Defining Priorities to Improve Patient Experience in Non-Muscle Invasive Bladder Cancer

Preferred labels and language to discuss low-risk lesions that may be cancer precursors: A review

OBJECTIVES

Patients diagnosed with low-risk lesions are confused about whether they have cancer, and experience similar anxiety to those with invasive cancer, which affects quality of life. Current labels for low-risk lesions were chosen by clinicians and lack meaning to patients.

METHODS

We reviewed published research on preferred labels and language for low-risk lesions, and the rationale for those preferences.

RESULTS

Of 6569 titles screened, we included 13 studies. Among healthy adults with cervix or prostate lesions, use of the term "cancer" rather than "nodule" or "lesion" resulted in greater anxiety, higher perceived disease severity, and selection of more invasive treatment. Physicians asked about removing "carcinoma" from thyroid lesion labels to reduce patient anxiety and discourage over-treatment did not support this change, instead preferring a term that included "neoplasm".

CONCLUSIONS

This review revealed a startling paucity of research on preferences for low-risk lesion labels and language, and associated rationale. Future research is needed to understand how to improve communication about low-risk lesions.

PRACTICE IMPLICATIONS

To reduce anxiety and improve the overall well-being of patients, it is crucial to gain a deeper understanding of how to improve patient-provider conversations regarding screen-detected lesions with a low risk of developing into invasive cancer.

Factors Influencing Patient Decision-Making in the Treatment of Muscle-Invasive Bladder Cancer

BACKGROUND

In 2023, an estimated 82,290 individuals were diagnosed with bladder cancer in the United States. For muscle-invasive bladder cancer (MIBC), the American Urological Association recommends offering radical cystectomy with cisplatin-based neoadjuvant chemotherapy. However, patients are increasingly requesting alternative treatments.

OBJECTIVE

To describe factors influencing selection of radical cystectomy with cisplatin-based neoadjuvant chemotherapy (NAC + RC), radical cystectomy monotherapy (RC), or tri-modality therapy (TMT) among patients with MIBC.

METHODS

Individual, semi-structured phone interviews were conducted with 18 adults who underwent MIBC treatment at the University of North Carolina, recruiting six patients each from three treatment groups: 1) NAC + RC, 2) RC, and 3) TMT. Interview transcriptions were qualitatively analyzed using QSR NVivo, with major themes and sub-themes extracted. Patients also completed the Shared Decision-Making Questionnaire (SDM-Q-9; range 0-100).

RESULTS

Concern for survival and risks, quality of life, and varied patient preferences for involvement influenced the decision-making process. Concern surrounding sexual function, bladder preservation, and urostomy bags drove patients towards TMT. High levels of shared decision-making were observed overall, with a median SDM-Q-9 score of 95 (IQR 89-100). Patients undergoing TMT reported the highest median SDM-Q-9 score (97, IQR 94-100), while those receiving radical cystectomy alone had the lowest (66, IQR 37-96).

CONCLUSIONS

Patients with MIBC described a multifaceted treatment decision-making process, highlighting key influences, concerns, and unmet needs. Understanding this process can help address misconceptions and align treatment choices with patient goals. Physicians can use these insights to engage in shared decision-making, ultimately improving patient experiences and outcomes.

ERAS for Ambulatory TURBT: Enhancing Bladder Cancer Care (EMBRACE) randomised controlled trial protocol

INTRODUCTION

Transurethral resection of bladder tumour (TURBT) is one of the more common procedures performed by urologists. It is often described as an 'incision-free' and 'well-tolerated' operation. However, many patients experience distress and discomfort with the procedure. Substantial opportunity exists to improve the TURBT experience. An enhanced recovery after surgery (ERAS) protocol designed by patients with bladder cancer and their providers has been developed.

METHODS AND ANALYSIS

This is a single-centre, randomised controlled trial to investigate the effectiveness of an ERAS protocol compared with usual care in patients with bladder cancer undergoing ambulatory TURBT. The ERAS protocol is composed of preoperative, intraoperative and postoperative components designed to optimise each phase of perioperative care. 100 patients with suspected or known bladder cancer aged ≥18 years undergoing initial or repeat ambulatory TURBT will be enrolled. The change in Quality of Recovery 15 score, a measure of the quality of recovery, between the day of surgery and postoperative day 1 will be compared between the ERAS and control groups.

