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Editorial: Predicting progression in T1 non‐muscle‐invasive bladder cancer: back to histology

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Stage pT1 bladder carcinomas (BCs) represent a difficult clinical scenario as they have different outcomes and are associated with a high risk of progression to muscle‐invasive tumours. The optimal therapeutic approach for individual patients in this setting is still unclear: conservative treatment with BCG instillation and intravesical chemotherapy may lead to disease progression and death, while radical cystectomy may represent a mutilating overtreatment for patients with tumours that may have low potential for progression.

The ability to discriminate those patients who will probably progress to carcinoma invading bladder muscle is therefore crucial. Among prognostic factors associated with progression to muscle invasion, tumour grade is one of the most important. In their important paper, van de Putte et al. [1] aimed to compare the prognostic value of the WHO 1973 and 2004 grading systems, the latter being recommended by the AUA guidelines as the most widely accepted in the USA [2], although it has not been proven superior to the other [3].

The authors collected transurethral resections from 601 primary T1 BCs, initially managed conservatively (BCG), from four institutions, and three pathologists reviewed the slides. Importantly, a second transurethral resection was performed if the muscularis propria was absent and/or the initial resection was incomplete. Grade was assigned according to the WHO 1973 (G1–3) and WHO 2004 (low grade [LG] and high grade [HG]) systems. None of the cases was classified as G1. The prognostic value of both grading systems for progression‐free and cancer‐specific survival was then assessed. Notably, the author found WHO1973 G3 to be significantly negatively associated with progression‐free survival and cancer‐specific survival on multivariable analysis, while the WHO 2004 grading system was not. Importantly, intra‐observer variability was assessed in 66 cases and was found to be almost perfect for the WHO 1973 and moderate to substantial for the WHO 2004 system, while inter‐observer variability ranged from moderate to substantial for both systems. One of the reasons for the lack of prognostic potential of the WHO 2004 system, as underscored by the authors, is the fact that the morphological criteria defined in the WHO 2004 system cause an important shift of many cases from the G2 to HG category, rendering it an almost one‐tier system with consequently very few LG tumours. Other studies have assessed the prognostic value of the WHO 1973 and WHO 2004 systems [3] but so far no clear superiority emerged for one system over the other, probably because of relatively low sample sizes.

Other clinical prognostic factors associated with progression to muscle‐invasive tumours include tumour dimension, the presence of multiple lesions, the presence of carcinoma in situ, lymphovascular invasion and level of lamina propria invasion. Regarding the latter prognostic factor, different studies have defined T1 sub‐staging according to invasion above (T1a), within (T1b) or beyond (T1c) the muscularis mucosae and vascular plexus; however, this approach has been found not to be applicable in >40% of cases because of difficulties in identifying the vascular plexus or lack of orientation of the specimens. A more friendly and reproducible method has been proposed by some of the authors of the study, consisting of a categorization of T1 BCs into microinvasive (T1m) and extensively invasive (T1e) tumours, which has been demonstrated to be applicable in 100% of cases and more reproducible [4]. Further study incorporating T1 sub‐staging together with grade may prove very useful.

Different studies have been performed to identify prognostic markers at the molecular level; however, despite huge efforts, no molecular biomarker with prognostic potential is currently suitable for clinical application [5]. Moreover, in six studies that investigated T1 sub‐stage and molecular markers in the same series, T1 sub‐stage showed the highest prognostic value [4]. More recently, subtyping BC into basal‐like and genomically unstable or squamous cell carcinoma‐like tumours has emerged as a promising tool for dividing T1 BCs into low‐ and high‐risk categories [6]; however, such an approach must be combined with the prognostic value of the classic histological variables discussed so far before eventually being integrated into prognostic tools.

In this regard, van de Putte et al. [1] have shown that tumour grade still represents a powerful marker in T1 BC and that the WHO 2004 grading system cannot replace the WHO 1973 system as a prognosticator of T1 BC; therefore, as recommended by the European Association of Urology guidelines, the WHO 1973 grading system categories should always be present in the pathology reports.

