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Herzberg H, Ventura Y, Lifshitz K, Savin Z, Golan S, Baniel J, Yossepowitch O, Mano R. Natural history and health care burden of non-curative treatment for muscle-invasive bladder cancer. Urol Oncol 2024; 42:246.e7-246.e13. [PMID: 38641474 DOI: 10.1016/j.urolonc.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/31/2023] [Accepted: 03/10/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE Muscle-invasive bladder cancer is an aggressive disease. Yet, many patients, especially those with advanced age and multiple comorbidities, do not receive treatment with curative intent. We evaluated the disease course and health care burden of these patients. MATERIALS AND METHODS Bi-center, retrospective analysis of patients diagnosed with muscle-invasive bladder cancer who did not undergo curative-intent treatment (radical cystectomy or trimodal therapy) between 2016 and 2021. Patient characteristics and treatment burden were described. Metastasis-free, cancer-specific, and overall survivals were evaluated using the Kaplan-Meier method. RESULTS Sixty-six patients with a median age of 86 (IQR 78,90) were evaluated. The median follow-up for survivors was 29 months (IQR 9, 44). All patients were diagnosed with muscle-invasive bladder cancer, and 32 (48%) presented with clinical T3 and T4 disease. The median age adjusted Charlson comorbidity index at diagnosis was 7 (IQR 6,8). Treatment with curative intent was not provided due to comorbidities and low-performance status in 58 patients (88%) and patient refusal in 8 (12%). Two-year estimated metastasis-free survival, cancer-specific survival, and overall survival were 11%, 18%, and 12%, respectively. During follow-up, 7 patients (10%) were treated with chemotherapy, 4 (6%) received immunotherapy, 21 (32%) radiation, and 17 (26%) had emergent operations due to hematuria. Twenty-four patients (37%) required nephrostomy tubes, and 39 (59%) required an indwelling urinary catheter for various periods. Forty-three patients (65%) suffered from recurrent hematuria episodes. Overall, median emergency room visits were 4 (IQR 2, 6), and median hospital admission was 16 days (IQR 9, 29). CONCLUSIONS Untreated muscle-invasive bladder cancer is associated with a limited lifespan and a high disease burden for the patient and health system. These data should be taken into consideration and portrayed to the patient when curative intent treatment is chosen to be avoided.
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Affiliation(s)
- Haim Herzberg
- Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yossi Ventura
- Division of Urology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karin Lifshitz
- Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ziv Savin
- Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shay Golan
- Division of Urology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jack Baniel
- Division of Urology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Yossepowitch
- Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Mano
- Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Verschoor N, Heemsbergen WD, Boormans JL, Franckena M. Bladder-sparing (chemo)radiotherapy in elderly patients with muscle-invasive bladder cancer: a retrospective cohort study. Acta Oncol 2022; 61:1019-1025. [PMID: 35880448 DOI: 10.1080/0284186x.2022.2101381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Organ-sparing treatment for muscle-invasive bladder cancer by maximal transurethral removal of the tumor (TURB) followed by chemoradiation (CRT) has shown promising results in recent studies, and is therefore considered to be an acceptable alternative for the standard of radical cystectomy (RC) in selected patients. We report on outcomes in a single-center, retrospective CRT cohort in comparison to a RC and radiotherapy only (RT) cohort. PATIENTS AND METHODS The patient population included n = 84 CRT patients, n = 93 RC patients, and n = 95 RT patients. Primary endpoints were local control (LC) up to 2 years and overall survival (OS) up to 5 years. Cox regression was performed to determine risk factors for LC and OS in the CRT group. Acute genito-urinary (GU) and gastro-intestinal (GI) toxicity were scored with CTCAE version 4 for the RT and CRT cohort. Logistic regression was used to determine risk factors for toxicity. We followed the EQUATOR guidelines for reporting, using the STROBE checklist for observational research. RESULTS Baseline characteristics were different between the treatment groups with in particular worse comorbidity scores and higher age in the RT cohort. The CRT schedule was completed by 96% of the patients. LC at 2 years was 83.4% (90% CI 76.0-90.8) for CRT vs. 70.9% (62.2-79.6) for RC and 67.0% (56.8-77.2) for RT. OS at 5 years was 48.9% (38.4-59.4) for CRT vs. 46.6% (36.4-56.8) for RC, and 27.6% (19.4-35.8) for RT. High T stage was significantly associated with worse LC and OS in the CRT group. GU/GI toxicity grade ≥2 occurred in 43 (48.3%) RT patients and 38 (45.2%) CRT patients. CONCLUSIONS The organ-preserving strategy with CRT was feasible and tolerable in this patient population, and the achieved LC and OS were satisfactory in comparison to the RC cohort and literature.
