Risk Of Bladder Cancer Death Research Articles

Determination of four trihalomethanes in ship ballast water by gas chromatography-negative chemical ionization-mass spectrometry

我国每年的船舶压载水排放量巨大,压载水中含有浮游生物、病原体及其幼虫或孢子等,若处理不当,会对排放水域的生态环境造成严重影响。排放压载水前常使用电解法对其进行处理,电解产生的次氯酸钠溶液,能有效杀灭残余的微生物。但电解后会产生副产物三卤甲烷(THMs),其对人体有一定的健康风险,建立船舶压载水中三卤甲烷的测定方法具有重要意义。该研究建立了采用气相色谱-负化学源质谱(GC-NCI-MS)测定船舶压载水中4种三卤甲烷(包括三氯甲烷、二氯一溴甲烷、一氯二溴甲烷、三溴甲烷)的分析方法。船舶压载水样品经过顶空进样技术处理后,通过DB-5MS UI毛细管色谱柱(30 m×0.25 mm×1.0 μm)分离,气相色谱-负化学源质谱仪测定,在选择离子扫描(SIM)模式下分析,采用外标法进行定量。4种三卤甲烷在0.2~50 μg/L范围内线性关系良好,相关系数(r)≥0.995,定量限(S/N=10)为0.1~0.2 μg/L,在0.2、0.5、2.0 μg/L 3个加标水平下,4种THMs的平均回收率为90.3%~106.8%,相对标准偏差(RSD)为1.4%~6.2%。该方法准确、稳定、可靠,可用于测定船舶压载水中4种THMs的含量。使用建立的测定方法对36个船舶压载水进行测定,三溴甲烷、二溴一氯甲烷、一溴二氯甲烷与三氯甲烷的检出率分别为83.3%、69.4%、22.2%和19.4%,检出值分别为34.25~221.5 μg/L、3.52~41.87 μg/L、1.52~8.56 μg/L和0.02~5.46 μg/L。

Primary versus secondary muscle-invasive bladder cancer: survival after curative treatment

Purpose To assess if cancer-specific survival (CSS) following curative intent treatment (CIT) for muscle-invasive bladder cancer (MIBC) differs between patients presenting with MIBC (primary) and patients presenting with non-muscle-invasive bladder cancer who progress to MIBC (secondary). Methods This study uses data from the Cancer Registry of Norway on patients initially diagnosed with bladder cancer in 2008–2012 and treated with radical cystectomy (RC) or radiotherapy (RT). To ensure a clinically relevant population, we selected patients with a pre-treatment histology confirming muscle-invasion. Survival models were applied to evaluate differences in observed and adjusted CSS by type of MIBC and stratified by type of CIT. Adjustment was made for age group, sex, previous cancer, diagnostic hospital’s academic status and geographical region, and type of CIT. Results We identified 650 eligible patients: 589 (91%) primary MIBC and 61 (9%) secondary MIBC. A total of 556 (86%) patients underwent RC and 94 (14%) RT. The 5-year CSS for primary MIBC was 56% and 59% for secondary MIBC (p = 0.68). The type of MIBC did not impact the risk of bladder cancer death (HR = 0.85, CI = 0.55–1.33, p = 0.48), nor when stratified for CIT (RC: HR = 0.93, CI = 0.57–1.53, p = 0.78); RT: HR = 0.71, CI = 0.24–2.16, p = 0.55). Conclusion This first nation-wide population-based study comparing CSS between primary and secondary MIBC showed no significant difference in survival regardless of type of CIT. Continued surveillance of patients with non-muscle-invasive bladder cancer is necessary to detect early progression to MIBC. Future studies should include molecular and genetic characteristics in addition to detailed clinicopathologic information.

