Expert Commentary Articles


  • A Multicentered, Propensity Matched Analysis Comparing Laparoscopic and Open Surgery for pT3a Renal Cell Carcinoma: Expert Commentary

    Laparoscopic renal surgery (LRS) has long been recognized for its improvements over open renal surgery for patient quality of life. However, LRS efficiency in terms of oncology and recurrences has yet to be compared. This team attempted to do just that by contrasting ORS and LRS on patients with Pathologic T3a (pT3a).
    Published September 15, 2017
  • APOBEC Mutagenesis is Associated with FGFR3 S249C Mutations in Bladder Cancer - Expert Commentary

    FGFR3 mutations are common in urothelial carcinoma. The APOBEC mutational process is the dominant mutational mechanism in bladder cancer. The relationship between the overexpression of FGFR3 S249C mutation and APOBEC mutagenesis is not well understood. A new study published by Shi et al. in European Urology examined the link between the APOBEC mutational load and different FGFR3 recurrent mutations in bladder cancer.
    Published August 16, 2019
  • Association of Testosterone Replacement With Cardiovascular Outcomes Among Men With Androgen Deficiency: Expert Commentary

    As men get older, starting at the age of 30 years, their testosterone levels decrease by an average of 3.1 to 3.5ng/dL per year1. Low levels of testosterone can lead to androgen deficiency, symptoms which include: loss of sexual desire, erectile dysfunction, breast enlargement or tenderness, hot flashes, reduced energy, irritability, and depressed mood. Exogenously administered testosterone, or testosterone replacement therapy (TRT) is used to treat androgen deficiency2; Some studies have shown an increase in cardiovascular  (CV) adverse events when using TRT3-5, while others show that TRT may have CV benefits6-8. The primary goal of this study was to view more closely the association between TRT and CV outcomes in androgen deficient men. 

    This was a retrospective cohort study that looked at men at least 40 years old between January 1, 1999 and December 31, 2010, with evidence of androgen deficiency, either by coded diagnosis or serum testosterone testing. The cohort was then followed-up to the first 90, 180, and 365 days through December 31, 2012, and was classified into ever-TRT or never-TRT groups. The primary outcome was c omposite of 4 CV events: (1) acute myocardial infarction, (2) unstable angina, (3) combined stroke, and (4) sudden cardiac death. Baseline conditions and comorbidities were accounted for and controlled. For statistical analysis, a multivariable Cox proportional hazards model was used. 

    In total, 129, 544 were identified in the study and 44,335 of these men met inclusion and exclusion criteria. The cohort consisted of 8808 men in the ever-TRT group and 35,527 men in the never-TRT group. The rates of the composite cardiovascular end point were 23.9 vs 16.9 per 1000 person in the never-TRT and ever-TRT groups, respectively. The adjusted hazard ratio (HR) for the composite cardiovascular end point in the ever-TRT group was 0.67. When outcome was restricted to combine stroke and cardiac events, similar scores of 0.72 and 0.66 were seen, respectively.

    In conclusion, the results of the study showed that TRT was associated with a lower risk of CV events, which are consistent with other studies9-11. In addition, it is recommended that men with hypogonadism be receiving TRT, as they are other plentiful of health benefits. Some limitations that the authors note was the criteria for identifying androgen-deficient males did not meet strict criteria and therefore by misclassified as androgen-deficient, and the observational nature of the study. 

    Written by: Zhamshid Okhunov, MD Department of Urology, University of California, Irvine Urology

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    • Venhola M, Reunanen M, Taskinen S et al: Interobserver and intra-observer agreement in interpreting urodynamic measurements in children. J Urol 2003; 169: 2344.
    • Bauer SB, Nijman RJ, Drzewiecki BA et al: International Children’s Continence Society standardization report on urodynamic studies of the lower urinary tract in children. Neurourol Urodyn 2015; 34: 640
    Published November 9, 2017
  • Bladder Cancer Outcomes in Women Vary over Time - Expert Commentary

