemotherapy combined with intravesical chemotherapy after TURBT (P<0.001). The progression rate was 10.6% for patients who underwent intravesical chemotherapy alone and 2.3% for patients who underwent the combined chemotherapies (P=0.003). Kaplan–Meier curves showed significant differences in recurrence-free survival and progression-free survival between the two treatment strategies, with a log-rank P-value of <0.001 and 0.003, respectively. Multivariable analyses revealed that intravenous chemotherapy was the independent prognostic factor for tumor recurrence and progression in the cohort. Conclusion Intravenous chemotherapy combined with intravesical chemotherapy offers a better oncologic outcome than the intravesical chemotherapy alone for patients with T1G3 bladder urothelial carcinoma after TURBT, and it may be considered as a new therapy strategy for T1G3 bladder cancer.
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Affiliation(s)
- Yu Zhang
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Linguo Xie
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Tao Chen
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Wanqin Xie
- Key Laboratory of Genetics and Birth Health of Hunan Province, The Family Planning Research Institute of Hunan Province, Changsha, People's Republic of China
| | - Zhouliang Wu
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Hao Xu
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Chen Xing
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Nan Sha
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Zhonghua Shen
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Yunkai Qie
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Xiaoteng Liu
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Hailong Hu
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
| | - Changli Wu
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin, People's Republic of China
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Rouprêt M, Malavaud B, Molinier L, Leleu H, Blachier M, Marteau F. Coût–efficacité de la résection transurétrale de vessie en lumière bleue chez les patients atteints d’un cancer de la vessie non infiltrant en France. Prog Urol 2015; 25:256-64. [DOI: 10.1016/j.purol.2015.01.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 01/03/2015] [Accepted: 01/03/2015] [Indexed: 02/01/2023]
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Al Hussein Al Awamlh B, Lee R, Chughtai B, Donat SM, Sandhu JS, Herr HW. A Cost-effectiveness Analysis of Management of Low-risk Non–muscle-invasive Bladder Cancer Using Office-based Fulguration. Urology 2015; 85:381-6. [DOI: 10.1016/j.urology.2014.09.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 08/06/2014] [Accepted: 09/02/2014] [Indexed: 11/26/2022]
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Cost-effectiveness of neoadjuvant chemotherapy before radical cystectomy for muscle-invasive bladder cancer. Urol Oncol 2014; 32:1172-7. [DOI: 10.1016/j.urolonc.2014.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 04/30/2014] [Accepted: 05/03/2014] [Indexed: 11/21/2022]
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Yeung C, Dinh T, Lee J. The health economics of bladder cancer: an updated review of the published literature. PHARMACOECONOMICS 2014; 32:1093-104. [PMID: 25056838 DOI: 10.1007/s40273-014-0194-2] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The purpose of this paper is to provide a current view of the economic burden of bladder cancer, with a focus on the cost effectiveness of available interventions. This review updates a previous systematic review and includes 72 new papers published between 2000 and 2013. Bladder cancer continues to be one of the most common and expensive malignancies. The annual cost of bladder cancer in the USA during 2010 was $US4 billion and is expected to rise to $US5 billion by 2020. Ten years ago, urinary markers held the potential to lower treatment costs of bladder cancer. However, subsequent real-world experiments have demonstrated that further work is necessary to identify situations in which these technologies can be applied in a cost-effective manner. Adjunct cytology remains a part of diagnostic standard of care, but recent research suggests that it is not cost effective due to its low diagnostic yield. Analysis of intravesical chemotherapy after transurethral resection of bladder tumor (TURBT), neo-adjuvant therapy for cystectomy, and robot-assisted laparoscopic cystectomy suggests that these technologies are cost effective and should be implemented more widely for appropriate patients. The existing literature on the cost effectiveness of bladder cancer treatments has improved substantially since 2000. The body of work now includes many new models, registry analyses, and real-world studies. However, there is still a need for new implementation guidelines, new risk modeling tools, and a better understanding of the empirical burden of bladder cancer.