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Affiliation(s)
- Noortje Verschoor
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wilma D Heemsbergen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joost L Boormans
- Department of Urology, Erasmus Medical Centre, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Martine Franckena
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Alati A, Fabiano E, Geiss R, Mareau A, Charles-Nelson A, Bibault JE, Giraud P, Kreps S, Méjean A, Housset M, Durdux C. Bladder preservation in older adults with muscle-invasive bladder cancer: A retrospective study with concurrent chemotherapy and twice-daily hypofractionated radiotherapy schedule. J Geriatr Oncol 2022; 13:978-986. [PMID: 35717533 DOI: 10.1016/j.jgo.2022.05.014] [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: 12/29/2021] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Bladder cancer occurs mainly in older adults and surgery is not always possible when there are geriatric conditions and comorbidities. Trimodal treatment (TMT) combining trans-urethral resection of bladder tumour (TURBT) followed by concurrent chemoradiation (CRT) would be a curative alternative in such patients. METHODS All consecutive patients 75 years of age and older with non-metastatic muscle-invasive bladder cancer (MIBC) treated with TMT by Georges Pompidou European Hospital team were retrospectively analysed. Induction CRT combined hypofractionated twice-daily radiotherapy targeting bladder and pelvis to a total dose of 24 Gy (Gy) with concurrent platinum salt and 5-fluorouracil. Consolidation CRT to a total dose of 44 Gy was proposed to patients with biopsy-proven complete response after induction phase and those with persistent tumour underwent salvage cystectomy. We assessed using Kaplan-Meier method overall survival (OS), cancer specific survival (CSS), invasive recurrence-free survival (IRFS), metastasis-free survival (MFS), survival with bladder preserved (SBP), and toxicities. With a Cox model for OS and the Fine Gray method of competing risk for secondary endpoints, we analysed in univariate (u) and multivariate (m) analysis the impact of tumour characteristics and patient profiles: gender, age, age-adjusted Charlson comorbidity index, polypharmacy, and malnutrition. RESULTS From 1988 to 2017, 85 patients were included. After induction, complete response rate was 83.5%. With a median follow-up of 63 months, 5 year-OS, CSS, IRFS, MFS and SBP were 61.0%, 77.6%, 71%, 82.9%, and 70.2% respectively. A persistent tumour after induction impacted SBP (SHRm 3.61; p = 0.004), CSS (SHRm 3.27; p = 0.023), and MFS (SHRm 3.68; p = 0.018). Late grade 3 urinary and gastrointestinal toxicities were 3.5% and 1.2%. CONCLUSION We report here the largest series of bladder preservation over 75 years in a curative intent. Outcomes and tolerance in selected older adults compared favourably with surgical series and with CRT studies using classical fractionation.
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Affiliation(s)
- Aurélia Alati
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France.
| | - Emmanuelle Fabiano
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Romain Geiss
- Geriatric Department, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Alexis Mareau
- Clinical Research Unit, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Anais Charles-Nelson
- Clinical Research Unit, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Jean-Emmanuel Bibault
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Philippe Giraud
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Sarah Kreps
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Arnaud Méjean
- Department of Urology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Martin Housset
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Catherine Durdux
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
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Effect of Chinese Medicine on the Biological Behavior and Magnetic Resonance Imaging of Bladder Cancer. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:1124526. [PMID: 34737776 PMCID: PMC8563130 DOI: 10.1155/2021/1124526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/16/2021] [Indexed: 11/17/2022]
Abstract
Objective This study aimed to investigate the effects of traditional Chinese medicine (TCM) on biological behavior and magnetic resonance imaging and recurrence rate of patients with bladder cancer. Method Forty-seven postoperative bladder cancer patients treated in our hospital who met the criteria were selected and randomly divided into the TCM treatment group (observation group) and the group without TCM treatment (control group). In the TCM treatment group, the prescription was slightly adjusted according to the different symptoms, and the main prescription remained unchanged. According to the treatment plan, patients continued to undergo bladder irrigation chemotherapy plus TCM treatment, while the control group was only treated with bladder irrigation chemotherapy. The number of patients with recurrence at 3 and 6 months and 1 year, the effects on patients' clinical symptoms, and quality of life were observed, respectively. The changes in MRI images, blood routine, immune function, and leukocyte level and other related indexes before and after treatment were compared between the two groups. Results After the patients in the observation group were treated with traditional Chinese medicine, the patients' quality of life significantly improved. The patients' CD3+, CD4+, and CD4+/CD8+ indexes were significantly higher than those of the control group. The levels of Hb and PLT of the patients in the observation group were significantly lower than those of the patients in the control group. Patients in the observation group had higher leukocyte levels and a lower recurrence rate than patients in the control group. Conclusion TCM with chemotherapy drugs can effectively improve patients' immune function, increase the level of T-lymphocyte subpopulation, and improve bone marrow hematopoietic function, which has a significant effect on the prevention and treatment of bladder cancer recurrence after surgery.