ETHICS AND DISSEMINATION

The trial has been approved by the Johns Hopkins Institutional Review Board #00392063. Participants will provide informed consent to participate before taking part in the study. Results will be reported in a separate publication.

TRIAL REGISTRATION NUMBER

NCT05905276.

Use of Bladder-Related Medication in Non-Muscle Invasive Bladder Cancer Patients

Repeated transurethral bladder resections (TURBs) and instillation treatments in non-muscle invasive bladder cancer (NMIBC) might influence bladder function and, therefore, quality of life. Bladder-related medication is a surrogate marker of compromised bladder function. The objective was to investigate whether TURBs and adjuvant instillation therapy are associated with the use of anticholinergics, β3-agonists, and cystitis-relevant antibiotics. We divided all Danish patients diagnosed with primary NMIBC during 2002-2017 registered in the Danish National Patient Registry (DNPR) based on TURB-load within the first five years from diagnosis (1 TURB, 2-4 TURBs, ≥5 TURBs). Instillation therapy with either mitomycin C (MMC) or bacillus Calmette-Guerin vaccine (BCG) was independent exposure (yes or no). We included 17,774 patients; 76% men, median age: 70 years (IQR: 63, 77). Patients exposed to ≥5 TURBs had a higher risk of using bladder-relaxing medication than patients exposed to 1 TURB, HR = 4.01 [3.33; 4.83], and higher risk of cystitis, HR = 2.27 [2.05; 2.51]. BCG-exposed patients had a higher risk of bladder-relaxing medication use compared to non-exposed, HR = 1.92 [1.69; 2.18], and a higher risk of cystitis, HR = 1.39 [1.31; 1.48]. Repeated TURBs have the highest impact on bladder function. Adjuvant instillation therapy is also associated with the use of bladder-related medication.

Identifying the supportive care needs of people affected by non-muscle invasive bladder cancer: An integrative systematic review

PURPOSE

To understand supportive care needs among people with non-muscle invasive bladder cancer (NMIBC).

METHODS

An integrative systematic review was reported using the Preformed Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Seven electronic databases were searched for relevant studies, including all quantitative, qualitative, and mixed methods studies, irrespective of research design. The review process was managed by Covidence systematic review software. Two reviewer authors independently performed data extraction using eligibility criteria. Quality appraisal was conducted, and a narrative synthesis was performed.

RESULTS

A total of 1129 articles were screened, of which 21 studies met the inclusion criteria. The findings revealed that the frequency of supportive care needs reported by NMIBC participants included psychological/emotional (16/21:76%), physical (16/21:76%), practical (8/21:38%), interpersonal/intimacy (7/21:33%), family-related (7/21:33%), health system/information (5/21:23%), social (4/21:19%), patient-clinician communication (3/21:14%), spiritual (1/21:5%) and daily needs (1/21:5%).

CONCLUSION

People affected by NMIBC experience anxiety, depression, uncertainty, and fear of recurrence. The physical symptoms reported included urinary issues, pain, sleeping disorders and fatigue. These supportive care needs persist throughout the participants' treatment trajectory and can impact their quality of life.

IMPLICATIONS FOR CANCER SURVIVORS

Identifying supportive care needs within the NMIBC population will help inform future interventions to provide patient-centred care to promote optimal well-being and self-efficacy for people diagnosed with NMIBC.

Patients' Emotional Talk During Surveillance Cystoscopy for Non-muscle Invasive Bladder Cancer: Opportunities for Improving Communication

OBJECTIVE

To examine the emotional communication that takes place between patients and health care providers during surveillance cystoscopy for non-muscle invasive bladder cancer (NMIBC).

METHODS

Participants were 57 patients with a diagnosis of NMIBC attending for surveillance cystoscopy and 10 health care professionals (HCPs). Cystoscopy procedures were audio-recorded and transcribed verbatim. Two approaches to analysis of transcriptions were undertaken: (1) a template analysis and (2) Verona Coding Definitions of Emotional Sequences.