Risk of bladder cancer death in patients younger than 50 with non-muscle-invasive and muscle-invasive bladder cancer

Introduction and objectives Bladder cancer is primarily a disease of older age and little is known about the differences between patients diagnosed with bladder cancer at a younger versus older age. Our objectives were to compare bladder cancer specific survival in patients aged <50 versus those aged 50–70 at time of diagnosis. Materials and methods The Swedish bladder cancer database provided data on patient demographics, clinical characteristics and treatments for this observational study. Cox proportional hazard regression models were adjusted for appropriate variables. All analyses were stratified by disease stage (non-muscle-invasive bladder cancer and muscle-invasive bladder cancer. Furthermore, we compared the frequency of lower urinary tract infections within 24 months prior to bladder cancer diagnosis by sex and age groups. Results The study included 15,452 newly-diagnosed BC patients (1997–2014); 1,207 (8%) patients were <50 whilst 14,245 (92%) were aged 50–70. Patients aged <50 at diagnosis were at a decreased risk of bladder cancer death (HR = 0.82, 95%CI: 0.68–0.99) compared to those aged 50–70. When stratified by non-muscle-invasive and muscle-invasive bladder cancer, this association remained in non-muscle-invasive patients only (<50, HR = 0.43, 95% CI: 0.28–0.64). The frequency of lower urinary tract infection diagnoses did not differ between younger and older patients in either men or women. Conclusions Patients diagnosed with non-muscle-invasive bladder cancer when aged <50 are at decreased risk of bladder cancer-specific death when compared to their older (50-70) counterparts. These observations raise relevant research questions about age-related differences in diagnostic procedures, clinical decision-making and, not least, potential differences in tumour biology.

P0738 - Risk of bladder cancer death in patients younger than 50 with non-muscle-invasive and muscle-invasive bladder cancer

P0738 - Risk of bladder cancer death in patients younger than 50 with non-muscle-invasive and muscle-invasive bladder cancer

Partial Versus Complete Bacillus Calmette-Guérin Intravesical Therapy and Bladder Cancer Outcomes in High-risk Non–muscle-invasive Bladder Cancer: Is NIMBUS the Full Story?

BackgroundIt is important to understand the implications of reduced bacillus Calmette-Guérin (BCG) treatment intensity, given global shortages and early termination of the NIMBUS trial. ObjectiveTo assess the association of partial versus complete BCG induction with outcomes. Design, setting, and participantsThis is a retrospective cohort study of veterans diagnosed with high-risk non–muscle-invasive bladder cancer (NMIBC; high grade [HG] Ta, T1, or carcinoma in situ) between 2005 and 2011 with follow-up through 2014. InterventionPatients were categorized into partial versus complete BCG induction (one to five vs five or more instillations). Partial BCG induction subgroups were defined for comparison with the NIMBUS trial. Outcome measurements and statistical analysisPropensity score–adjusted regression models were used to assess the association of partial BCG induction with risk of recurrence and bladder cancer death. Results and limitationsAmong 540 patients, 114 (21.1%) underwent partial BCG induction. Partial versus complete BCG induction was not significantly associated with the risk of recurrence in HG Ta (cumulative incidence [CIn] 46.6% vs 53.9% at 5 yr, p = 0.38) or T1 (CIn 47.1% vs 56.7 at 5 yr, p = 0.19) disease. Similarly, we found no increased risk of bladder cancer death (HG Ta: CIn 4.7%7vs 5.4% at 5 yr, p = 0.87; T1: CIn 10.0% vs 11.4% at 5 yr, p = 0.77). NIMBUS-like induction was associated with an increased risk of recurrence in patients with HG Ta disease, although not statistically significant. Unmeasured confounding is a limitation. ConclusionsCancer outcomes were similar among high-risk NMIBC patients who underwent partial versus complete BCG induction, suggesting that future research is needed to determine how to optimize BCG delivery for the greatest number of patients, especially during global shortages. Patient summaryOutcomes were similar between patients receiving partial and complete courses of bacillus Calmette-Guérin (BCG) therapy. Future research is needed to determine how to best deliver BCG to the greatest number of patients, particularly during medication shortages.