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[Optimizing the management of bladder cancer in older patients]. Prog Urol 2019; 29:849-864. [PMID: 31771768 DOI: 10.1016/j.purol.2019.08.273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 08/08/2019] [Accepted: 08/19/2019] [Indexed: 11/22/2022]
Abstract
AIM To define and present potential improvements for the management of bladder cancer in older patients. METHOD Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: bladder cancer, treatment, BCG, chemotherapy, cystectomy, and elderly. RESULTS The oncological principles of medico-surgical management of bladder cancer do not differ according to age. On the other hand, the patient comorbidities have been likely to alter the tolerance of these treatments. At the NMIBC stages, no adaptation of the standard treatment has demonstrated any interest. At the MIBC stages, the prognosis was improved by geriatric multidisciplinary perioperative management. CONCLUSION The indications and principles of surgical treatments must be identical regardless of the patient age. At the NMIBC stages, adjuvant therapy, including BCG therapy, should not be questioned because of the age of the patient. On the other hand, at the localized MIBC stages, neoadjuvant and adjuvant chemotherapy should not be considered as a standard and their indications assessed individually after geriatric assessment.
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Klén R, Salminen AP, Mahmoudian M, Syvänen KT, Elo LL, Boström PJ. Prediction of complication related death after radical cystectomy for bladder cancer with machine learning methodology. Scand J Urol 2019; 53:325-331. [PMID: 31552774 DOI: 10.1080/21681805.2019.1665579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: To create a pre-operatively usable tool to identify patients at high risk of early death (within 90 days post-operatively) after radical cystectomy and to assess potential risk factors for post-operative and surgery related mortality.Materials and methods: Material consists of 1099 consecutive radical cystectomy (RC) patients operated at 16 different hospitals in Finland 2005-2014. Machine learning methodology was utilized. For model building and testing, the data was randomly divided into training data (n = 733, 66.7%) and independent testing data (n = 366, 33.3%). To predict the risk of early death after RC from baseline variables, a binary classifier was constructed using logistic regression with lasso regularization. Finally, a user-friendly risk table was constructed for practical use.Results: The model resulted in an area under the receiver operating characteristic curve (AUROC) of 0.73 (95% CI = 0.59-0.87). The strongest risk factors were: American Society of Anesthesiologists physical status classification (ASA), congestive heart failure (CHF), age adjusted Charlson comorbidity index (ACCI) and chronic pulmonary disease.Conclusion: This study with a novel methodological approach adds CHF and chronic pulmonary disease to previously known independent prognostic risk factors for early death after RC. Importantly, the risk prediction tool uses purely pre-operative data and can be used before surgery.
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Affiliation(s)
- Riku Klén
- Turku Centre for Biotechnology, University of Turku and Åbo Akademi University, Turku, Finland.,Turku PET Centre, University of Turku, Turku, Finland
| | - Antti P Salminen
- Department of Urology, Turku University Hospital and University of Turku, Turku, Finland
| | - Mehrad Mahmoudian
- Turku Centre for Biotechnology, University of Turku and Åbo Akademi University, Turku, Finland.,Department of Future Technologies, University of Turku, Turku, Finland
| | - Kari T Syvänen
- Department of Urology, Turku University Hospital and University of Turku, Turku, Finland
| | - Laura L Elo
- Turku Centre for Biotechnology, University of Turku and Åbo Akademi University, Turku, Finland
| | - Peter J Boström
- Department of Urology, Turku University Hospital and University of Turku, Turku, Finland
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Jodon G, Fischer SM, Kessler ER. Treatment of Urothelial Cancer in Elderly Patients: Focus on Immune Checkpoint Inhibitors. Drugs Aging 2019; 35:409-421. [PMID: 29744750 DOI: 10.1007/s40266-018-0540-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Urothelial carcinoma, or bladder cancer, is a malignancy that most commonly affects older patients. The median age at diagnosis is 73 years, and care of these patients requires consideration not just of the disease-related factors such as stage and histology, but also of patient-related factors. Many of these patients have concurrent medical morbidities and additional changes related to the aging process. Older patients with cancer are a unique population requiring additional considerations and assessment in treatment decision-making. It is important to look beyond chronologic age. The traditional treatment for advanced disease has relied on platinum-based chemotherapy. These multi-agent regimens require consideration of baseline organ function as well as competing conditions that may heighten toxicity. The advent of a new class of cancer therapeutics, the immune checkpoint inhibitors, has changed the care of patients with advanced disease considerably. These immunotherapeutics have been approved for treating patients with disease progression on chemotherapy, or those who are ineligible (or unfit) to receive cisplatin-based therapy. This expansion of the population of patients eligible for treatment has great applicability to the unique considerations in an older patient population. In general, these new immunotherapies are well tolerated and effective in this group of patients.
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Affiliation(s)
- Gray Jodon
- University of Colorado School of Medicine, Denver, CO, USA
| | - Stacy M Fischer
- University of Colorado School of Medicine, Denver, CO, USA.,University of Colorado Cancer Center, Aurora, USA
| | - Elizabeth R Kessler
- University of Colorado School of Medicine, Denver, CO, USA. .,University of Colorado Cancer Center, Aurora, USA.
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