RESULTS

Communication during cystoscopy generally comprised of "social/small talk," "results of the cystoscopy," and "providing instructions to the patient." Emotional talk was present in 41/57 consultations, with 129 emotional cues and concerns expressed by patients. Typically patients used hints to their emotions rather than stating explicit concerns. The majority (86%) of HCPs responses to the patient did not explicitly mention the patient's emotional concern or cue. Urology trainees were less likely than other HCPs to provide space for patients to explore their emotional concerns (t = -1.78, P <.05).

CONCLUSION

Emotional communication was expressed by the majority of patients during cystoscopy. While all HCPs responded to patients' emotional communication, there were a number of missed opportunities to "pick-up" on patients' emotional cues and improve communication. Urologists need to be aware of the nuances of patients' emotional communication. Learning to identify and respond appropriately to emotional cues may improve communication with patients.

'I Had It. I Don't Think I Have It…But I Do Feel It Will Come Back Somewhere': A Qualitative Investigation of the Experience of People With Non-Muscle Invasive Bladder Cancer

Very little is known about the impact of living with non-muscle invasive bladder cancer (NMIBC). NMIBC patients' experiences of their illness-in terms of their perceptions, coping strategies and psychological wellbeing-were explored. This study describes an interpretative phenomenological analysis (IPA) of individuals' accounts of living with NMIBC while on routine surveillance for cancer recurrence. Ten individuals took part in face-to-face semi-structured interviews. Three superordinate themes were derived from the data. The first theme, Being Diagnosed and Treated for NMIBC, concerned the observation that participants considered the physical implications, timeline and practicalities of their illness of primary importance and focused less on its psychological aspects. The second theme, Grappling with the Illness, outlined the impact of the doctor-patient relationship. The final theme, 'I don't treat it as a problem. I treat it as an issue', delineated how participants managed difficult emotions in the context of the illness. Findings from this study demonstrated that participants generally found effective ways to cope with their illness and experience of ongoing surveillance, though delay of emotional responses was common. Clinical implications for healthcare professionals are outlined including the importance of high-quality communication with the urology team.

Can Peripheral Blood Systemic Immune Response Parameters Predict Oncological Outcomes in Patients with Non-Muscle-Invasive Bladder Cancer?

Background

Many studies have investigated most cancer types - associations with systemic inflammatory response (SIR) parameters. Aim: This study investigated predictive values of SIR parameters in oncological outcomes and survival - to primary non-muscle-invasive bladder cancer (NMIBC) patients.

Materials and Methods

We analyzed 74 primary NMIBC patients. Clinical features, laboratory results, and tumor characteristics were recorded. In addition, the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), serum C-reactive protein, albumin-to-globulin ratio (AGR), and modified Glasgow prognostic scores (mGPS) were calculated.

Results

The - mean age of the patients was - 67.41 ± 11.31 years, and the follow-up duration was 38.77 ± 19.53 months. We - found no significant NLR, CRP, and AGR - correlations with tumor characteristics and oncological outcomes. There were significant - correlations between MLR and pathological-T-stage and the PLR, pathological-T-stage, and tumor count. Carcinoma in situ was associated with a high mGPS. Multivariate analysis revealed no significant - correlations between systemic inflammatory response parameters and oncological outcomes. Patients with a high mGPS had poor cancer-specific survival. Increased NLR was associated with reduced overall survival.

Conclusions

This study revealed no significant correlation between SIR parameters and oncological outcomes. Therefore, we need more reliable indicators than SIR parameters in NMIBC patients in clinical practice.

Patient Preferences for Treatment of Bacillus Calmette-Guérin-unresponsive Non-muscle-invasive Bladder Cancer: A Cross-country Choice Experiment

Background

Patients with non-muscle-invasive bladder cancer (NMIBC) that is unresponsive to bacillus Calmette-Guérin (BCG) immunotherapy face a difficult choice. Immediate radical cystectomy (RC) is effective but might represent overtreatment. Continuing bladder preservation with medical therapy is an alternative, but it risks progression to muscle-invasive bladder cancer (MIBC) and a reduction in survival.

Objective

To understand the trade-offs patients are willing to make in selecting treatments for BCG-unresponsive NMIBC.

Design setting and participants

Adults with NMIBC from the UK, France, Germany, and Canada who reported current receipt of BCG, disease unresponsive to BCG, or receipt of RC in the previous 12 mo after failure of BCG were recruited to participate in an online choice experiment. Patients were asked to make repeated choices between two hypothetical medical treatments and the option to undergo immediate RC. The medical treatments required trade-offs between the time to RC, the mode and frequency of administration, the risk of experiencing serious side effects, and the risk of disease progression.

Outcome measurements and statistical analysis

Error component logit models were used to calculate relative attribute importance (RAI) scores as the maximum percentage contribution to a preference and acceptable benefit-risk trade-offs.

Results and limitations

Most of the 107 participants (average age 63 yr) never selected RC (89%) as their preferred option in the choice experiment. Preferences were most affected by time to RC (RAI 55%), followed by risk of progressing to MIBC (RAI 25%), medication administration (RAI 12%), and the risk of serious side effects (RAI 8%). To increase the time to RC from 1 yr to 6 yr, patients accepted a 43.8% increase in the risk of progression and a 66.1% increase in the risk of serious side effects.

Conclusions

Patients with BCG-treated NMIBC valued bladder-sparing treatments and were willing to make substantial benefit-risk trade-offs to delay RC.

Patient summary

Adults with bladder cancer not invading the bladder muscle completed an online experiment in which they chose between hypothetical medications and bladder removal. The results show that patients would be willing to accept different risks associated with medications to delay bladder removal. Patients considered disease progression the most important risk of medicinal treatment.

Multi-country clinical practice patterns, including use of biomarkers, among physicians’ treatment of BCG-unresponsive non-muscle invasive bladder cancer (NMIBC)

Background

Intravesical bacillus Calmette-Guérin (BCG) fails in a considerable proportion of non-muscle invasive bladder cancer (NMIBC) patients despite treatment per recommended protocol. This real-world study aimed to understand the current patterns of treatment and disease management for the broad BCG-unresponsive NMIBC patient population, alongside collecting sufficient data on patients who do not undergo cystectomy.

Methods

This was a multicenter, retrospective survey of physicians treating BCG-unresponsive NMIBC patients. Data were collected in eight countries – France, Germany, Spain, Italy, United Kingdom, United States, China, and Japan – between January and May 2019. The study consisted of a short online physician survey and a retrospective chart review of eligible BCG-unresponsive NMIBC patients. Physicians abstracted chart data for the last 10 (five patients in Japan) eligible BCG-unresponsive NMIBC patients meeting the inclusion criteria, and the data were analysed for all countries combined using descriptive statistics. Country-specific analyses were also carried out, as appropriate.

Results

Overall, 508 physicians participated in the study. Almost one-quarter (22.9%) of physicians’ current NMIBC patient caseload was BCG-unresponsive, whereby BCG therapy was no longer considered an option. Half of physicians (49.4%) did not regularly use biomarker tests in their practice, with particularly few physicians undertaking biomarker testing in Spain and Japan. Biomarker testing varied considerably, with the proportions of physicians selecting ‘none’ ranging from 11.4% in China to 70.3% in Japan. Physicians reported transurethral resection of the bladder tumor (TURBT) and BCG as the most common current treatments received by their patients. Chemotherapy and anti-PD-L1 treatment options were considered impactful new therapies by 94.7% and 90.0% of physicians surveyed in this study, respectively.

Conclusions

The most common treatments received by patients in this study were TURBT and BCG. Emerging new treatments are driven by exploring biomarkers, but in real-world clinical practice only half of physicians or fewer regularly tested their NMIBC patients for biomarkers; PD-1/PD-L1 was the most common biomarker test used. Most physicians reported that, in addition to chemotherapy, anti-PD-L1 was an impactful new therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-00959-z.

Care planning priorities of older patients with advanced bladder cancer

OBJECTIVES

Advanced bladder cancer (ABC) disproportionately affects older adults, and little is known about older patients' priorities for care planning in advanced cancer. Patient-centered communication remains crucial to shared decision-making between patients, families, and providers. Yet, older patients with cancer may not always know how to express their preferences, and oncologists do not always review patients' informational needs. This study aimed to understand preferences of older patients with ABC related to their communication with providers and navigation of care planning.