Geographic Distribution of Racial Differences in Bladder Cancer Mortality in the United States: A Nationwide Population-Based Study

African-Americans (AAs) have up to two times increased risk of bladder cancer death than Caucasians. Bladder cancer mortality increases exponentially once it invades the muscle. Geographic heterogeneity in bladder cancer mortality according to race remains to be determined. The purpose of this study was to determine the geographic distribution of muscle-invasive bladder cancer (MIBC) mortality according to race. Analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data for 6,044 patients aged 66-85 diagnosed with clinical stage T2-T4 N0M0 bladder cancer from January 1, 2002 to December 31, 2011. Fine and Gray competing risks regression models, including an unadjusted model and an adjusted model with an interaction term between race and registry, were used to assess the association of race with bladder cancer-specific mortality (BCSM) according to tumor registry. Out of 6,044 patients, 5,408 (89.5%) were Caucasian, 352 (5.82%) were non-Hispanic AA, 85 (1.4%) were Hispanic, and 199 (3.29%) were other. Of the 18 registries, AAs with bladder cancer were largely concentrated in Louisiana (19%), New Jersey (17.9%) and Georgia (17.6%). New Jersey was the only registry where AAs had increased risk of BCSM than Caucasians and only for stage T2 disease: (AHR, 1.74; 95% CI 1.22-2.47, P=0.002). AAs in New Jersey had worse BCSM than Caucasians regardless of management: no curative treatment (AHR, 1.61; 95% CI 1.09-2.37, P=0.0168), radical cystectomy (AHR, 2.05; 95% CI 1.26-3.35, P=0.0039), and trimodal therapy (AHR, 1.55; 95% CI 1.03-2.35, P=0.0367). We observed geographic variation in death from bladder cancer which impacted one registry which had one of the largest population of AAs. These findings support further investigation into the social determinants of race (i.e. socioeconomic status and distance to health care facility) which may drive these results.

5\u03b1-reductase inhibitors impact prognosis of urothelial carcinoma

Background5α-reductase inhibitors (5-ARIs) inhibit the pathway of converting the testosterone to dihydrotestosterone and are widely used in benign prostatic hyperplasia patients. Since androgen receptor activation may play a role in urothelial tumorigenesis, we conducted this retrospective cohort study to determine whether 5α-reductase inhibitors (5-ARIs) administration is associated with bladder cancer mortality, bladder cancer recurrence and upper tract urothelial carcinoma mortality, using the Taiwan National Health Insurance database.MethodsThe data of this retrospective cohort study were sourced from the Longitudinal Health Insurance Database of Taiwan, compiled by the Taiwan National Health Insurance database from 1996 to 2010. It consists of 18,530 men with bladder cancer, of whom 474 were 5-ARIs recipients and 4384 men with upper tract urothelial carcinoma, of whom 109 were 5-ARIs recipients. Propensity Score Matching on the age and geographic data was done at the ratio of 1:10. We analyzed the odds ratios (OR) and 95% confidence interval (CI) of the risk of bladder cancer death, bladder cancer recurrence rate and upper tract urothelial carcinoma related death by the 5-ARIs administration.ResultsThose who received 5-ARIs showed a lower risk of bladder cancer related death compared to nonusers in multivariable adjusted analysis (OR 0.835, 95% CI 0.71–0.98). However, there was no significant difference in the bladder cancer recurrence rate (OR 0.956, 95% CI 0.82–1.11) and upper tract urothelial carcinoma related mortality in multivariable adjusted analysis (OR 0.814, 95% CI 0.6–1.1).ConclusionsPatients who receive 5-ARIs have lower bladder cancer related mortality compared to those who don’t. 5-ARIs may prove to be a viable strategy to improve bladder cancer outcomes.

PD50-08 THE IMPACT OF LOW- VERSUS HIGH-INTENSITY SURVEILLANCE CYSTOSCOPY ON SURGICAL CARE AND CANCER OUTCOMES IN PATIENTS WITH HIGH-RISK NON-MUSCLE-INVASIVE BLADDER CANCER (NMIBC)

