The first article was published in European Urology by Bosschieter et al.  “Value of an immediate intravesical instillation of mitomycin C in patients with non-muscle-invasive bladder cancer: A prospective multicentre randomized study in 2243 patients.” The objective of this RCT was to compare the effect of a mitomycin C instillation within 24 hours to an instillation two weeks after TURBT in patients with NMIBC with or without adjuvant instillations. The authors found that for immediate vs delayed instillation, recurrence risks were 43% and 46% in the low-risk group (5-yr follow-up, p=0.11), 20% and 32% in the intermediate risk group group (3-yr follow-up, p=0.037), and 28% and 35% in the high-risk group group (3-yr follow-up, p=0.007), respectively. For all patients, the recurrence risk was 27% (95%CI, 24%-30%) in the immediate and 36% (95%CI, 33%-39%) in the delayed instillation group (p<0.001), with a 27% reduction in relative recurrence risk (HR 0.73, 95%CI, 0.63-0.85). Dr. Konety states that he will still consider post-TUR mitomycin C instillation for intermediate risk patients who are still more than likely to get an adjuvant intravesical chemotherapy. With regards to low-risk patients, he questions the benefit of post-TUR mitomycin C and postulates that fulguration alone may be sufficient.
The second article was published in the Journal of Urology by Kiss et al.  “Stenting prior to cystectomy is an independent risk factor for upper urinary tract recurrence.” The impetus for this study is that patients who present with hydronephrosis may require drainage of the affected kidney before radical cystectomy - drainage can be done by retrograde stenting or percutaneously. Retrograde stenting carries the risk of tumor seeding to the upper urinary tract. Thus, the objective of this study was to assess whether patients are at higher risk for upper urinary tract recurrence if retrograde stenting has been performed prior to radical cystectomy. A retrospective review of 1,005 patients undergoing radical cystectomy revealed that preoperative drainage of the upper urinary tract was performed in 114 patients (11%) - 53 (46%) with a Double-J stent and 61 (54%) by percutaneous nephrostomy. Upper urinary tract recurrence occurred in 31 patients (3%), including 7 of 53 (13%) in the Double-J group, and 0% in the nephrostomy group. There were also upper tract recurrences in 3% of the no drainage group. Double-J stenting was strongly associated with upper tract recurrences on multivariable analyses (HR 4.54, 95%CI 1.43-14.38). Dr. Konety states that this study reaffirms his practice of using a percutaneous nephrostomy tube to drain patients with obstruction and he will continue to avoid placing stents even in tumors close to the ureteral orifice.
The third article was published in the Journal of Urology by Casilla-Lennon et al.  “Financial toxicity among patients with bladder cancer: Reasons for delay in care and effect on quality of life.” The impetus for this study was that costly surveillance and treatment of bladder cancer can lead to financial toxicity, which is defined as a “treatment related financial burden”. The objective of the authors of this study was to define the prevalence of financial toxicity among patients with bladder cancer and identify delays in care and its effect on health-related quality of life. There were 138 patients in the University of North Carolina Health Registry Cancer Survivorship Cohort who were asked whether they agreed with the statement of “having to pay more for medical care than you can afford” – a ‘yes’ defined as financial toxicity. Most patients were male (75%) and most were Caucasian (89%). Among the participants, 33 (24%) endorsed financial toxicity. Participants who were younger (p = 0.02), black (p = 0.01), reported less than a college degree (p = 0.01) and had noninvasive disease (p = 0.04) were more likely to report financial toxicity. Patients who endorsed financial toxicity were more likely to report delaying care (39% vs 23%, p = 0.07) due to the inability to take time off work or afford general expenses. Dr. Konety notes that based on this data, he will incorporate financial assessment for his patients and tailor treatment with this consideration.
Presented by: Badrinath R. Konety, MD, University of Minnesota, Minneapolis, MN
1. Bosschieter J, Nieuwenhuijzen JA, van Ginkel T, et al. Value of an immediate intravesical instillation of mitomycine C in patients with non-muscle-invasive bladder cancer: A prospective multicentre randomized study in 2243 patients. Eur Urol 2018;73(2):226-232.
2. Kiss B, Furrer MA, Wuethrich PY, et al. Stenting prior to cystectomy is an independent risk factor for upper urinary tract recurrence. J Urol 2017;198(6):1263-1268.
3. Casilla-Lennon MM, Choi SK, Deal AM, et al. Financial toxicity among patients with bladder cancer: Reasons for delay in care and effect on quality of life. J Urol 2018;199(5):1166-1173.
Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA