Viveka Ströck

Should Follow-up Cystoscopy in Bacillus Calmette-Guérin–Treated Patients Continue After Five Tumour-Free Years?

BACKGROUND It is not known how long follow-up cystoscopy in tumour-free bacillus Calmette-Guérin (BCG)-treated patients should continue. OBJECTIVE Determine the incidence of late recurrences and progression after a tumour-free period of >5 yr after BCG treatment. DESIGN, SETTING, AND PARTICIPANTS Data on 542 patients with non-muscle-invasive bladder cancer treated with BCG between 1986 and 2003 were analysed. Of 542 patients, 204 patients (37.6%) were tumour-free for ≥5 yr. The median tumour-free period was 105.5 mo (range: 60-252 mo). MEASUREMENTS To compare the tumour-free group with patients who were not tumour-free for 5 yr, traditional variables (tumour grade, tumour stage, age, gender, tumour number and size, primary or recurrent tumour, BCG strain, previous chemotherapy, previous upper tract tumour, number of earlier resections, and European Organisation for Research and Treatment of Cancer recurrence and progression risk groups) were analysed using the Fisher exact test for dichotomous variables, the Mantel-Haenszel chi-square test for ordered categorical variables, and the Mann-Whitney U-test for continuous variables. Kaplan-Meier curves for time to recurrence were constructed using Statistica software (StatSoft, Tulsa, Oklahoma, USA). Differences between groups were tested with the log-rank test. For continuous variables, Cox proportional hazard regression was performed to find significant effect on the time to recurrence. RESULTS AND LIMITATIONS Twenty-two of 204 patients (10.8%) had a recurrence after being tumour-free for ≥5 yr. The Kaplan-Meier estimated risk for recurrence was 12.5% at 10 yr and 20.5% at 15 yr. Among patients with TaG1-TaG2 before BCG, 11 of 79 patients (13.9%) had recurrences, including three patients with invasive extravesical tumours. Among the bladder recurrences were seven TaG1s and one carcinoma in situ (CIS). Among the 125 patients with TaG3/CIS/T1 before BCG, 11 patients (8.8%) had recurrences, including 2 patients with invasive ureter tumours. The bladder recurrences were one T2, four CIS, and four TaG1. Late recurrences were 8.5 times more common among patients with recurrent tumours before BCG compared with patients treated after their first tumour episode. The study was retrospective and nonrandomised but unselected and population-based. CONCLUSIONS A tumour-free period of 5 yr after BCG treatment is a good prognostic sign, but recurrences after >10 yr are not unusual. Literature data and the present report support cystoscopy follow-up for ≥10-15 tumour-free years, at least among patients with recurrent tumours and/or high-grade lesions before BCG treatment.

Late bacille Calmette-Guérin infection with a large focal urinary bladder ulceration as a complication of bladder cancer treatment.

Study Type – Therapy (case series) 
Level of Evidence 4

Treatment according to guidelines may bridge the gender gap in outcome for patients with stage T1 urinary bladder cancer

Abstract Objective: The aim of this investigation was to study differences between male and female patients with stage T1 urinary bladder cancer (UBC) regarding intravesical instillation therapy, second resection and survival. Materials and methods: This study included all patients with non-metastatic primary T1 UBC reported to the Swedish National Register of Urinary Bladder Cancer (SNRUBC) from 1997 to 2014, excluding those treated with primary cystectomy. Differences between groups were evaluated using chi-squared tests and logistic regression, and survival was investigated using Kaplan–Meier and log-rank tests and Cox proportional hazards analysis. Results: In all, 7681 patients with T1 UBC (77% male, 23% female) were included. Females were older than males at the time of diagnosis (median age at presentation 76 and 74 years, respectively; p < .001). A larger proportion of males than females underwent intravesical instillation therapy (39% vs 33%, p < .001). Relative survival was lower in women aged ≥75 years and women with G3 tumours compared to men. However, women aged ≥75 years who had T1G3 tumours and underwent second resection followed by intravesical instillation therapy showed a relative survival equal to that observed in men. Conclusions: This population-based study demonstrates that women of all ages with T1 UBC undergo intravesical instillation therapy less frequently than men, and that relative survival is poorer in women aged ≥75 years than in men of the same age when intravesical instillation therapy and second resection are not used. However, these disparities may disappear with treatment according to guidelines.

Cohort profile : The Swedish National Register of Urinary Bladder Cancer (SNRUBC) and the Bladder Cancer Data Base Sweden (BladderBaSe)

Purpose To monitor the quality of bladder cancer care, the Swedish National Register of Urinary Bladder Cancer (SNRUBC) was initiated in 1997. During 2015, in order to study trends in incidence, effects of treatment and survival of men and women with bladder cancer, we linked the SNRUBC to other national healthcare and demographic registers and constructed the Bladder Cancer Data Base Sweden (BladderBaSe). Participants The SNRUBC is a nationwide register with detailed information on 97% of bladder cancer cases in Sweden as compared with the Swedish Cancer Register. Participants in the SNRUBC have registered data on tumour characteristics at diagnosis, and for 98% of these treatment data have been captured. From 2009, the SNRUBC holds data on 88% of eligible participants for follow-up 5 years after diagnosis of non-muscle invasive bladder cancer, and from 2011, data on surgery details and complications for 85% of participants treated with radical cystectomy. The BladderBaSe includes all data in the SNRUBC from 1997 to 2014, and additional covariates and follow-up data from linked national register sources on comorbidity, socioeconomic factors, detailed information on readmissions and treatment side effects, and causes of death. Findings to date Studies based on data in the SNRUBC have shown inequalities in survival and treatment indication by gender, regions and hospital volume. The BladderBaSe includes 38 658 participants registered in SNRUBC with bladder cancer diagnosed from 1 January 1997 to 31 December 2014. The BladderBaSe initiators are currently in collaboration with researchers from the SNRUBC investigating different aspects of bladder cancer survival. Future plans The SNRUBC and the BladderBaSe project are open for collaborations with national and international research teams. Collaborators can submit proposals for studies and study files can be uploaded to servers for remote access and analysis. For more information, please contact the corresponding author.

Intravesical instillations and cancer-specific survival in patients with primary carcinoma in situ of the urinary bladder

Abstract Objective: The aim of this study was to evaluate the use of intravesical treatment and cancer-specific survival of patients with primary carcinoma in situ (CIS). Materials and methods: Data acquisition was based on the Swedish National Registry of Urinary Bladder Cancer by selecting all patients with primary CIS. The analysis covered gender, age, hospital type and hospital volume. Intravesical treatment and death due to bladder cancer were evaluated by multivariate logistic regression and multivariate Cox analysis, respectively. Results: The study included 1041 patients (median age at diagnosis 72 years) with a median follow-up of 65 months. Intravesical instillation therapy was given to 745 patients (72%), and 138 (13%) died from bladder cancer during the observation period. Male gender [odds ratio (OR) = 1.56, 95% confidence interval (CI) 1.13–2.17] and treatment at county (OR = 1.65, 95% CI 1.17–2.33), university (OR =2.12, 95% CI 1.48–3.03) or high-volume (OR = 1.92, 95% CI 1.34–2.75) hospitals were significantly associated with higher odds of intravesical instillations. The age category ≥80 years had a significantly lower chance of receiving intravesical therapy (OR = 0.44, 95% CI 0.26–0.74) and a significantly higher risk of dying from bladder cancer (hazard ratio = 3.03, 95% CI 1.71–5.35). Conclusion: Significantly more frequent use of intravesical treatment of primary CIS was found for males and for patients treated at county, university and high-volume hospitals. Age ≥80 years was significantly related to less intravesical treatment and poorer cancer-specific survival.

A Prospective Study of the Size, Number and Histopathology of New and Recurrent Bladder Tumors

Introduction: We prospectively registered the grade, stage, number and size of bladder tumor recurrences as to our knowledge this has not yet been done. New tumors were included in the study for comparative purposes. Methods: All 581 transurethral resections, random biopsies and fulgurations for a suspected bladder tumor were prospectively registered during a 15‐month period at a single institution. Tumor size was determined using the size of the resection loop or biopsy forceps as a reference. Results: Of all suspected new and recurrent bladder tumors 22% were benign or inflammatory lesions. A total of 167 patients with a new urothelial tumor and 214 recurrences in 166 patients were registered during the study period. Compared to new tumors, recurrences were more often noninvasive (88% vs 67%, p <0.001), more often 10 mm or less in diameter (63% vs 18%, p <0.001) and more often multifocal (55% vs 38%, p <0.01). New and recurrent tumors had a median size of 20 and 8 mm, respectively. Conclusions: The absolute majority of suspected bladder tumor recurrences are benign or low grade noninvasive malignant tumors and are less than 10 mm in diameter. This finding suggests that there is great potential for cost reductions when a significant proportion of patients with suspected recurrences after treatment of low grade tumors could undergo biopsy and fulguration using local anesthesia in the office instead of general anesthesia.