INTRODUCTION AND OBJECTIVE: Surveillance guidelines for NMIBC are based on expert opinion and informed by limited evidence. To assess the association of low- vs. guideline-recommended high-intensity cystoscopic surveillance with outcomes among patients with high-risk non-muscle invasive bladder cancer (NMIBC). METHODS: A retrospective cohort study of Veterans Affairs patients diagnosed with high-risk NMIBC between 2005 and 2011 with follow-up through 2014. Patients were categorized by number of surveillance cystoscopies over two years following diagnosis: low- (1-5) vs. high-intensity (6 or more) surveillance. Propensity score adjusted regression models were used to assess the association of low-intensity cystoscopic surveillance with frequency of transurethral resections, and risk of progression to invasive disease and bladder cancer death. RESULTS: Among 1,542 patients, 520 (33.7%) underwent low-intensity cystoscopic surveillance. Patients undergoing low-intensity surveillance had fewer transurethral resections (37 vs. 99 per 100 person-years; p<0.001). Low vs. high-intensity surveillance was not associated with risk of bladder cancer death among patients with non-invasive (cumulative incidence [CIn] 5.7% vs. 8.2% at 5 years, p=0.25) or with invasive disease at diagnosis (CIn 10.1% vs. 9.7% at 5 years, p=0.81). Among a subset of patients with non-invasive disease, low-intensity surveillance was associated with decreased risk of progression to invasive disease or bladder cancer death (CIn 19.3% vs. 31.4% at 5 years, p=0.002). CONCLUSIONS: Patients with high-risk NMIBC undergoing low- vs. high-intensity cystoscopic surveillance underwent fewer transurethral resections, but did not experience an increased risk of progression or bladder cancer death. These findings provide a strong rationale for a clinical trial to determine whether low-intensity surveillance is comparable to high-intensity surveillance for cancer control in high-risk NMIBC.Source of Funding: None

The impact of low- versus high-intensity surveillance cystoscopy on surgical care and cancer outcomes in patients with high-risk non-muscle-invasive bladder cancer (NMIBC).

To assess the association of low- vs. guideline-recommended high-intensity cystoscopic surveillance with outcomes among patients with high-risk non-muscle invasive bladder cancer (NMIBC). A retrospective cohort study of Veterans Affairs patients diagnosed with high-risk NMIBC between 2005 and 2011 with follow-up through 2014. Patients were categorized by number of surveillance cystoscopies over two years following diagnosis: low- (1-5) vs. high-intensity (6 or more) surveillance. Propensity score adjusted regression models were used to assess the association of low-intensity cystoscopic surveillance with frequency of transurethral resections, and risk of progression to invasive disease and bladder cancer death. Among 1,542 patients, 520 (33.7%) underwent low-intensity cystoscopic surveillance. Patients undergoing low-intensity surveillance had fewer transurethral resections (37 vs. 99 per 100 person-years; p<0.001). Risk of death from bladder cancer did not differ significantly by low (cumulative incidence [CIn] 8.4% [95% CI 6.5-10.9) at 5 years) vs. high-intensity surveillance (CIn 9.1% [95% CI 7.4-11.2) at 5 years, p = 0.61). Low vs. high-intensity surveillance was not associated with increased risk of bladder cancer death among patients with Ta (CIn 5.7% vs. 8.2% at 5 years p = 0.24) or T1 disease at diagnosis (CIn 10.2% vs. 9.1% at 5 years, p = 0.58). Among patients with Ta disease, low-intensity surveillance was associated with decreased risk of progression to invasive disease (T1 or T2) or bladder cancer death (CIn 19.3% vs. 31.3% at 5 years, p = 0.002). Patients with high-risk NMIBC undergoing low- vs. high-intensity cystoscopic surveillance underwent fewer transurethral resections, but did not experience an increased risk of progression or bladder cancer death. These findings provide a strong rationale for a clinical trial to determine whether low-intensity surveillance is comparable to high-intensity surveillance for cancer control in high-risk NMIBC.

1123 - Antihypertensive drugs and risk of bladder cancer death in Finland

1123 - Antihypertensive drugs and risk of bladder cancer death in Finland

Bladder Cancer Survival of Men Receiving 5α-Reductase Inhibitors

Androgens may have a role in bladder carcinogenesis. We studied whether 5α-reductase inhibitors were associated with bladder cancer specific mortality in a population based cohort of men with bladder cancer. The study cohort consisted of 10,720 Finnish men with bladder cancer newly diagnosed in 1997 to 2012 who were identified in a national cancer registry. Median followup was 4.17 years after bladder cancer diagnosis. We analyzed the HR and 95% CI of the risk of bladder cancer death by 5α-reductase inhibitor administration using Cox regression adjusted for age, gender, comorbidities, primary bladder cancer treatment and tumor extent at diagnosis. Lag time analyses were performed to assess the long-term risk association. Simultaneous administration α-blockers was considered to estimate possible confounding by indication. Administering 5α-reductase inhibitors before bladder cancer diagnosis was associated with a lower risk of bladder cancer death (HR 0.84, 95% CI 0.73-0.97). The risk decrease became stronger with years of use. Conversely prediagnostic administration of α-blockers was not associated with bladder cancer survival (HR 1.02, 95% CI 0.91-1.13). Similarly 5α-reductase inhibitor administration after diagnosis was associated with a decreased risk of bladder cancer death (HR 0.77, 95% CI 0.68-0.88). Bladder cancer survival was not associated with α-blockers (HR 0.98, 95% CI 0.90-1.07). The risk decrease due to 5α-reductase inhibitors persisted up to 5 years. Patients who receive 5α-reductase inhibitors have improved disease specific survival after bladder cancer diagnosis compared to those who donot receive them while α-blockers were not associated with survival. This supports the benefits of 5α-reductase inhibitors in bladder cancer.

Radical cystectomy for recurrent urothelial carcinoma after prior partial cystectomy: perioperative and oncologic outcomes.

To evaluate perioperative and oncologic outcomes of patients undergoing radical cystectomy (RC) for recurrence of urothelial carcinoma (UC) after prior partial cystectomy (PC), and to compare these outcomes to patients undergoing primary RC. Patients who underwent RC for recurrence of UC after prior PC were matched 1:3 to patients undergoing primary RC based on age, pathologic stage, and decade of surgery. Perioperative and oncologic outcomes were compared using Wilcoxon sign-rank test, McNemars test, the Kaplan-Meier method, and Cox proportional hazards regression analyses. Overall, the cohorts were well matched on clinical and pathological characteristics. No difference was noted in operative time (median 322 versus 303min; p=0.41), estimated blood loss (median 800 versus 700cc, p=0.10) or length of stay (median 9 versus 10days; p=0.09). Similarly, there were no differences in minor (51.7 versus 44.3%; p=0.32) or major (10.3 versus 12.6%; p=0.66) perioperative complications. Median follow-up after RC was 5.0years (IQR 1.5, 13.1years). Notably, CSS was significantly worse for patients who underwent RC after PC (10year-46.8 versus 65.9%; p=0.03). On multivariable analysis, prior PC remained independently associated with an increased risk of bladder cancer death (HR 2.28; 95% CI 1.17, 4.42). RC after PC is feasible, without significantly adverse perioperative outcomes compared to patients undergoing primary RC. However, the risk of death from bladder cancer may be higher, suggesting the need for careful patient counseling prior to PC and the consideration of such patients for adjuvant therapy after RC.

The Cancer of the Bladder Risk Assessment (COBRA) score: Estimating mortality after radical cystectomy.

Risk stratification of patients with urothelial carcinoma of the bladder (UCB) after cystectomy has important clinical and research implications. The authors assessed the relative effect of tumor stage and lymph node status on cancer-specific survival (CSS) after cystectomy and developed a simplified risk-assessment tool. In total, 14,828 patients who underwent cystectomy with lymph node dissection for UCB were identified from the Surveillance, Epidemiology, and End Results database (1988-2011). The relative importance of tumor stage and lymph node status with regard to CSS was assessed using stratified Kaplan-Meier and Cox proportional-hazards analyses. The patients were split randomly into development and validation cohorts. Additional validation using overall survival was performed on 19,362 patients from the National Cancer Data Base. The Cancer of Bladder Risk Assessment (COBRA) tool was created using a Cox model incorporating age, tumor stage, and lymph node density. Performance was validated using observed versus expected survival plots and the Harrell concordance index. Patients with muscle invasive (T2), lymph node-positive disease had a survival curve similar to that in patients with extravesical (T3 and T4), lymph node-negative disease (2-year CSS, 67% and 70%, respectively). Each point increase in the COBRA score (range, 0-7) was associated with a 1.61-fold increase (95% confidence interval, 1.56-fold to 1.65-fold increase) in the risk of bladder cancer death in the development cohort. The model accurately stratified patients across risk levels in the development cohort and the 2 validation cohorts (C-index, 0.712, 0.705, and 0.68, respectively). The COBRA score offers a straightforward, validated risk-stratification tool that incorporates the relative contribution of tumor stage and lymph node involvement to patient prognosis after cystectomy for UCB. Cancer 2017;123:4574-4582. © 2017 American Cancer Society.

Determinants of Survival for Adolescents and Young Adults with Urothelial Bladder Cancer: Results from the California Cancer Registry

Bladder cancer is a common malignancy often diagnosed in older adults. Previous studies have reported racial/ethnic disparities in bladder cancer survival outcomes but have not focused on younger patients. We identified whether factors influencing cause specific survival in adolescents and young adults (ages 15 to 39) differed from older adults, and defined prognostic factors specifically in adolescents and young adults using the California Cancer Registry. Patients diagnosed with bladder cancer between 1988 through 2012 were included in the study. The primary outcome measure was cause specific survival. A multivariable Cox proportional hazards regression model was used to evaluate predictors of cause specific survival in patients of all ages and in adolescents/young adults. Interactions of age and other variables between younger and older adult patients were assessed. Of 104,974 patients with bladder cancer we identified 1,688 adolescent and young adult patients (1.6%). Compared to older patients these patients had a 58% reduced risk of bladder cancer death (HR 0.42, p <0.001). Significant age interactions were identified involving race/ethnicity and histology. Among adolescents and young adults, nonHispanic African-American patients with low socioeconomic status had poor cause specific (HR 7.1, p <0.001) and overall (HR5.02, p <0.001) survival. Racial/ethnic and socioeconomic disparities exist in adolescent and young adult patients with bladder cancer in California. Further studies are warranted to identify the underlying causes in order to overcome these disparities.

Adjuvant chemotherapy is associated with decreased mortality after radical cystectomy for locally advanced bladder cancer

We sought to evaluate the association of adjuvant chemotherapy with the risk of subsequent mortality among patients with locally advanced urothelial carcinoma (UC) of the bladder undergoing radical cystectomy (RC). We identified 675 patients who underwent RC for pT2-4 and/or N+ UC between 1980 and 2005. Adjuvant chemotherapy was defined as treatment within 90 days of RC. Survival was estimated using the Kaplan-Meier method and compared according to receipt of adjuvant chemotherapy with the log-rank test. Multivariate models were used to analyze the impact of adjuvant chemotherapy on disease progression and survival. A total of 80 (12 %) patients received adjuvant chemotherapy. Median age was 69 years [interquartile range (IQR) 63, 76]. Median follow-up was 11 years (IQR 8, 16). Patients receiving adjuvant chemotherapy were more likely to have pT3-4 tumors (71 vs. 61 %; p < 0.001) and pN+ (85 vs. 19 %; p < 0.001). The 5-year cancer-specific survival was 46 % in those receiving adjuvant chemotherapy and 51 % in those that did not (p = 0.63). The 5-year overall survival was 39 % in those receiving adjuvant chemotherapy and 38 % in those that did not (p = 0.24). When controlling for age, sex, stage, and performance status, adjuvant chemotherapy was associated with a 29 % decrease in the risk of bladder cancer death (HR 0.71, p = 0.06) and a 39 % decrease in the risk of all-cause mortality (HR 0.61, p = 0.002). After controlling patient and tumor features, adjuvant chemotherapy was associated with a trend toward reduction in cancer-specific mortality and a statistically significant reduction in all-cause mortality.

The SPARC Score: A Multifactorial Outcome Prediction Model for Patients Undergoing Radical Cystectomy for Bladder Cancer

While multiple independent clinicopathological variables are associated with the outcome of radical cystectomy for bladder cancer, limited prediction tools exist to facilitate individualized risk assessment. We developed the SPARC (Survival Prediction After Radical Cystectomy) score, a prediction model for bladder cancer specific survival after radical cystectomy. We evaluated 2,403 patients who underwent radical cystectomy without neoadjuvant therapy at our institution between 1980 and 2008 with pathological re-review of all specimens. Of these patients 1,776 with nonmetastatic urothelial carcinoma were identified for analysis. A multivariate model was developed using stepwise selection to determine variables associated with cancer specific survival. We created a scoring system based on the β coefficients of this model. Median followup after radical cystectomy in patients alive at last followup was 10.5 years (IQR 7.3, 15.3), during which time 610 had died of bladder cancer. In addition to pathological tumor stage, nodal status, multifocality and lymphovascular invasion, the patient specific factors of Charlson comorbidity index, Eastern Cooperative Oncology Group (ECOG) performance status, current smoking, preoperative hydronephrosis and receipt of adjuvant chemotherapy were significantly associated with the risk of bladder cancer death. We used cumulative scores of these variables to stratify patients into risk groups with 95%, 80%, 60%, 38% and 23% 5-year cancer specific survival from the lowest to the highest risk group, respectively (p<0.0001). The concordance index of this model was 0.75. We present a model to individualize the estimation of cancer specific survival after radical cystectomy. Pending external validation, these data may be used for patient counseling, specifically in regard to recommendations for adjuvant therapy and surveillance frequency, as well as for clinical trial development.

Identifying Better Practices for Early-stage Bladder Cancer

Practice guidelines for nonmuscle invasive (ie, early stage) bladder cancer are ambiguous, resulting in substantial practice variation without a clear patient benefit. To profile urologist practice styles and empirically derive better patterns of use for common bladder cancer services. Retrospective cohort. Elderly patients diagnosed with early-stage bladder cancer between January 1, 1992 and December 31, 2005 in Surveillance, Epidemiology, and End Results-Medicare linked data. After identifying each patient's treating urologist, we fit multilevel models to obtain reliability-adjusted measures of the urologist's use of surveillance-associated (cytoscopy and urine cytology) and treatment-associated (intravesical therapy) services during the 2 years after diagnosis. We then used the Cox proportional hazards regression to evaluate the association between a patient's risk of bladder cancer death and his urologist's frequency of service use. Regardless of disease severity, no measurable patient benefit was associated with care delivery by a urologist residing in the highest quartile for cystoscopy or intravescial therapy use. However, maximal intensity of cytology use was associated with a lower risk of bladder cancer death for patients with high-grade stage Ta/Tis (highest vs. lowest intensity quartiles: hazard ratio, 0.73; 95% confidence interval, 0.56-0.95) and stage T1 disease (hazard ratio, 0.59; 95% confidence interval, 0.49-0.72). Our analysis supports a more tailored approach to patients with early-stage bladder cancer. Further, it serves as an example for applying observational data to characterize better clinical practices in the absence of experimental studies.

Immunohistochemical staining of CA 50antigen in human bladder cancer: Relation to histologic grade, clinical stage, and prognosis

The immunohistochemical detection of tumor marker CA 50 was studied in bladder cancer of WHO grades I–III. The material consisted of tumors in 83 patients and the mean clinical follow-up time was thirteen years (range 9.6–22 years). The fraction of CA 50-positive cells (FPtot) in microscopic image was scored 0–100 percent. Also the maximally staining region was selected, and the fraction of CA 50-positive cells in this region was scored 0–100 percent (FPmax). The average staining intensity of CA 50-positive cells was scored from 0 to 3 in the whole section (ASItot) and in the maximally staining area (ASImax). The inverse relation between histologic grade, FPtot (p = 0.0001), and ASItot (p = 0.006) was statistically significant. FPtot (p = 0. 039) and ASItot (p = 0.018) were also inversely related to clinical stage. Occurrence of metastasis during the follow-up was associated with low CA 50 positivity (FPtot, p = 0.003; ASItot, p = 0.002). The lower the staining intensity or the lower the fraction of CA 50-positive cells, the more aggressive was the tumor. In survival analysis, low FPtot (p = 0.002) and ASItot (p = 0.007) values were related to high risk of bladder cancer death. The results show that immunohistochemical staining of bladder tumor specimens with CA 50 can be used to predict bladder cancer aggressiveness and survival.