 

References

  1. van de Putte EEF, Bosschieter J, van der Kwast TH et al. The World Health Organization 1973 classification system for grade is an important prognosticator in T1 non‐muscle‐invasive bladder cancer. BJU Int 2018; 122: 978–85
  2. Chang SS, Boorjian SA, Chou R et al. Diagnosis and treatment of non‐muscle invasive bladder cancer: AUA/SUO guideline. J Urol 2016; 196: 1021–93
  3. Babjuk M, Bohle A, Burger M et al. EAU guidelines on non‐muscle‐invasive urothelial carcinoma of the bladder: update 2016. Eur Urol 2017; 71: 447–614
  4. van Rhijn BW, Liu L, Vis AN et al. Prognostic value of molecular markers, sub‐stage and European Organisation for the Research and Treatment of Cancer risk scores in primary T1 bladder cancer. BJU Int 2012; 110: 1169–76
  5. Munari E, Chaux A, Maldonado L et al. Cyclin A1 expression predicts progression in pT1 urothelial carcinoma of bladder: a tissue microarray study of 149 patients treated by transurethral resection. Histopathology 2015; 66: 262–9
  6. Patschan O, Sjodahl G, Chebil G et al. A molecular pathologic framework for risk stratification of stage T1 urothelial carcinoma. Eur Urol 2015; 68: 824–32

 

Article of the month: Effect of timing of an immediate instillation of mitomycin C after TUR in 941 patients with NMIBC

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Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

The effect of timing of an immediate instillation of mitomycin C after transurethral resection in 941 patients with non-muscle-invasive bladder cancer

Judith Bosschieter*, R. Jeroen A. van Moorselaar*, André N. Vis*, Tessa van Ginkel*, Birgit I. Lissenberg‐Witte†, Goedele M.A. Beckers* and Jakko A. Nieuwenhuijzen*

 

Departments of *Urology and †Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands

 

Read the full article

Abstract

Objective

To investigate whether the timing of an immediate instillation of mitomycin C (on the day of transurethral resection of bladder tumour [TURBT] or 1 day later) has an impact on time to recurrence of non‐muscle‐invasive bladder cancer (NMIBC).

Patients and Methods

All patients with NMIBC who were enrolled in a prospective trial between 1998 and 2003, and treated with an early mitomycin C instillation (on the day of TURBT or 1 day later), were selected. Statistical analysis was performed with Kaplan–Meier curves and multivariable Cox regression.

Fig. 1 Kaplan–Meier analysis showing time to recurrence for patients treated with an immediate instillation of MMC on the day of TURBT (Day‐0 group) or 1 day after (Day‐1 group).

Results

Administering an instillation of mitomycin C on the day of TURBT or 1 day later did not show a statistically significant difference in time to recurrence in a univariable model (log‐rank P = 0.99). After correcting for the number of scheduled adjuvant instillations, no statistically significant difference could be detected either: hazard ratio 1.05 (95% confidence interval 0.81–1.35, P = 0.74).

Conclusion

These data do not support the hypothesis that a very early instillation (on the day of TURBT) of mitomycin C decreases the risk of recurrence as compared with an early instillation (1 day after TURBT).

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Editorial: Postoperative intravesical chemotherapy has an important role in reducing subsequent bladder tumours – why is it not routine?

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Transurethral resection of bladder tumour (TURBT) is a frequent operation performed by urologists worldwide. Although on occasion the procedure can be quite challenging, the majority are relatively straightforward with little morbidity. In most cases, where the medical system allows, it is an outpatient procedure. Nonetheless, with the exception of small low‐grade tumours the patient is anaesthetised. It is costly, as the procedure requires medical clearance, an operating room team and equipment.

Most patients with bladder cancer have Ta or less frequently T1 tumours. Despite an initial TURBT, 30–80% of patients develop another tumour. Most are new tumours and some may be recurrences. The reasons for the high ‘recurrence’ rate are the continued impact of the carcinogen, e.g. cigarettes, incomplete resection, missed tumours, and tumour implantation on the altered urothelium. The urologist can help reduce these events by stressing the importance of limiting carcinogen exposure e.g. smoking cessation, striving to perform a complete TURBT, reviewing the entire bladder after the TURBT to avoid missing tumours (using narrow‐band imaging or fluorescent cystoscopy if available), and limiting implantation of tumour cells on the altered urothelial surface with the use of postoperative intravesical chemotherapy (POIVC).

There is a large body of evidence that POIVC reduces the chance of a subsequent tumour [1]. I became convinced that implantation occurs after animal studies demonstrated that bladder cancer cells placed into the bladder preferentially implant and grow only if the urothelial surface had been cauterised or otherwise damaged prior to exposure to the bladder cancer cells [2]. Prospective randomised trials eventually confirmed the benefit of POIVC [3]. The paper published in this issue of the BJUI by Bosschieter et al. [4] indicates that POIVC is equally effective if given the same day or the day after TURBT. Thus, if there are obstacles to instilling the medication on the day of the TURBT the drug can be administered the following day.

The evidence in favour of POIVC for bladder tumours is particularly impressive for Grade 1–2 Ta tumours. In my view, all patients with primary or ‘recurrent’ single or multiple papillary Grade 1–2 Ta tumours are the optimal candidates to receive POIVC [5]. POIVC is recommended by the European Association of Urology (EAU) and AUA/Society of Urologic Oncology (SUO) [6,7] yet, the adoption of this guideline is far from uniform. I queried my colleagues from the International Bladder Cancer group (IBCG), as they are conversant in the scientific basis for POIVC and represent several countries with different medical systems [8]. Their comments are pertinent and consistent with my understanding of the issues. Here are some of the common reasons for not following the guidelines: (i) Some urologists are not convinced that the reduction in the ‘recurrence’ rate is sufficient to use POIVC. (ii) The most common chemotherapeutic agent for POIVC in the USA is mitomycin C and it is expensive. The cost for 40 mg is ~$1000. It is approximately $500 in Europe. (iii) Hospitals have rules regarding the delivery of chemotherapy and the pharmacy and nursing departments may not make it easy to instil the drug in the postoperative setting. Some hospitals require notification a day before the surgery and the drug is wasted if the drug is not used. (iv) Urologists are concerned about extravasation and uncertainty of the tumour grade and stage. There may be other reasons but these help explain why POIVC is not routine.

On the other hand many patients with bladder cancer require frequent TURBTs. I am certain that following an uneventful TURBT or office cauterisation for Grade 1–2 Ta bladder cancer, they would choose to receive POIVC if properly informed. Urologists are proficient at judging whether a tumour fits the criteria for POIVC and if they underestimate the grade or stage the patient may still benefit. If urologists cannot instil the chemotherapy on the day of the TURBT, they can instil the drug the following day without compromising effectiveness. I believe it is our job to do what we can to help our patients and in this instance we should do our best to minimise subsequent tumour events, which includes the use of adjuvant chemotherapy.

Mark S. Soloway

Memorial Hospital Hollywood, Miami, FL, USA

References

  1. Perlis N, Zlotta AR, Beyene J, Finelli A, Fleshner NE, Kulkarni GS. Immediate post‐ transurethral resection of bladder tumor intravesical chemotherapy prevents non‐muscle invasive bladder tumor recurrence: an updated meta‐analysis on 2548 patients and quality –of‐evidence review. Eur Urol 2013; 64: 421–30
  2. Weldon TE, Soloway MS. Susceptibility of urothelium to neoplastic cellular implantation. Urology 1975; 5: 824–7
  3. Tolley DA, Hargreave TB, Smith PH et al. Effect of intravesical mitomycin C on recurrence of newly diagnosed superficial bladder cancer: interim report from the Medical Research Council Subgroup on Superficial Bladder cancer. Br Med J 1988; 296: 1259–61
  4. Bosschchieter J, von Moorselaar JA, Vis AN et al. The effect of timing of an immediate instillation of mitomycin C after transurethral resection in 941 patients with non‐muscle‐invasive bladder cancer. BJU Int 2018; 122: 571–5
  5. Klaassen Z, Soloway MS. European Association of Urology and American Urological Association/Society of Urologic Oncology guidelines on risk categories for non‐muscle‐invasive bladder cancer may lead to overtreatment for low‐grade Ta bladder tumors. Urology 2017; 105: 14–7
  6. Babjuk M, Böhle A, Burger M et al. EAU guidelines in non‐muscle invasive urothelial carcinoma of the bladder: update 2016. Eur Urol 2017; 71: 447–61
  7. Chang SS, Boorjian SA, Chou R et al. Diagnosis and treatment of non‐muscle invasive bladder cancer: AUA/SUO guideline. J Urol 2016; 196: 1021–9
  8. Brausi M, Witjes F, Lamm D et al. A review of current guidelines and best proactive recommendations for the management of nonmuscle invasive bladder cancer by the International Bladder Cancer Group. J Urol 2011; 186: 2158–67

 

Highlights from the Irish Society of Urology Annual Meeting 2018

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Dr Kent T. Perry Jr. delivers a lecture on minimally invasive kidney surgery

The Irish Society of Urology annual meeting has a strong tradition of attracting world class guest speakers, and this year was no different. We were joined by Dr Kent T. Perry Jr. (Co-Director of the Minimally Invasive Surgery Program & Associated Professor at Northwestern University Chicago), Professor Hendrik Van Poppel (Adj. Secretary General of EAU for Education), Mr Jeremy Ockrim (Honorary Lecturer and Consultant Urologist at University College London), Mr Kieran O’Flynn (Immediate BAUS past president and Consultant Urologist at Salford Royal Foundation), and Dr Matthias Hofer (Assistant Professor at Dept. Urology, Northwestern University Chicago). The excellent programme of guest speakers started on Friday afternoon with Dr Matthias Hofer’s talk on urethral reconstruction-a ‘no frills’ overview of a complex topic which surely inspired several trainees in the room to consider a career in Reconstructive Urology.

The historic Strokestown House, Co. Roscommon

The Saturday formal dinner was held in the historic Strokestown House in Roscommon-the former home of the Packenham Mahon family, built on the site of a 16th Century castle, which was home to the O’Conor-Roe Gaelic Chieftains. It is now the site of the National Famine Museum. We were treated to a fascinating tour of the house on arrival, before enjoying a wonderful dinner, and some fantastic harp-playing. The presidential chain was conferred to the incoming president, Mr Paul Sweeney of The Mercy University Hospital in Cork, and the society are already looking ahead to exciting things during his tenure as president.

 

About the authors:

Dr Clare O’Connell is a first year Urology SpR in the Department of Urology & Transplant in Beaumont Hospital, Dublin (@oconnellclare).

 

 

 

Dr Sorcha O’Meara is a second year Urology SHO in the Department of Urology in The Mater Misericordiae University Hospital, Dublin (@sorchaOm).

 

 

 

Article of the Week: Impact of bladder cancer on health‐related quality of life

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Every Week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video discussing the paper.

If you only have time to read one article this week, it should be this one.

Impact of bladder cancer on health‐related quality of life

Angela B. Smith*†, Byron Jaeger‡, Laura C. Pinheiro§, Lloyd J. Edwards‡, Hung-Jui Tan*†, Matthew E. Nielsen*†¶ and Bryce B. Reeve†§

 

*Department of Urology , †Lineberger Comprehensive Cancer Center, Multidisciplinary Genitourinary Oncology, ‡Department of Biostatistics, Gillings School of Global Public Health, §Department of Health Policy and Management, Gillings School of Global Public Health , and Department of Epidemiology, Gillings School of Global Public Health, UNC, Chapel Hill, NC, USA

 

Read the full article

Abstract

Objectives

To identify changes in health‐related quality of life (HRQoL) after diagnosis of bladder cancer in older adults in comparison with a group of adults without bladder cancer (controls).

Patients and Methods

Data from the Surveillance, Epidemiology and End Results registries were linked with Medicare Health Outcomes Survey (MHOS) data. Medicare beneficiaries aged ≥65 years in the period 1998–2013, who were diagnosed with bladder cancer between baseline and follow‐up through the MHOS, were matched with control subjects without cancer using propensity scores. Linear mixed models were used to estimate predictors of HRQoL changes.

Results

After matching, 535 patients with bladder cancer (458 non‐muscle‐invasive bladder cancer [NMIBC] and 77 with muscle‐invasive bladder cancer [MIBC]) and 2 770 control subjects without cancer were identified. Both patients with NMIBC and those with MIBC reported significant declines in HRQoL scores over time vs controls: physical component summary −2 and −5.3 vs −0.4, respectively; bodily pain −1.9 and −3.6 vs −0.7; role physical −2.7 and −4.7 vs −0.7; general health −2.4 and −6.1 vs 0; vitality −1.2 and −3.5 vs −0.1; and social functioning −2.1 and −5.7 vs −0.8. All scores ranged from 0 to 100. When stratified by time since diagnosis, HRQoL improved over 1 year for some domains (role physical), but remained lower across most domains.

Conclusions

After diagnosis, patients with bladder cancer experienced significant declines in physical, mental and social HRQoL relative to controls. Decrements were most pronounced among individuals with MIBC. Methods to better understand and address HRQoL decrements among patients with bladder cancer are needed.

Read more articles of the week

Editorial: Well‐being beyond the bladder. How do we improve the overall health of patients with bladder cancer?

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Declines in quality of life and physical function are commonly associated with all cancers 1, and in this month’s issue of BJUI, Smith et al. 2 describe the changes in quality of life that occur specifically in patients with bladder cancer. The authors examine 535 individuals with bladder cancer (of whom 77 [14%] had invasive disease) and matched them to 2770 non‐cancer controls using propensity scores. The Surveillance, Epidemiology and End Results (SEER) registry was linked with the Medicare Health Outcomes Survey. This dataset represents linkages of population‐based SEER data with survey data for Medicare‐managed enrollees. In this study, patients were surveyed at different times with respect to their diagnosis and the authors identified all patients who were surveyed some time before and after their diagnosis. By harnessing this dataset, the authors describe changes that occur in mental and physical function. The authors should be commended for conducting an analysis that seeks to quantify the impact of a bladder cancer diagnosis on multiple dimensions affecting quality of life.

A few findings are worth highlighting. First, the quality of life of a patient with bladder cancer declines more between a pre‐diagnosis and post‐diagnosis assessment as compared with matched, non‐cancer controls. As any urological oncologist can attest, a bladder cancer diagnosis causes permanent changes to a patient’s life. Second, people with bladder cancer have deficits in multiple domains of well‐being and not just in physical function. Third, people with bladder cancer have impairments in well‐being whether they have non‐invasive or invasive disease. Fourth, decrements were more pronounced in those with invasive disease. In fact, patients who underwent cystectomy had statistically significant declines in nearly all physical domains and similar declines in mental health‐related quality of life across several domains, including emotional, vitality and social functioning. Lastly, a predictor of a significant decrease in both the physical component and mental component score included a diagnosis of recent depression. This insightful study shows the potential impact of a bladder cancer diagnosis on mental and physical health‐related quality of life.

So, with these detriments in mind, can urologists do anything to address these declines in quality of life for patients with bladder cancer?

In clinical practice, urologists may be able to play an active role in mitigating the negative consequences of therapy, be it for invasive or non‐invasive disease. If a urologist is following a patient with non‐muscle‐invasive bladder cancer, then there are clinical visits for cystoscopy, intravesical instillation and follow‐up, during which a provider can regularly check in with a patient and offer recommendations. If a patient has muscle‐invasive bladder cancer, they are typically seen a few times before surgery and there is an incentive to address potentially modifiable sources of morbidity before a major operation plagued by complications.

While encouraging healthy behaviours is common sense and may help some patients, understanding the difference between motivating self‐care (e.g. coaching our patients) and recommending programmes that are scientifically established and effective (e.g. recommending a programme proven in a randomized controlled trial) are different. One major challenge in promoting healthy behaviours in our patients is understanding their mindset, i.e. their motivation to make meaningful change. The Transtheoretical Model is a biopsychosocial model that conceptualizes intent for changing behaviour: pre‐contemplation, contemplation, preparation, action, maintenance and termination 3. Based on a continuum of patient activation and knowledge of these stages, interventions can be designed more effectively and focused on individuals. Conversation content, clinician effort and clinical resources can be judiciously allotted instead of offering all options to all patients.

The presence of validated interventions that have been determined to consistently improve quality of life is evolving. A new area of preoperative care known as prehabilitation, is being studied in patients with cancer and seeks to optimize preoperative factors, such as increasing fitness, improving nutritional status, encouraging smoking cessation and decreasing anxiety 4. Although studies vary in quality, content and outcomes measured 5, there is still an opportunity to exercise common sense and make practical suggestions.

For busy urologists who manage patients with bladder cancer, any patient can benefit from:

  1. Mindful conversations: having open and regular communication about quality of life.
  2. Measurements: tracking patient‐reported outcome measures longitudinally to follow well‐being systematically and identify detrimental changes early.
  3. Multidisciplinary resources: offer support (Fig. 1) based on conversations (#1) and scores (#2).

Conversations only require a little provider time, monitoring patient‐reported outcomes can be facilitated by the use of technology such as the electronic health record, and most institutions have previously established resources that patients can use during their care. Strategies may be low‐cost, quick and capable of helping patients or caregivers. Also, data show that routine assessment of patient‐reported outcome measures in patients with advanced cancers may be associated with improved overall survival 6.

Figure 1

Open in figure viewerPowerPoint
Potential targets to improve patient well‐being during bladder cancer care.

Acknowledging that other dimensions of health are affected after a bladder cancer diagnosis may allow us to track, address and ultimately improve the health of our patients. When we care for patients with bladder cancer, focusing cancer treatment is paramount; however, we can also extend this treatment by being cognisant of quality of life. Complementing oncological care with efforts to promote health in other ways allows us to promote well‐being and treat these patients beyond the bladder.

 

Matthew Mossanen*†, Justin C. Brown† and Deborah Schrag†
*Division of Urology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA and †Dana Farber Cancer Institute, Boston, MA, USA

 

Read the full article
References

 

  • 1 Petrick JL, Reeve BB, Kucharska‐Newton AM et al. Functional status declines among cancer survivors: trajectory and contributing factors. Journal of Geriatric Oncology 2014; 5: 359–67

 

  • 2 Smith AB, Jaeger B, Pinheiro LC et al. Impact of bladder cancer on health‐related quality of life. BJU Int 2018; 121: 549–57

 

 

  • 4 Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment‐related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil 2013; 92: 715–27

 

 

  • 6 Basch E, Deal AM, Dueck AC et al. Overall survival results of a trial assessing patient‐reported outcomes for symptom monitoring during routine cancer treatment. JAMA 2017; 318: 197–8

 

Video: Impact of bladder cancer on health‐related quality of life

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Impact of bladder cancer on health‐related quality of life

 

Read the full article

Abstract

Objectives

To identify changes in health‐related quality of life (HRQoL) after diagnosis of bladder cancer in older adults in comparison with a group of adults without bladder cancer (controls).

Patients and Methods

Data from the Surveillance, Epidemiology and End Results registries were linked with Medicare Health Outcomes Survey (MHOS) data. Medicare beneficiaries aged ≥65 years in the period 1998–2013, who were diagnosed with bladder cancer between baseline and follow‐up through the MHOS, were matched with control subjects without cancer using propensity scores. Linear mixed models were used to estimate predictors of HRQoL changes.

