Are we following the guidelines on non-muscle invasive bladder cancer?

Challenges and opportunities in NMIBC management across Latin America: insights from healthcare providers and a patient advocacy group

Non-muscle invasive bladder cancer (NMIBC) is characterised by high rates of recurrence and progression, requiring substantial healthcare resources. In Latin America, the incidence of NMIBC is set to increase due to an aging population and lifestyle changes. To better understand the current challenges for NMIBC treaters and patients, a mixed-methods approach was leveraged combining secondary research with qualitative interviews from healthcare providers in Brazil, Colombia, Mexico and Argentina. Our analysis found that significant challenges persist across the region, particularly due to Bacillus Calmette-Guérin shortages, inconsistent adherence to clinical guidelines and significant socioeconomic disparities for patients accessing healthcare services. Addressing these challenges requires improved patient advocacy, strategic use of clinical trials and better resource distribution to enhance NMIBC management across Latin America.

Impact of Effective Intravesical Therapies on Quality of Life in Patients with Non-Muscle Invasive Bladder Cancer: A Systematic Review

BACKGROUND

Conventional and newly emerged intravesical modalities have demonstrated prophylactic effectiveness that may improve quality of life (QoL) in non-muscle invasive bladder cancer. The purpose of this study is to analyze existing QoL evidence in patients receiving any form of intravesical therapy.

METHODS

A PubMed search without time restriction was conducted to identify all relevant studies in accordance with the PICOT question. Additionally, a search was also performed in the Cochrane library database, Internet, and citation. The CONSORT 2010 checklist and STROBE statement checklist were used to evaluate the risk of bias of the included studies.

RESULTS

A total of 24 eligible articles were included, which consisted of 11 interventional and 13 observational studies. Intravesical therapy with Bacillus Calmette-Guérin (BCG) or certain chemotherapeutic agents worsens symptom burdens and functional performance during the initial induction phase while continuous improved is observed throughout the maintenance treatment and beyond. Hyperthermia has shown a positive trend in enhancing QoL of patients receiving intravesical chemotherapy, which requires more investigations. However, QoL data were unavailable for other forms of immunotherapy, immune checkpoint inhibitors, electromotive drug administration, and photodynamic therapy.

CONCLUSIONS

Limited studies suggested the long-term positive impact of intravesical BCG immunotherapy and chemotherapy. However, existing evidence was lacking to clarify the impact of many emerging intravesical therapies that have suggested to be effective and safe, which demands treatment-specific QoL studies.

Optimizing treatment for non muscle-invasive bladder cancer with an app

OBJECTIVES

To evaluate overall and recurrence-progression rate-adjusted concordance of treatment prescription in non-muscle-invasive bladder cancer (NMIBC) of an app based on the best available scientific evidence and the urologist's opinion.

METHODS

Development of an app (APPv) specifically designed for the treatment and follow-up of NMIBC and validation of the proposed APPv treatment endpoint by means of a prospective double-blind observational concordance study of related samples in 100 patients with initial or successive histological diagnosis of NMIBC.

RESULTS

The treatment prescribed by the urologist agrees with that proposed by the APPv in 64% of cases (kappa index 0.55, P < 0.0001). Regarding low risk, the agreement is 77% (kappa 0.55, P = 0.002), 63% (kappa 0.52, P < 0.0001) for intermediate risk, 17% (kappa 0.143, P = 0.014) in high risk and 66% (kappa 0.71, P = 0.01) for very high risk. Of patients receiving adjuvant intravesical treatment according to APPv, 89.1% remain free of recurrence vs. 61.1% of those with disagreement (P = 0.0004), with a RR 0.46 (95%CI: 0.25-0.86) vs. RR 2.4 (95%CI: 1.5-3.8, P = 0.001). In the APPv-urologist agreement group, 100% of patients are free of progression and 88.9% in the disagreement group (P = 0.004) with a RR 1 vs. RR 1.125 (95%CI: 1-1.26, P = 0.004).

CONCLUSIONS

APPv can improve adherence to treatment recommendations according to clinical practice guidelines and health outcomes at NMIBC.

Presence and predominance of histological grade 3 define cT1HG bladder cancer prognostic groups

PURPOSE

Current World Health Organization/International Society of Urological Pathology (2004 WHO/ISUP) grading of bladder urothelial carcinoma relies on the highest pathologic grade of the specimen and does not reflect the inherent qualitative and quantitative heterogeneity of disease.

MATERIALS AND METHODS

We retrospectively studied consecutive urothelial high-grade cT1 (cT1HG) carcinomas submitted to adjuvant bacille Calmette-Guérin between 2008 and 2015 to evaluate the prognostic potential of grade 3 (presence or predominance) according to the 1973 WHO system concerning disease progression and cancer-specific death.