    Understanding differences in bladder cancer outcomes between men and women can help physicians tailor optimal treatment and follow-up strategies.
    Published November 11, 2019
  • Carcinoma In Situ of the Bladder with Plasmacytoid Features - Expert Commentary

    Carcinoma in situ (CIS) is a distinct pathological entity. The significance of histological variants associated with CIS is not well-understood.
    Published September 9, 2019
  • Clinical Outcomes in Patients with Micropapillary Urothelial Carcinoma of the Bladder - Expert Commentary

    Micropapillary (MP) is a histological variant of bladder cancer. As with most other histological variants of bladder cancer, the available data is derived from small case series and treatment is based on expert opinion. More knowledge about treatment and prognosis of MP UBC is needed to identify the optimal therapy for MP UBC. 
    Published May 15, 2019
  • Comparing the Outcomes of ddMVAC vs. GC before Cystectomy in Patients with Muscle Invasive Bladder Cancer - Expert Commentary

    Patients with muscle-invasive bladder cancer  (MIBC) who are treated with neoadjuvant chemotherapy (NAC) before cystectomy have a survival advantage. Few studies comparing cancer control and survival outcomes for different NAC regimens exist.
    Published October 26, 2018
  • Conditional Reprogramming of Patient-derived Bladder Cancer Cells for Personalized Treatment Strategies – Expert Commentary

    There is a broad spectrum of bladder cancer responsiveness to treatment in the clinic. The development of practical methods to provide accurate, individualized drug sensitivity information from each patient's tumor is needed to improve outcomes.
    Published August 16, 2019
  • Diagnosing Bladder Cancer using Urinary Cell-Free microRNA - Expert Commentary

    Although hematuria is the most common symptoms of bladder cancer (BC), it can be caused by many non-malignant conditions. The low sensitivity of voided urine cytology (VUC) and the invasiveness the cystoscopy, create an unmet need for a noninvasive test with high accuracy to detect BC in patients with hematuria. 
    Published October 24, 2018
  • Does Pathologic Response to Neoadjuvant Chemotherapy Predict Survival in Muscle-Invasive Bladder Cancer Patients? - Expert Commentary

    Patients who achieved a pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) have a better prognosis compared to patients with pathologic residual disease (pRD). The clinical value of these pathological responses over the long-term to NAC is not well understood.

    A new article published by Waingankar et al. in Urologic Oncology: Seminars and Original Investigations1examined the impact of NAC pathological response on the anticipated survival (conditional survival) based on the years from the RC. Using the National Cancer Database, the investigators identified patients diagnosed with localized MIBC and treated with NAC and RC between 1998 and 2012. They included 1,533 patients in the study. Of these, 314 patients achieved pCR (pathologic stage of Ta, Tis, or T0 and N0) and 1,239 had pRD patients (≥ pT1 disease and/or ≥pN1). They used Kaplan-Meier analysis to calculate the survival between the two groups and used a Cox proportional hazard model to study the effect of achieving pCR on survival from the time of RC.

    During the follow-up period, Patients with pCR had a significantly higher initial probability of survival in year zero (P < 0.001). This effect was sustained in subsequent years. Patients with pCR had improved overall survival relative to those with pRD. As expected, the prognosis for MIBC patients continued to improve with ongoing survivorship, both for patients with pCR and pRD following NAC and RC.

    This study adds to the growing literature examining the pCR after NAC as a predictor of overall survival. However, several pathologic and clinical factors affect the accuracy of pCR assessment. Testing this concept in prospective clinical trials is needed to validate pCR as an endpoint for future clinical trials.

    Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine

    1. Waingankar, Nikhil, Rachel Jia, Kathryn E. Marqueen, Francois Audenet, John P. Sfakianos, Reza Mehrazin, Bart S. Ferket, Madhu Mazumdar, and Matthew D. Galsky. "The impact of pathologic response to neoadjuvant chemotherapy on conditional survival among patients with muscle-invasive bladder cancer." In Urologic Oncology: Seminars and Original Investigations. Elsevier, 2019.

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    Published September 9, 2019
  • Early Detection of Bladder Urothelial Cell Carcinoma Using Micronuclei, Nucleoplasmic Bridges and Nuclear Buds - Expert Commentary

    Chromosomal damage, breakage, loss, and rearrangement are early events in cancer initiations. A recent study published by Podrimaj-Bytyqi et al. in Scientific Reports evaluated the use of chromosomal damage as a biomarker for the early detection of bladder cancer using micronuclei (MN) assays. The investigator assessed the frequencies of biomarkers of chromosomal damage including: (MN), nucleoplasmic bridges (NPBs) and nuclear buds (NBUDs) as predictors of genomic instability. The study enrolled 40 non-smoker urothelial carcinoma patients and 20 controls. The investigators simultaneously conducted MN assays in urothelial exfoliated cells (UEC), buccal exfoliated cells (BEC), and a cytokinesis-block micronucleus (CBMN) cytome assay in peripheral blood lymphocytes (PBL). 
    Published March 12, 2019
  • Early Detection of Relapse using Circulating Tumor DNA in Patients with Urothelial Bladder Carcinoma – Expert Commentary

    The use of circulating tumor DNA (ctDNA) as an early detection tool is a promising development. However, the clinical utility of ctDNA in urothelial bladder cancer is not fully understood.
    Published August 16, 2019
  • Efficacy and Safety of Neoadjuvant Pembrolizumab in Patients with Muscle-Invasive Bladder Cancer - Expert Commentary

    Neoadjuvant chemotherapy followed by radical cystectomy (RC) with lymph node dissection is the standard of care in patients with muscle-invasive urothelial bladder carcinoma (MIBC). Unfortunately, many patients are ineligible or unwilling to receive cisplatin-based neoadjuvant chemotherapy.
    Published March 6, 2019
  • Expert Commentary: Adjuvant chemotherapy in patients with urothelial carcinoma and adverse pathologic features receiving prior neoadjuvant chemotherapy and radical cystectomy

    Neoadjuvant chemotherapy is a standard of care for patients with cisplatin-eligible muscle-invasive urothelial carcinoma. For patients who do not receive neoadjuvant chemotherapy, there is evidence of a benefit associated with cisplatin-based adjuvant chemotherapy after radical cystectomy for patients with pT3/T4 and/or pN+ bladder cancer. It is unknown whether additional adjuvant chemotherapy is beneficial for patients with adverse pathological features after neoadjuvant chemotherapy and radical cystectomy. 
    Published September 2, 2017
  • Expert Commentary: Avelumab, an Anti–Programmed Death-Ligand 1 Antibody, In Patients With Refractory Metastatic Urothelial Carcinoma: Results From a Multicenter, Phase Ib Study.

    Platinum-resistant urothelial carcinoma is a lethal disease. After a long period of therapeutic stagnation, the last two years have witnessed an explosion in the development of new second-line therapies.
    Published August 10, 2017
  • Expert Commentary: Circulating Tumor Cells in Bladder and Upper Tract Urothelial Carcinoma

    Circulating tumor cells (CTCs) are cancer cells shed from the tumor that enter the circulation. Isolating circulating tumor cells from urothelial carcinoma patients has several potential diagnostic, prognostic and predictive clinical applications but the available data has been inconclusive.
    Published July 11, 2017
  • Expert Commentary: Do Molecular Subtypes of Muscle-invasive Bladder Cancer Predict Response to Neoadjuvant chemotherapy?