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Defining optimum treatment of patients with pancreatic adenocarcinoma using regret-based decision curve analysis. Ann Surg 2014; 259:1208-14. [PMID: 24169177 DOI: 10.1097/sla.0000000000000310] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To use regret decision theory methodology to assess three treatment strategies in pancreatic adenocarcinoma. BACKGROUND Pancreatic adenocarcinoma is uniformly fatal without operative intervention. Resection can prolong survival in some patients; however, it is associated with significant morbidity and mortality. Regret theory serves as a novel framework linking both rationality and intuition to determine the optimal course for physicians facing difficult decisions related to treatment. METHODS We used the Cox proportional hazards model to predict survival of patients with pancreatic adenocarcinoma and generated a decision model using regret-based decision curve analysis, which integrates both the patient's prognosis and the physician's preferences expressed in terms of regret associated with a certain action. A physician's treatment preferences are indicated by a threshold probability, which is the probability of death/survival at which the physician is uncertain whether or not to perform surgery. The analysis modeled 3 possible choices: perform surgery on all patients; never perform surgery; and act according to the prediction model. RESULTS The records of 156 consecutive patients with pancreatic adenocarcinoma were retrospectively evaluated by a single surgeon at a tertiary referral center. Significant independent predictors of overall survival included preoperative stage [P = 0.005; 95% confidence interval (CI), 1.19-2.27], vitality (P < 0.001; 95% CI, 0.96-0.98), daily physical function (P < 0.001; 95% CI, 0.97-0.99), and pathological stage (P < 0.001; 95% CI, 3.06-16.05). Compared with the "always aggressive" or "always passive" surgical treatment strategies, the survival model was associated with the least amount of regret for a wide range of threshold probabilities. CONCLUSIONS Regret-based decision curve analysis provides a novel perspective for making treatment-related decisions by incorporating the decision maker's preferences expressed as his or her estimates of benefits and harms associated with the treatment considered.
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Bachir BG, Dragomir A, Aprikian AG, Tanguay S, Fairey A, Kulkarni GS, Breau RH, Black PC, Kassouf W. Contemporary cost-effectiveness analysis comparing sequential bacillus Calmette-Guerin and electromotive mitomycin versus bacillus Calmette-Guerin alone for patients with high-risk non-muscle-invasive bladder cancer. Cancer 2014; 120:2424-31. [DOI: 10.1002/cncr.28731] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/09/2014] [Accepted: 03/12/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Bassel G. Bachir
- Division of Urology, Department of Surgery; McGill University Health Center; Montreal Quebec Canada
| | - Alice Dragomir
- Division of Urology, Department of Surgery; McGill University Health Center; Montreal Quebec Canada
| | - Armen G. Aprikian
- Division of Urology, Department of Surgery; McGill University Health Center; Montreal Quebec Canada
| | - Simon Tanguay
- Division of Urology, Department of Surgery; McGill University Health Center; Montreal Quebec Canada
| | - Adrian Fairey
- Division of Urology, Department of Surgery, Faculty of Medicine; University of Alberta; Edmonton Alberta Canada
| | - Girish S. Kulkarni
- Division of Urology, Department of Surgery; University Health Network, University of Toronto; Toronto Ontario Canada
- Institute for Clinical and Evaluative Sciences, University of Toronto; Toronto Ontario Canada
| | - Rodney H. Breau
- Division of Urology, Clinical Epidemiology; Ottawa Hospital Research Institute; Ottawa Ontario Canada
| | - Peter C. Black
- Department of Urologic Sciences; University of British Columbia; Vancouver British Columbia Canada
| | - Wassim Kassouf
- Division of Urology, Department of Surgery; McGill University Health Center; Montreal Quebec Canada
- McGill Urology Residency Program Director; McGill University Health Center; Montreal Quebec Canada
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Angulo JC, Palou J, García-Tello A, de Fata FR, Rodríguez O, Villavicencio H. Second transurethral resection and prognosis of high-grade non-muscle invasive bladder cancer in patients not receiving bacillus Calmette-Guérin. Actas Urol Esp 2014; 38:164-71. [PMID: 24613147 DOI: 10.1016/j.acuro.2014.01.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 01/13/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To define the natural history of T1G3 bladder tumor not receiving intravesical Bacillus Calmette-Guerin (BCG) and assess the diagnostic and therapeutic value of a second transurethral resection (Re-TUR) in these patients. PATIENTS AND METHODS Retrospective study on the natural history of 210 patients treated at two institutions for T1G3 bladder carcinoma without associated CIS. In no case was BCG administered; 79 (37.6%) received TUR alone, and 131 (62.4%) Re-TUR 4 to 6 weeks later; 23 (12.4%) underwent cystectomy for tumor progression. RESULTS Median follow-up was 55 (78 IQR) months, male/female ratio 8/1, and mean age 70.6+11.8 (range 37-93). 