MATERIALS AND METHODS

This qualitative descriptive study involved in-depth interviews and focus groups with older patients with ABC and their care partners, which explored their priorities for care planning and communication with providers, decision-making processes, and valued traits in ABC care. Data were analyzed using thematic analysis.

RESULTS

Ten participants attended focus groups or interviews. Seven patients were male and three care partners were female. The mean age was 74. Time since ABC diagnosis ranged from three to seventeen months. Four key themes illustrate participants' priorities in their ABC care as older adults: 1. The significance of key phrasing in communication from oncologists, 2. The need for clear expectation-setting about prognosis and treatment, 3. The role of others in patient care decisions, and 4. Valued traits in care communication.

CONCLUSION

Older patients with ABC and their care partners are active participants in their care. Oncologists should prioritize setting clear expectations for treatment, involving family in care planning, and communicating honestly about expected changes to quality of life and functional status.

Approaches to Non-Muscle-Invasive Bladder Cancer

PURPOSE OF REVIEW

Non-muscle-invasive bladder cancer (NMIBC) is a heterogenous malignancy with high recurrence and progression rates, which necessitate uniform recommendations for diagnosis and management. Herein, we review the literature, with an emphasis on guidelines and contemporary diagnostic techniques and interventions.

RECENT FINDINGS

Guidelines around the world have adopted a schema which risk-stratify cases at diagnosis, to offer evidence-based treatment and surveillance recommendations. Enhanced endoscopic technologies can improve detection of NMIBC and reduce recurrence. The present Bacillus Calmette-Guerin (BCG) shortage in the USA has led to new strategies to prioritize the most high-risk cases. The entity of BCG-unresponsive high-risk NMIBC remains a challenge to manage, with multiple novel treatments under investigation; fortunately, new therapies have been approved, such as immune checkpoint inhibitors, and others are showing tremendous promise. The standardization of NMIBC management, with evolving detection techniques and therapeutics, offers great potential to improve patient outcomes and survivorship.

Supportive Care Needs of Patients on Surveillance and Treatment for Non-Muscle-Invasive Bladder Cancer

OBJECTIVE

This literature review provides an overview of non-muscle-invasive bladder cancer diagnosis (NMIBC), treatment, and surveillance. Existing evidence is reviewed to identify the NMIBC patient pathway, highlight its effect on quality of life, and identify supportive care needs of this patient group. A framework to guide nurses in the care of this underserved population is proposed.

DATA SOURCES

Electronic databases including CINAHL, Medline, PsychInfo, Cochrane, and Google Scholar were searched.

CONCLUSION

NMIBC is a chronic disease with high recurrence and progression rates with most patients requiring invasive treatment and burdensome surveillance schedules with frequent hospital visits. Treatment-related side effects may interrupt therapy and possibly result in its discontinuation. Patients' quality of life can be negatively affected at various stages of the cancer trajectory. Specialist nurses provide holistic care throughout all stages of the patient journey to optimize supportive care, information provision, and delivery of appropriate treatment and surveillance protocols. NMIBC research is historically underfunded with a paucity of evidence identifying the supportive care needs of this population. Further research is urgently required to fill the gaps identified.

IMPLICATIONS FOR NURSING PRACTICE

This timely paper raises the profile of unmet supportive care needs in an underserved research cancer population. Suggestions are proposed to improve the quality of nursing care through standardized practices and the development and integration of patient pathways. Evidence of the effect of NMIBC on family members or carers is absent from the literature. Future research implications and directions are proposed.

Predicting risk of multiple levels of recurrence and progression after initial diagnosis of nonmuscle-invasive bladder cancer in a multisite, community-based cohort

BACKGROUND

Nonmuscle-invasive bladder cancer (NMIBC) has heterogeneous recurrence and progression outcomes. Available risk calculators estimate recurrence and progression but do not predict the recurrence stage or grade, which may influence downstream treatment. The objective of this study was to predict risk-stratified NMIBC recurrence and progression based on recurrence tumor classification and grade.

METHODS

In total, 2956 patients with NMIBC (<T2) who were diagnosed at Kaiser Permanente Northwest and Geisinger from 1994 to 2015 were identified. Recurrences were annotated for tumor classification and grade. Four risk-stratified outcomes were created based on the tumor classification and grade of the recurrence: 1) any recurrence, 2) intermediate-risk recurrence (Ta high grade, carcinoma in situ, T1 low grade) or higher, 3) high-risk recurrence (T1 high grade) or progression (clinical T2), and 4) progression. Multivariable Cox proportional hazards regression was used to compute 1-year and 5-year risk estimates for each outcome based on initial tumor classification and grade.

RESULTS

Over a median follow-up of 29.4 months, there were 1062 recurrences (35.9%), including 111 progressions (3.8%). The adjusted hazard of high-risk recurrence or progression increased, depending on initial tumor classification and grade: The adjusted hazard ratio was 2.60 (95% CI, 1.62-4.15) for Ta high-grade tumors, 4.74 (95% CI, 3.01-7.47) for tumor in situ or Ta with carcinoma in situ, and 7.14 (95% CI, 4.97-10.26) T1 high-grade tumors. Using Ta high-grade tumors as an example, the 1-year and 5-year predicted rates of adjusted risk of a high-risk recurrence or progression were 4.4% and 7.9%, respectively.

CONCLUSIONS

The 1-year and 5-year predicted risk of high-risk recurrences and progression increased with higher tumor classification and grade at diagnosis. These granular risk estimates may further inform risk-stratified treatment and surveillance for patients with NMIBC.

Operationalizing patient-centered cancer care: A systematic review and synthesis of the qualitative literature on cancer patients' needs, values, and preferences

OBJECTIVE

Efficiently addressing patient priorities and concerns remains a challenge in oncology. Systematic operationalization of patient-centered care (PCC) can support improved assessment and practice of PCC in this unique care setting. This review aimed to synthesize the qualitative empirical literature exploring the National Academy of Medicine (NAM)'s PCC constructs of values, needs, and preferences among patients' during their cancer treatment experiences.

METHODS

A systematic review of qualitative studies published between 2002 and 2018 addressing adult patient values, needs, and preferences during cancer treatment was conducted. Medline, EMBASE, PsycINFO, and SCOPUS databases were searched on September 10, 2018. Methodological rigor was assessed using a modified version of the Evaluation Tool for Qualitative Studies. Included study findings were analyzed using line-by-line coding; and the emergent themes were compared to the National Academy of Medicine (NAM)'s PCC dimensions.

RESULTS

Twenty-nine primary studies were included in the synthesis. Descriptive themes for values (autonomy, being involved, family, hope, normality, and sincerity), needs (care coordination, information, privacy, support of physical well-being, emotional support (family/friends, peer, provider), and self-support), and preferences (care coordination, decision-making, information delivery, source of social support, and treatment) were identified. "Cancer care context" emerged as an important domain in which these constructs are operationalized. This thematic framework outlines PCC attributes that oncology care stakeholders can evaluate to improve patient experiences.

CONCLUSIONS

These findings build on previous PCC research and may contribute to the systematic assessment of patient priorities and the improvement of oncology care quality from the patient perspective.

Predictive Values of Preoperative Prognostic Nutritional Index and Systemic Immune-Inflammation Index for Long-Term Survival in High-Risk Non-Muscle-Invasive Bladder Cancer Patients: A Single-Centre Retrospective Study

Purpose

This study aimed to investigate the associations between the preoperative prognostic nutritional index (PNI), systemic immune-inflammation index (SII) and overall survival (OS) and cancer-specific survival (CSS) in high-risk non-muscle-invasive bladder cancer (NMIBC) patients who received intravesical instillation of Bacillus Calmette-Guerin (BCG) after transurethral resection of bladder tumour (TURBT).

Patients and Methods

We retrospectively collected data from 387 high-risk NMIBC patients between January 2004 and December 2014. PNI was calculated as total lymphocyte count (10⁹/L)×5+albumin concentration (g/L). SII was calculated as neutrophil count (10⁹/L)×platelet count (10⁹/L)/lymphocyte count (10⁹/L). The cutoff values of PNI and SII were determined through receiver operating characteristic (ROC) analysis. OS and CSS were estimated by Kaplan–Meier analysis. The Log rank test was used to compare differences between the groups. Univariate and multivariate Cox regression analyses were performed to assess the predictive values of PNI and SII for OS and CSS. Additionally, highest-risk NMIBC patients were also divided into low or high groups according to PNI and SII. The OS and CSS of highest-risk NMIBC patients were estimated using Kaplan-Meier analysis with the Log rank test.