Results

After matching, 535 patients with bladder cancer (458 non‐muscle‐invasive bladder cancer [NMIBC] and 77 with muscle‐invasive bladder cancer [MIBC]) and 2 770 control subjects without cancer were identified. Both patients with NMIBC and those with MIBC reported significant declines in HRQoL scores over time vs controls: physical component summary −2 and −5.3 vs −0.4, respectively; bodily pain −1.9 and −3.6 vs −0.7; role physical −2.7 and −4.7 vs −0.7; general health −2.4 and −6.1 vs 0; vitality −1.2 and −3.5 vs −0.1; and social functioning −2.1 and −5.7 vs −0.8. All scores ranged from 0 to 100. When stratified by time since diagnosis, HRQoL improved over 1 year for some domains (role physical), but remained lower across most domains.

Conclusions

After diagnosis, patients with bladder cancer experienced significant declines in physical, mental and social HRQoL relative to controls. Decrements were most pronounced among individuals with MIBC. Methods to better understand and address HRQoL decrements among patients with bladder cancer are needed.

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Video: Centralisation of RC for bladder cancer in England

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Centralisation of radical cystectomies for bladder cancer in England, a decade on from the ‘Improving Outcomes Guidance’: the case for super centralisation

Read the full article

Abstract

Objective

To analyse the impact of centralisation of radical cystectomy (RC) provision for bladder cancer in England, on postoperative mortality, length of stay (LoS), complications and re-intervention rates, from implementation of centralisation from 2003 until 2014. In 2002, UK policymakers introduced the ‘Improving Outcomes Guidance’ (IOG) for urological cancers after a global cancer surgery commission identified substantial shortcomings in provision of care of RCs. One key recommendation was centralisation of RCs to high-output centres. No study has yet robustly analysed the changes since the introduction of the IOG, to assess a national healthcare system that has mature data on such institutional transformation.

Patients and Methods

RCs performed for bladder cancer in England between 2003/2004 and 2013/2014 were analysed from Hospital Episode Statistics (HES) data. Outcomes including 30-day, 90-day, and 1-year all-cause postoperative mortality; median LoS; complication and re-intervention rates, were calculated. Multivariable statistical analysis was undertaken to describe the relationship between each surgeon and the providers’ annual case volume and mortality.

Results

In all, 15 292 RCs were identified. The percentage of RCs performed in discordance with the IOG guidelines reduced from 65% to 12.4%, corresponding with an improvement in 30-day mortality from 2.7% to 1.5% (P = 0.024). Procedures adhering to the IOG guidelines had better 30-day mortality (2.1% vs 2.9%; P = 0.003) than those that did not, and better 1-year mortality (21.5% vs 25.6%; P < 0.001), LoS (14 vs 16 days; P < 0.001), and re- intervention rates (30.0% vs 33.6%; P < 0.001). Each single extra surgery per centre reduced the odds of death at 30 days by 1.5% (odds ratio [OR] 0.985, 95% confidence interval [CI] 0.977–0.992) and 1% at 1 year (OR 0.990, 95% CI 0.988–0.993), and significantly reduced rates of re-intervention.

Conclusion

Centralisation has been implemented across England since the publication of the IOG guidelines in 2002. The improved outcomes shown, including that a single extra procedure per year per centre can significantly reduce mortality and re-intervention, may serve to offer healthcare planners an evidence base to propose new guidance for further optimisation of surgical provision, and hope for other healthcare systems that such widespread institutional change is achievable and positive.

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Article of the Week: Centralisation of RC for bladder cancer in England

/by

Every Week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video discussing the paper.

If you only have time to read one article this week, it should be this one.

Centralisation of radical cystectomies for bladder cancer in England, a decade on from the ‘Improving Outcomes Guidance’: the case for super centralisation

Mehran Afshar*, Henry Goodfellow†, Francesca Jackson-Spence‡, Felicity Evison§, John Parkin§, Richard T. Bryan‡, Helen Parsons, Nicholas D. James§‡ and Prashant Patel§‡

 

*St George’s Hospital NHS Trust, London, UK, †The Royal Free London NHS Trust, London, UK, ‡University of Birmingham, Birmingham, UK, §University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK, and Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
Read the full article

Abstract

Objective

To analyse the impact of centralisation of radical cystectomy (RC) provision for bladder cancer in England, on postoperative mortality, length of stay (LoS), complications and re-intervention rates, from implementation of centralisation from 2003 until 2014. In 2002, UK policymakers introduced the ‘Improving Outcomes Guidance’ (IOG) for urological cancers after a global cancer surgery commission identified substantial shortcomings in provision of care of RCs. One key recommendation was centralisation of RCs to high-output centres. No study has yet robustly analysed the changes since the introduction of the IOG, to assess a national healthcare system that has mature data on such institutional transformation.