RESULTS

Among 253 patients, grading distribution was 34.4% 1+2, 7.5% 2+1, 20.2% 2+2, 19.0% 2+3, 5.1% 3+2, and 13.8% 3+3. Recurrence was diagnosed in 115 (45.5%), progression in 83 (32.8%), and cancer-specific death in 50 patients (19.8%). Mean time to recurrence, progression, and death from disease were 35.9±31.7, 47.6±44.5, and 51.2±50.4 months, respectively. Grade 3 presence (2+3, 3+2, or 3+3) occurred in 96 (37.9%) and independently predicted time to progression (p<0.001; hazard ratio [HR], 3.11; 95% confidence interval [CI], 1.88-5.14). Grade 3 predominance (3+2 or 3+3) occurred in 48 (18.9%) and independently predicted time to disease-specific death.

CONCLUSIONS

Grade 3 presence and predominance are independent predictors of progression and disease-specific death and occur in about 40% and 20% of cT1HG, respectively. Describing qualitative and quantitative heterogeneity in urothelial carcinoma grading might improve the stratification of patients. This gives three prognostic high-grade groups based on WHO/ISUP 1973: prognostic grade group I (grade 3 absence), prognostic grade group II (grade 3 presence), and prognostic grade group III (grade 3 predominance).

COVID-19 impact on bladder cancer-orientations for diagnosing, decision making, and treatment

The world is going through an unprecedented time in history, and Urologists are, like many other healthcare professionals, facing and combating on two fronts: against the pandemic itself and cancer. When looking at the fatality rates, bladder cancer overcomes Coronavirus disease 2019 (COVID-19) by far and can be as high as 52%, so Urologists must not postpone investigation. Cystoscopy remains the gold standard for the investigation of bladder cancer and computed tomography (CT) urography for obtaining images of the upper tract in cases of macroscopic hematuria. Whenever transurethral resection of bladder tumor (TURB) is necessary, extra care must be taken to assure muscle sample, avoiding another surgical intervention and hospitalization, but when necessary it should not be postponed due to the elevated progression rate of the disease. Follow-up cystoscopies can be postponed for 6 months for low risk, 3 months for intermediate, 6 weeks for high risk, and not beyond 24 hours in case of emergencies as life-threatening hematuria, anemia, and urinary retention. Regarding chemotherapy, more than ever the key point is to evaluate each case individually. Bacille Calmette Guerin (BCG) must be considered only as an inducing course, in selected intermediate and most high-risk cancers. Whenever possible patients should be tested before surgery. Based on the current literature on optimal bladder cancer patients approach we comprehensively synthetize the major societies guidelines on the issue so far, adding a critical view to the topic. This article aims to guide Urologists on decision making against bladder cancer in the COVID-19 era.

Factors affecting guideline adherence in the initial treatment of non-muscle invasive bladder cancer: Retrospective study in a French peripheral hospital

OBJECTIVES

To assess whether the initial treatment of non-muscle invasive bladder cancer (NMIBC) was performed according to the guidelines, and to determine the reasons why initial treatment was not provided in nonadherence cases.

MATERIALS AND METHODS

We retrospectively reviewed all patients with NMIBC who underwent their first transurethral resection of bladder tumor (TURBT) at a peripheral hospital, between 2007 and 2016. The treatment offered to the patient was compared to the European Association of Urology guidelines according to risk stratification. For each patient who did not receive the treatment according to the guidelines, one of the following reasons was identified: poor patient compliance, poor patient general health status, urologist's decision, lack of resources.

RESULTS

One hundred fifty-nine patients were included with a mean age of 72.2 years at the time of NMIBC diagnosis. The low-risk patients were strictly treated according to the guidelines. Among the intermediate-risk patients, 14% received mitomycin C. Among the high-risk patients, 39% received intravesical Bacillus Calmette-Guerin. In the nonadherence cases (61%), the reasons were related to the patient in 44% of cases (poor compliance, 21%; poor patient general health status, 23%), urologist's decision in 54% of cases, and lack of resources in 2% of cases. Thirty-seven percent of the high-risk patients underwent re-resection.

CONCLUSIONS

Overall, adherence to NMIBC guidelines was low in all treatment types (intravesical therapy, re-resection, or cystectomy for very high-risk patients), but this finding was similar to that in previous studies. Reasons were mainly related to the urologist's decision or to the patient condition (poor compliance or poor general health status).

LEVEL OF EVIDENCE

3.

Prognostic impact of non-adherence to follow-up cystoscopy in non-muscle-invasive bladder cancer (NMIBC)

PURPOSE

To evaluate the underexplored context of cystoscopy adherent versus non-adherent patients in the follow-up of urothelial high-risk non-muscle-invasive bladder cancer (NMIBC).

METHODS

We performed a retrospective study (2005-2016) that evaluated patients´ demographical characteristics, histopathological data, recurrence, progression and cancer-specific mortality between adherent and non-adherents patients in the first 3 years of a proposed cystoscopy protocol.