    Neoadjuvant chemotherapy is a standard of care for muscle-invasive bladder cancer (MIBC). Recently, new molecular subtypes based on gene-expression were identified but their impact on response to neoadjuvant has been unclear.
    Published April 21, 2017
  • Expert Commentary: Gemcitabine and Cisplatin as neoadjuvant chemotherapy in Patients with Locally Advanced Bladder Cancer

    Methotrexate-vinblastine-doxorubicin-cisplatin (MVAC) neoadjuvant chemotherapy is a standard of care for muscle-invasive urothelial bladder cancer. However, gemcitabine-cisplatin (GC) is equally effective and associated with less toxicity in the metastatic setting. This has been extrapolated to the neoadjuvant setting in clinical practice. A recent study by Niedersüss-Beke et al. in the journal Oncologyprospectively evaluated the clinical outcomes of neoadjuvant GC in patients with locally advanced urothelial cancer.
    Published April 28, 2017
  • Expert Commentary: Multi Receptor Tyrosine Kinase Inhibitor Pazopanib Versus Weekly Paclitaxel In Relapsed Or Progressive Urothelial Cancer

    Patients with advanced platinum-resistant urothelial carcinoma have limited therapeutic options. Even after the advent of immune checkpoint inhibitors, only a third of patients will have a response. The development of targeted therapies for this disease state continues to be a priority.
    Published May 4, 2017
  • Expert Commentary: Neoadjuvant chemotherapy prior to radical cystectomy for muscle-invasive bladder cancer with variant histology

    Neoadjuvant chemotherapy is a standard of care for patients with urothelial muscle-invasive bladder cancer. Histologic variants of bladder cancer are less common but often clinically aggressive. Understanding whether neoadjuvant chemotherapy results in the same benefit in histological variants as in urothelial bladder cancer is crucial.
    Published August 8, 2017
  • Expert Commentary: The Molecular Characteristics of Upper Tract Urothelial Carcinoma

    Upper tract urothelial carcinoma is less common than bladder urothelial carcinoma. The biological characteristics of this form of the disease is not completely understood. A new study published in European Urology by Moss et al. performed an integrated DNA, RNA and protein analysis of upper tract urothelial carcinoma to characterize its molecular landscape. 
    Published July 11, 2017
  • Expert Commentary:Contemporary use trends and survival outcomes in patients undergoing radical cystectomy or bladder-preservation therapy for muscle-invasive bladder cancer

    Bladder preservation therapy is a definitive treatment option for clinically localized bladder cancer.  Previous studies demonstrated improved 10-year locoregional control when comparing chemo-radiotherapy with radiation therapy alone. However, evidence from prospective or randomized controlled trials comparing survival outcomes of patients treated with bladder preservation with those of patients receiving radical cystectomy is generally lacking.
    Published August 8, 2017
  • Factors Associated with Recurrence in Primary Carcinoma in situ of the Bladder Treated with Bacillus Calmette-Guérin - Expert Commentary

    Primary carcinoma in situ (P-CIS) of the bladder is rare. Adjuvant intravesical Bacillus Calmette-Guérin (BCG) immunotherapy has been reported to be effective in reducing recurrence rates in CIS and P-CIS patients but the clinical factors associated with the recurrence of P-CIS are not well-defined. 
    Published November 5, 2018
  • FOXA1 and Oncogenic HRAS are Required for Maintenance of Urothelial Hyperplasia - Expert Commentary

    The oncogene addiction model occurs when cancer cells become dependent on one mutated oncogene or pathway for the maintenance of a malignant phenotype. Withdrawal of the oncogenic signal leads to the regression of cancer. The role of oncogenic addiction in precursor lesions such as hyperplasia is not well understood. A recent study by Yee et al.  in Scientific Reports examined the interaction between Forkhead box A1 (FOXA1), a transcriptional activator of the Upk2-promoter in controlling the expression of oncogenic HRAS to induce urothelial hyperplasia in transgenic mice.1 By knocking out FOXA1, the investigators simulated oncogenic HRAS withdrawal. This resulted in a significant reduction of urothelial proliferation consistent oncogenic addiction to HRAS.

    Interestingly, the investigators found that reduced proliferation did not affect basal cells indicating that the regulation of oncogenic HRAS by Upk2 occurs mainly in luminal cells. These results demonstrate the dependence of urothelial hyperplasia on the continuous expression of Foxa1 and activated HRAS in this model.