19.5% were free of recurrence at 10 years, and 61.9% free of progression. Independent prognostic factors for progression were solid pattern (HR: 2.71; P=.0004), multiplicity (HR: 2.26; P=.003), and recurrence at 3 months (HR: 3.4; P=.003). Cancer-specific survival was 81.5% at 5 and 69% at 10 years. Independent predictors of survival were: progression during the first year (HR: 17.9; P<.0001), solid pattern (HR: 2.13; P=.02), multiplicity (HR: 2.05; P=.03), and age>65 years (HR: 2.9; P=.03). Re-TUR avoided under-staging (7.4%), detected T1G3 residual disease (10.7%), reduced recurrence rate at 3 months (11.4 to 4.6%; P=.06), and rate of progression on the 1st year (13.9 to 3.8%; P=.0075). However, in these patients the risk remains and no differences were detected in the long term in terms of recurrence (log-rank, P=.14), progression (P=.91), or cancer death (P=.21) in patients treated with Re-TUR. CONCLUSION The recurrence in the first 3 months of a T1G3 tumor not receiving BCG is the main risk factor for progression, and progression of this type of tumors within the first year is the main factor of cancer death. The Re-TUR improves both variables but it does not change the long-term prognosis.
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Affiliation(s)
- J C Angulo
- Servicio de Urología, Hospital Universitario de Getafe, Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, España.
| | - J Palou
- Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España
| | - A García-Tello
- Servicio de Urología, Hospital Universitario de Getafe, Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, España
| | - F R de Fata
- Servicio de Urología, Hospital Universitario de Getafe, Departamento Clínico, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, España
| | - O Rodríguez
- Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España
| | - H Villavicencio
- Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, España
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Daneshmand S. Determining the Role of Cystectomy for High-grade T1 Urothelial Carcinoma. Urol Clin North Am 2013; 40:233-47. [DOI: 10.1016/j.ucl.2013.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Chen J, Yao Z, Qiu S, Chen L, Wang Y, Yang J, Li J. Comparing intra-arterial chemotherapy combined with intravesical chemotherapy versus intravesical chemotherapy alone: a randomised prospective pilot study for T1G3 bladder transitional cell carcinoma after bladder-preserving surgery. Cardiovasc Intervent Radiol 2013; 36:1521-1526. [PMID: 23511989 DOI: 10.1007/s00270-013-0594-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 01/30/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare the efficacy of intra-arterial chemotherapy combined with intravesical chemotherapy versus intravesical chemotherapy alone for T1G3 bladder transitional cell carcinoma (BTCC) followed by bladder-preserving surgery. MATERIALS AND METHODS Sixty patients with T1G3 BTCC were randomly divided into two groups. After bladder-preserving surgery, 29 patients (age 30-80 years, 24 male and 5 female) received intra-arterial chemotherapy in combination with intravesical chemotherapy (group A), whereas 31 patients (age 29-83 years, 26 male and 5 female) were treated with intravesical chemotherapy alone (group B). Twenty-nine patients were treated with intra-arterial epirubicin (50 mg/m(2)) + cisplatin (60 mg/m(2)) chemotherapy 2-3 weeks after bladder-preserving surgery once every 4-6 weeks. All of the patients received the same intravesical chemotherapy: An immediate prophylactic was administered in the first 6 h. After that, therapy was administered one time per week for 8 weeks and then one time per month for 8 months. The instillation drug was epirubicin (50 mg/m(2)) and lasted for 30-40 min each time. The end points were tumour recurrence (stage Ta, T1), tumour progression (to T2 or greater), and disease-specific survival. During median follow-up of 22 months, the overall survival rate, tumour-specific death rate, recurrence rate, progression rate, time to first recurrence, and adverse reactions were compared between groups. RESULTS The recurrence rates were 10.3 % (3 of 29) in group A and 45.2 % (14 of 31) in group B, and the progression rates were 0 % (0 of 29) in group A and 22.6 % (7 of 31) in group B. There was a significant difference between the two groups regarding recurrence (p = 0.004) and progression rates (p = 0.011). Median times to first recurrence in the two groups were 15 and 6.5 months, respectively. The overall survival rates were 96.6 and 87.1 %, and the tumour-specific death rates were 0 % (0 of 29) and 13.5 % (4 of 31) in groups A and B, respectively. During the intra-arterial chemotherapy cycle, although more than 50 % patients experienced some toxicities, most were minor and reversible [grade 1-2 (46.7 %) vs. grade 1-2 (6.9 %)]. CONCLUSION These findings suggest that combining intra-arterial chemotherapy with intravesical chemotherapy could delay tumour recurrence and progression compared with intravesical chemotherapy alone and this type treatment is relatively safe.