Results

The patients were divided into two groups according to the cutoff values of PNI (<50.17 vs ≥50.17) and SII (<467.76 vs ≥467.76). Kaplan–Meier analysis revealed that low PNI and high SII were associated with poorer OS and CSS in high-risk NMIBC patients. Univariate and multivariate Cox regression analyses revealed that PNI and SII were independent predictive factors for OS and CSS. Kaplan–Meier analysis also revealed that low PNI and high SII were related to poorer OS and CSS in highest-risk NMIBC patients.

Conclusion

These results suggest that preoperative PNI and SII, based on standard laboratory measurements, may be useful noninvasive, inexpensive and simple tools for predicting the long-term survival of high-risk NMIBC patients who received intravesical instillation of BCG after TURBT.

Quality of life and adverse events in patients with nonmuscle invasive bladder cancer receiving adjuvant treatment with BCG, MMC, or chemohyperthermia

INTRODUCTION

Chemohyperthermia (CHT) with mitomycin C (MMC) is together with Bacillus Calmette-Guérin (BCG), and passive MMC, a treatment option for patients with non muscle-invasive bladder cancer. There are no data published about the impact of CHT in quality of life (QoL). We evaluated QoL and adverse events (AE) in this 3-arm observational study.

PATIENTS AND METHODS

Prospective observational study from September 2016 to March 2017, we recruited consecutive patients that received adjuvant treatment after transurethral resection of bladder tumor. Patients received induction courses of either BCG, CHT, or passive MMC. Patients filled the questionnaires Functional assessment of cancer therapy for bladder cancer patients (FACT-Bl) and International prostate symptom score (IPSS) before, during, and after the induction course. A urologist documented AE using Common Terminology Criteria for AE (CTCAE criteria).

RESULTS

A total of 56 patients, receiving a total of 296 bladder instillations (BCG n = 27, CHT n = 14 and MMC n = 15). FACT-Bl showed statistically significant differences in the fourth week in favor of CHT versus BCG, IPSS did not show statistically significant differences before, during, and after induction course in all 3 arms. All patients recovered their baseline QoL at the end of the induction treatment. Overall 55.5%, 50% and 20% of patients presented any grade of AE in the BCG, CHT and MMC groups respectively. About 7% of patients in BCG and CHT arms had to discontinue treatment due to AE. BCG and CHT showed a similar rate of AE but in CHT were mostly grade I and BCG had grade I, II, and IV. Passive MMC had the safest profile.

CONCLUSION

There are no clinically significant differences between BCG, CHT, and passive MMC regarding QoL and lower urinary tract symptoms during the induction course. CHT has a more favorable AE profile when compared with BCG.

DaBlaCa-11: Photodynamic Diagnosis in Flexible Cystoscopy-A Randomized Study With Focus on Recurrence

OBJECTIVE

To examine whether photodynamic diagnosis (PDD) in addition to flexible cystoscopy in the outpatient clinic can reduce risk of tumor recurrence in patients with previous nonmuscle invasive bladder cancer. PDD is an optical technique that enhances the visibility of pathologic tissue and helps guidance tumor resection.

METHODS

From February 2016 to December 2017, 699 patients from 3 urologic departments in Denmark were enrolled in a randomized controlled trial. Four months after transurethral resection of bladder tumor patients were randomized 1:1 to either an intervention group (hexaminolevulinate was instilled in the bladder before flexible cystoscopy with PDD video cystoscope) or a control group (white light flexible cystoscope), only. Primary endpoint was tumor recurrence within 8 months from the randomization. Secondary outcomes were numbers of procedures in general anesthesia, time to the first recurrence, differences in tumor size, risk of tumor progression, and identification of carcinoma in situ.