RESULTS

Among the 198 included patients, comparing cystoscopy non-adherent (n = 36, 18%) and adherent patients (n = 162, 82%), there was no demographic or histopathological differences; the rates of disease recurrence, progression and cancer-specific mortality were 15 (41.7%) versus 68 (42.2%), p = 0.58; 12 (33.3%) versus 28 (17.9%), p = 0.014 and 4 (11.1%) versus 19 (11.7%), p = 0.98, respectively. Cystoscopy non-adherence was associated with an inferior number of urinary cytology (p < 0.001) and 2.33 HR for cancer progression, p = 0.014, (95% CI 1.18-4.59).

CONCLUSIONS

Non-adherence to follow-up cystoscopy in NMIBC is associated with more than twice progression risk. Future studies are needed to confirm our results and correlate cystoscopy non-adherence to other covariates.

Does restaging transurethral resection of bladder tumour influence outcomes in patients treated with BCG immunotherapy? 491 cases in 20 years' experience

Introduction

Bladder cancer is one of the most common malignancies worldwide.

Aim

To analyse the influence of restaging transurethral resection of bladder tumour (reTURB) on outcomes in patients treated with BCG immunotherapy.

Material and methods

We analysed a database of 491 patients who were treated in a Bacillus Calmette-Guérin (BCG) outpatient department between 1998 and 2016. A minimum of 12 months of follow-up was required. The study included 235 patients with a history of the reTURB procedure and 256 patients without reTURB. The patients were analysed in terms of recurrence-free (RFS), progression-free (PFS), cancer-specific and overall survival.

Results

The RFS was significantly higher in the reTURB group for both general and subgroup analysis (T1HG, TaHG). The PFS was significantly higher in the reTURB group for both general and subgroup analysis (TaHG). In patients without lamina muscularis in the specimen there was a greater improvement in RFS due to the reTURB procedure than for other patients. ReTURB performed in T1 tumours with massive lamina propria infiltration had a positive influence on RFS. In patients with reTURB the presence of focal invasion was related to lower risk of progression. Both overall and cancer-specific survival were significantly improved by the reTURB procedure in T1HG and HG tumours.

Conclusions

This study highlights the importance of reTURB. It was found that the patients with TaHG tumours benefited the most in terms of RFS, PFS and cancer-specific survival. It was also demonstrated that massive lamina propria infiltration in T1 tumours is associated with the worst outcomes.

DHCR24 predicts poor clinicopathological features of patients with bladder cancer: A STROBE-compliant study

To investigate the prognostic value of DHCR24 for patients with bladder cancer (BC). We used public bladder cancer microarray studies to evaluate the expression of DHCR24 between normal bladder tissues and BC cells, to investigate the relationship between the expression of DHCR24 and the clinical features of BC patients. Survival analysis was performed to investigate the correlation between DHCR24 expression and the survivals of BC patients. Gene set enrichment analysis was conducted to identify relevant mechanisms. The results showed that DHCR24 was up-regulated in BC cells compared with that in normal bladder tissues (P = .0389). Results of chi-square test suggested that BC patients in DHCR24 low expression group were proved to have better clinical characteristics (including tumor grade, disease progression, T staging, and N staging) as compared with those in DHCR24 low expression group (P < .0001, P = .002, P = .005, and P = .002, respectively). BC patients in DHCR24 low expression group were associated with better cancer-specific survival and overall survival (P < .0001 and P = .0008, respectively). DHCR24 might promote the proliferation of BC cells through several oncogenesis-associated biological processes (estrogen response, heme metabolism, P53 pathway, cholesterol homeostasis, mTORC1 signaling, peroxisome, xenobiotic metabolism, glycolysis, and protein secretion). Thus, DHCR24 might be a therapeutic target for patients with BC.

Regulatory T Cells and Tumor-Associated Macrophages in the Tumor Microenvironment in Non-Muscle Invasive Bladder Cancer Treated with Intravesical Bacille Calmette-Guérin: A Long-Term Follow-Up Study of a Japanese Cohort

The clinical significance of regulatory T cells (Treg) and tumor-associated macrophages (TAM) in the tumor microenvironment of human bladder cancer remains unclear. The aim of this study is to explore their relevance to oncological features in non-muscle invasive bladder cancer (NMIBC). We carried out immunohistochemical analysis of forkhead box P3 (FOXP3, Treg maker), CD204 (TAM marker), and interleukin-6 (IL6) using surgical specimens obtained from 154 NMIBC patients. The Treg and TAM counts surrounding the cancer lesion and IL6-positive cancer cell counts were evaluated against clinicopathological variables. We focused on the ability of the Treg and TAM counts around the cancer lesion to predict outcomes after adjuvant intravesical Bacille Calmette–Guérin (BCG) treatment. High Treg counts were associated with female patients, older age, T1 category, and high tumor grade. TAM count was significantly correlated with Treg count and with IL6-positive cancer cell count. In our analysis of 71 patients treated with BCG, high counts of Treg and TAM were associated with shorter recurrence-free survival, and the former was an independent predictor of recurrence. Poor response to intravesical BCG was associated with Treg and TAM in the tumor microenvironment. Disrupting the immune network can be a supplementary therapeutic approach for NMIBC patients receiving intravesical BCG.