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MESH Headings
- Administration, Intravesical
- Adult
- Aged
- Aged, 80 and over
- Antibiotics, Antineoplastic/administration & dosage
- Antibiotics, Antineoplastic/therapeutic use
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/therapeutic use
- Carcinoma, Transitional Cell/drug therapy
- Carcinoma, Transitional Cell/surgery
- Chemotherapy, Adjuvant/methods
- Cisplatin/administration & dosage
- Cisplatin/therapeutic use
- Disease Progression
- Drug Therapy, Combination/methods
- Epirubicin/administration & dosage
- Epirubicin/therapeutic use
- Female
- Follow-Up Studies
- Humans
- Infusions, Intra-Arterial/methods
- Male
- Middle Aged
- Neoplasm Recurrence, Local/prevention & control
- Organ Sparing Treatments
- Pilot Projects
- Prospective Studies
- Survival Analysis
- Treatment Outcome
- Urinary Bladder/surgery
- Urinary Bladder Neoplasms/drug therapy
- Urinary Bladder Neoplasms/surgery
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Affiliation(s)
- Junxing Chen
- Department of Urology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Zhijun Yao
- Department of Urology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Shaopeng Qiu
- Department of Urology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Lingwu Chen
- Department of Urology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Yu Wang
- Department of Interventional Oncology, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Jianyong Yang
- Department of Interventional Oncology, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Jiaping Li
- Department of Interventional Oncology, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China.
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Emmert-Streib F, Abogunrin F, de Matos Simoes R, Duggan B, Ruddock MW, Reid CN, Roddy O, White L, O'Kane HF, O'Rourke D, Anderson NH, Nambirajan T, Williamson KE. Collectives of diagnostic biomarkers identify high-risk subpopulations of hematuria patients: exploiting heterogeneity in large-scale biomarker data. BMC Med 2013; 11:12. [PMID: 23327460 PMCID: PMC3570289 DOI: 10.1186/1741-7015-11-12] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Accepted: 01/17/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ineffective risk stratification can delay diagnosis of serious disease in patients with hematuria. We applied a systems biology approach to analyze clinical, demographic and biomarker measurements (n = 29) collected from 157 hematuric patients: 80 urothelial cancer (UC) and 77 controls with confounding pathologies. METHODS On the basis of biomarkers, we conducted agglomerative hierarchical clustering to identify patient and biomarker clusters. We then explored the relationship between the patient clusters and clinical characteristics using Chi-square analyses. We determined classification errors and areas under the receiver operating curve of Random Forest Classifiers (RFC) for patient subpopulations using the biomarker clusters to reduce the dimensionality of the data. RESULTS Agglomerative clustering identified five patient clusters and seven biomarker clusters. Final diagnoses categories were non-randomly distributed across the five patient clusters. In addition, two of the patient clusters were enriched with patients with 'low cancer-risk' characteristics. The biomarkers which contributed to the diagnostic classifiers for these two patient clusters were similar. In contrast, three of the patient clusters were significantly enriched with patients harboring 'high cancer-risk" characteristics including proteinuria, aggressive pathological stage and grade, and malignant cytology. Patients in these three clusters included controls, that is, patients with other serious disease and patients with cancers other than UC. Biomarkers which contributed to the diagnostic classifiers for the largest 'high cancer- risk' cluster were different than those contributing to the classifiers for the 'low cancer-risk' clusters. Biomarkers which contributed to subpopulations that were split according to smoking status, gender and medication were different. CONCLUSIONS The systems biology approach applied in this study allowed the hematuric patients to cluster naturally on the basis of the heterogeneity within their biomarker data, into five distinct risk subpopulations. Our findings highlight an approach with the promise to unlock the potential of biomarkers. This will be especially valuable in the field of diagnostic bladder cancer where biomarkers are urgently required. Clinicians could interpret risk classification scores in the context of clinical parameters at the time of triage. This could reduce cystoscopies and enable priority diagnosis of aggressive diseases, leading to improved patient outcomes at reduced costs.