Patients and Methods

RCs performed for bladder cancer in England between 2003/2004 and 2013/2014 were analysed from Hospital Episode Statistics (HES) data. Outcomes including 30-day, 90-day, and 1-year all-cause postoperative mortality; median LoS; complication and re-intervention rates, were calculated. Multivariable statistical analysis was undertaken to describe the relationship between each surgeon and the providers’ annual case volume and mortality.

Results

In all, 15 292 RCs were identified. The percentage of RCs performed in discordance with the IOG guidelines reduced from 65% to 12.4%, corresponding with an improvement in 30-day mortality from 2.7% to 1.5% (P = 0.024). Procedures adhering to the IOG guidelines had better 30-day mortality (2.1% vs 2.9%; P = 0.003) than those that did not, and better 1-year mortality (21.5% vs 25.6%; P < 0.001), LoS (14 vs 16 days; P < 0.001), and re- intervention rates (30.0% vs 33.6%; P < 0.001). Each single extra surgery per centre reduced the odds of death at 30 days by 1.5% (odds ratio [OR] 0.985, 95% confidence interval [CI] 0.977–0.992) and 1% at 1 year (OR 0.990, 95% CI 0.988–0.993), and significantly reduced rates of re-intervention.

Conclusion

Centralisation has been implemented across England since the publication of the IOG guidelines in 2002. The improved outcomes shown, including that a single extra procedure per year per centre can significantly reduce mortality and re-intervention, may serve to offer healthcare planners an evidence base to propose new guidance for further optimisation of surgical provision, and hope for other healthcare systems that such widespread institutional change is achievable and positive.

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Article of the Week: Association of HDI with global bladder, kidney, prostate and testis cancer

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Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Association of Human Development Index with global bladder, kidney, prostate and testis cancer incidence and mortality

Alyssa K. Greiman*, James S. Rosoff† and Sandip M. Prasad*‡

 

*Department of Urology, Medical University of South Carolina, Charleston, SC, †Department of Urology, Yale School of Medicine, New Haven, CT, and ‡Department of Surgery, Ralph M. Johnson VA Medical Center, Charleston, SC, USA

 

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Abstract

Objectives

To describe contemporary worldwide age-standardized incidence and mortality rates for bladder, kidney, prostate and testis cancer and their association with development.

Materials and Methods

We obtained gender-specific, age-standardized incidence and mortality rates for 184 countries and 16 major world regions from the GLOBOCAN 2012 database. We compared the mortality-to-incidence ratios (MIRs) at national and regional levels in males and females, and assessed the association with socio-economic development using the 2014 United Nations Human Development Index (HDI).

Results

Age-standardized incidence rates were 2.9 (bladder) to 7.4 (testis) times higher for genitourinary malignancies in more developed countries compared with less developed countries. Age-standardized mortality rates were 1.5–2.2 times higher in more vs less developed countries for prostate, bladder and kidney cancer, with no variation in mortality rates observed in testis cancer. There was a strong inverse relationship between HDI and MIR in testis (regression coefficient 1.65, R2 = 0.78), prostate (regression coefficient −1.56, R2 = 0.85), kidney (regression coefficient −1.34, R2 = 0.74), and bladder cancer (regression coefficient −1.01, R2 = 0.80).

Conclusion

While incidence and mortality rates for genitourinary cancers vary widely throughout the world, the MIR is highest in less developed countries for all four major genitourinary malignancies. Further research is needed to understand whether differences in comorbidities, exposures, time to diagnosis, access to healthcare, diagnostic techniques or treatment options explain the observed inequalities in genitourinary cancer outcomes.

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