RESULTS

A total of 351 patients were allocated to the intervention group (flexible PDD), and 348 to the control group (flexible white light). Throughout the following 8 months after randomization, only 117 patients in the intervention group had at least 1 tumor recurrence compared to 143 patients in the control group (P = .049). Odds ratio of 0.67 (P = .02, 95% CI: 0.48-0.95) correlates with a tumor reduction of 33% in favor of the intervention group.

CONCLUSION

Use of PDD in a routine surveillance cystoscopy first time after transurethral resection of bladder tumor for nonmuscle invasive bladder cancer reduces subsequent risk of tumor recurrence compared to WL cystoscopy alone.

Patient perspectives of vigorous intensity aerobic interval exercise prehabilitation prior to radical cystectomy: a qualitative focus group study

PURPOSE

Preoperative cardiopulmonary fitness is increasingly being recognized as an important factor influencing postoperative recovery outcomes in cancer patients. The aim of this study was to explore patient perspectives of preoperative high intensity aerobic interval exercise before radical cystectomy.

MATERIALS AND METHODS

Focus groups involving a purposive convenience sample of patients with bladder cancer (N = 14; mean age ± SD: 72.3 ± 6.0 years) were undertaken in a hospital education department. Data were analyzed using Framework analysis.

RESULTS

Participants identified physical (e.g., fitness) psychological (e.g., preparing for their operation) and social (e.g., peer support) benefits of the program. Key motivational factors for engaging in exercise prehabiliation were identified as social support, previous exercise experience and objective measures of progression. The need for clear information from healthcare providers to ensure that patients are adequately prepared for sessions was highlighted.

CONCLUSIONS

This qualitative study provides new insights into the perspectives and experiences of patients with bladder cancer regarding participation in preoperative vigorous intensity aerobic exercise. The study yielded novel perceptions on the physical, psychological and social health benefits accruing from the exercise program and patient views on program design features, which are important for informing future interventions and implementation strategies.IMPLICATIONS FOR REHABILITATIONA preoperative high intensity aerobic interval exercise program before radical cystectomy provides physical, psychological and social benefits to individuals living with bladder cancer.Supervised exercise, objective improvement, and peer and family support all contribute to motivation to engage with preoperative high intensity aerobic interval exercise.Individuals may require support post-radical cystectomy in order to continue with exercise due to the uncertainty around this.

Association between treatment of superficial bladder cancer and 10-year mortality in older adults with multiple chronic conditions

BACKGROUND

Multiple chronic conditions (MCC) are common among older patients with cancer; however, the exclusion of these patients from clinical trials has resulted in scarce knowledge concerning outcomes, resulting in variations in treatment. Superficial bladder cancer (SBC) disproportionately affects older adults, yet to the authors' knowledge few studies to date have examined whether treatment improves long-term survival. In the current study, the authors evaluated the association between treatment of SBC and 10-year mortality in medically complex older adults.

METHODS

The authors identified 1800 older (aged ≥60 years) patients with SBC (American Joint Committee on Cancer stage ≤I) from 2 community-based health systems who received treatment (bladder instillation and/or transurethral resection) or observation. Cox proportional hazards regression was performed adjusting for age, sex, race, health system, stage of disease/grade, and MCC (≥2 baseline chronic conditions). Propensity score analysis using stabilized inverse probability of treatment weights was used to compare 10-year mortality in the 2 treatment groups with adjustment for covariates.

RESULTS

Overall, 1485 patients (82.5%) and 315 patients (17.5%) received treatment and observation, respectively. In unweighted multivariable analysis, treatment was associated with a 30% reduction in death (adjusted hazard ratio [HR], 0.70; 95% confidence interval [95% CI], 0.58-0.85 [P<.01]) and MCC with a 72% increase in death (adjusted HR, 1.72; 95% CI, 1.44-2.05 [P<.01]). Weighted analysis with adjustment (doubly robust) also demonstrated a survival benefit for treatment (adjusted HR, 0.66; 95% CI, 0.52-0.84 [P<.01]).

CONCLUSIONS

The results of the current study demonstrated a clinically meaningful association between cancer treatment and survival benefit in older, medically complex patients with SBC, even after adjustment for medical complexity. These data provide a foundation for future work aimed at personalizing the treatment guidance of older patients with cancer with MCC.