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Affiliation(s)
- Frank Emmert-Streib
- Centre for Cancer Research & Cell Biology, Queens University Belfast, Belfast, Northern Ireland
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Yates DR, Brausi MA, Catto JW, Dalbagni G, Rouprêt M, Shariat SF, Sylvester RJ, Witjes JA, Zlotta AR, Palou-Redorta J. Treatment Options Available for Bacillus Calmette-Guérin Failure in Non–muscle-invasive Bladder Cancer. Eur Urol 2012; 62:1088-96. [DOI: 10.1016/j.eururo.2012.08.055] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 08/27/2012] [Indexed: 11/17/2022]
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Zhang Y, Denton BT, Nielsen ME. Comparison of surveillance strategies for low-risk bladder cancer patients. Med Decis Making 2012. [PMID: 23178638 DOI: 10.1177/0272989x12465353] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Low-grade noninvasive disease comprises approximately half of incident bladder cancer cases. These lesions have exceedingly low rates of progression to aggressive, muscle-invasive bladder cancer, and there is salient discordance with regard to management recommendations for these patients between the principal clinical practice guidelines. In this context, we compare the international guidelines with alternative surveillance strategies for low-risk bladder cancer patients. METHODS We used a partially observable Markov model based on states that defined patient risk levels associated with recurrence and progression of bladder cancer. The model also included states defining the effects of treatment, death from bladder cancer, and all other-cause mortality. Simulation was done to estimate quality-adjusted life years (QALYs), expected lifelong progression probability, and lifetime number of cystoscopies. RESULTS We compared current international guidelines and additional proposed surveillance strategies on the basis of QALYs. We conducted a bicriteria analysis to compare expected lifelong progression rate v. the number of cystoscopies. One-way sensitivity analysis was used to evaluate the influence of model parameters, including a patient's disutility associated with cystoscopy, bladder cancer mortality, and all other-cause mortality. CONCLUSIONS Age and comorbidity significantly affect the optimal surveillance strategy. Results suggest that younger patients should be screened more intensively than older patients, and patients having comorbidity should be screened less intensively.
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Affiliation(s)
- Yuan Zhang
- North Carolina State University, Raleigh, North Carolina (YZ)
| | - Brian T Denton
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan (BTD)
| | - Matthew E Nielsen
- Division of Urologic Surgery, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina (MEN)
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Sternberg IA, Keren Paz GE, Chen LY, Herr HW, Dalbagni G. Role of immediate radical cystectomy in the treatment of patients with residual T1 bladder cancer on restaging transurethral resection. BJU Int 2012; 112:54-9. [PMID: 23146082 DOI: 10.1111/j.1464-410x.2012.11391.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Bladder cancer patients with lamina propria invasion (T1 disease) and residual T1 disease on restaging transurethral resection of bladder tumour (re-TURBT) are at a very high risk for recurrence and progression. Despite this risk, most patients are treated with a bladder preserving approach and not immediate radical cystectomy (RC). In this study we have shown that a quarter of patients with T1 bladder cancer and residual T1 on re-TURBT who are treated with immediate RC are found to have carcinoma invading bladder muscle at RC and 5% have lymph node metastases. We have also found that >30% of patients treated with deferred RC after initial bladder-preserving therapy harbour carcinoma invading bladder muscle and almost 20% of these patients have lymph node metastases. Thus, immediate RC should be considered in all patients with T1 bladder cancer and residual T1 on re-TURBT. OBJECTIVE To report the overall survival (OS) and cancer-specific survival (CSS) of patients with residual T1 bladder cancer on restaging transurethral resection of the bladder tumour (re-TURBT). MATERIALS AND METHODS We performed a retrospective review of 150 evaluable patients treated for T1 bladder cancer with residual T1 disease found on re-TURBT between 1990 and 2007. Patients were treated with immediate radical cystectomy (RC) or a bladder-preserving approach (deferred or no RC). A univariate Cox proportional hazards regression model was used to test the association between treatment approach and survival. RESULTS Residual T1 bladder cancer was found in 150 evaluable patients, of whom 57 received immediate RC and 93 were treated with a bladder-preserving approach. Fourteen out of 57 patients receiving immediate RC and 8/26 patients receiving deferred RC had carcinoma invading bladder muscle in the RC specimen. Three out of 57 and 5/26 patients had lymph node metastases in the RC specimen. Median follow-up was 3.74 years. Thirty-nine patients died during follow-up, 16 from bladder cancer. There was no significant association between immediate RC and CSS (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.43-3.09, P = 0.8) or OS (HR 0.79, 95% CI 0.4-1.53, P = 0.5). CONCLUSIONS Because of the low number of events we cannot conclude whether RC offers a survival advantage in patients with residual T1 bladder cancer on re-TURBT. Since a quarter of patients had carcinoma invading bladder muscle, RC should be considered in these patients. A larger, preferably randomized, study with longer follow-up is needed.
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Affiliation(s)
- Itay A Sternberg
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Green DA, Rink M, Cha EK, Xylinas E, Chughtai B, Scherr DS, Shariat SF, Lee RK. Cost-effective treatment of low-risk carcinoma not invading bladder muscle. BJU Int 2012; 111:E78-84. [DOI: 10.1111/j.1464-410x.2012.11454.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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50
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Thomas F, Rosario DJ, Rubin N, Goepel JR, Abbod MF, Catto JWF. The long-term outcome of treated high-risk nonmuscle-invasive bladder cancer: time to change treatment paradigm? Cancer 2012; 118:5525-34. [PMID: 22544645 DOI: 10.1002/cncr.27587] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 01/11/2012] [Accepted: 03/13/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND The treatment of high-risk nonmuscle-invasive bladder cancer (NMIBC) is difficult given its unpredictable natural history and patient comorbidities. Because current case series are mostly limited in size, the authors report the outcomes from a large, single-center series. METHODS The authors reviewed all patients with primary, high-risk NMIBC at their institution from 1994 to 2010. Outcomes were matched with clinicopathologic data. Patients who had muscle invasion within 6 months or had insufficient follow-up (<6 months) were excluded. Correlations were analyzed using multivariable Cox regression and log-rank analysis (2-sided; P < .05). RESULTS In total, 712 patients (median age, 73.7 years) were included. Progression to muscle invasion occurred in 110 patients (15.8%; 95% confidence interval [CI], 13%-18.3%) at a median of 17.2 months (interquartile range, 8.9-35.8 months), including 26.5% (95% CI, 22.2%-31.3%) of the 366 patients who had >5 years follow-up. Progression was associated with age (hazard ratio [HR], 1.04; P = .007), dysplastic urothelium (HR, 1.6; P = .003), urothelial cell carcinoma variants (HR, 3.2; P = .001), and recurrence (HR, 18.3; P < .001). Disease-specific mortality occurred in 134 patients (18.8%; 95% CI, 16.1%-21.9%) at a median of 28 months (interquartile range, 15-45 months), including 28.7% (95% CI, 24.5%-33.3%) of those who had 5 years of follow-up. Disease-specific mortality was associated with age (HR, 1.1; P < .001), stage (HR, 1.7; P = .003), dysplasia (HR, 1.3; P = .05), and progression (HR, 5.2; P < .001). Neither progression nor disease-specific mortality were associated with the receipt of bacillus Calmette-Guerin (P > .6). CONCLUSIONS Within a program of conservative treatment, progression of high-risk NMIBC was associated with a poor prognosis. Surveillance and bacillus Calmette-Guerin were ineffective in altering the natural history of this disease. The authors concluded that the time has come to rethink the paradigm of management of this disease.
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Affiliation(s)
- Francis Thomas
- The Academic Urology Unit and Institute for Cancer Studies, University of Sheffield, Sheffield, United Kingdom
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