    This important study adds to our understanding of the events that result in oncogenic addiction in urothelial hyperplasia. Additional studies characterizing the molecular events that occur in normal urothelium and precursor lesions such as hyperplasia have the potential for improving early-detection and for designing strategies to prevent progression.

    Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine

    Reference: 1. Yee CH, Zheng Z, Shuman L, Yamashita H, Warrick JI, Wu XR, Raman JD, DeGraff DJ. Maintenance of the bladder cancer precursor urothelial hyperplasia requires FOXA1 and persistent expression of oncogenic HRAS. Sci Rep. 2019 Jan 22;9(1):270. doi: 10.1038/s41598-018-36720-6.

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    Published October 15, 2019
  • Gemcitabine-Eribulin in Cisplatin-Ineligible Patients with Metastatic Urothelial Carcinoma - Expert Commentary

    The optimal treatment for cisplatin-ineligible patients with metastatic urothelial cancer is unknown. A recent study published by Sadeghi et al. in the Journal of Clinical Oncology1 examined the efficacy of the gemcitabine-eribulin combination in this patient population.

    Cisplatin-ineligibility was defined as a creatinine clearance <60 ml/min and ≥30ml/min, grade 2 or above hearing loss and grade 2 or higher neuropathy. The study enrolled twenty-four patients between 2015 and 2017. Subjects received 1,000 mg/m2 of gemcitabine intravenously 30 minutes before 1.4 mg/m2 eribulin on day 1 and 8 in 21-day cycles until progression or unacceptable toxicity. The median age of enrolled patients was 73 years (range 62-88 years). Most patients had a performance status of 0 or 1. The majority of patients (16/24) had lymph node metastases, and several patients had visceral metastases.

    The observed objective response rate was 50% (95% CI, 29% to 71%) in 12/24 patients. The median overall survival was 11.9 months (95% CI, 5.6 to 20.4 months), and median progression-free survival was 5.3 months (95% CI, 4.5 to 6.7 months). Common toxicities included fatigue (83% of patients), neutropenia (79%), anemia (63%), alopecia (50%), elevated AST (50%), constipation, nausea, and thrombocytopenia (42% each).

    This study demonstrated the efficacy of the combination of gemcitabine-eribulin in cisplatin-ineligible metastatic urothelial cancer patients. Prospective trials comparing the efficacy of carboplatin-based regimens, immunotherapy, and gemcitabine-eribulin combinations are needed to determine the optimal treatment regimen.

    Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine

    1. Sadeghi, Sarmad, Susan G. Groshen, Denice D. Tsao-Wei, Rahul Parikh, Amir Mortazavi, Tanya B. Dorff, Cheryl Kefauver et al. "Phase II California Cancer Consortium Trial of Gemcitabine-Eribulin Combination in Cisplatin-Ineligible Patients With Metastatic Urothelial Carcinoma: Final Report (NCI-9653)." Journal of Clinical Oncology (2019): JCO-19.

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    Published September 9, 2019
  • Gene Methylation and Urine Cytology to Monitor Bladder Cancer - Expert Commentary

    Currently, intermediate or high-risk non-muscle-invasive bladder cancer patients (NMIBC) require intensive follow-up. This usually consists of urethrocystoscopy (gold standard) and urine cytology to monitor the recurrence of NMIBC. The current methods are expensive and invasive and have low sensitivity. 
    Published July 23, 2018
  • Immune Phenotype of Peripheral Blood Mononuclear Cells in Patients with High-risk Non-muscle Invasive Bladder Cancer - Expert Commentary

    Non-muscle-invasive bladder cancer (NMIBC) has a high recurrence rate. Although the BCG therapy is recommended as an immune targeting treatment in high-risk NMIBC tumors, the BCG’s role in the eliciting a response by the innate and adaptive immunity is unclear. A recent study by Audenet et al. published recently in the World Journal of Urology, investigated the immune phenotype of peripheral blood mononuclear cells (PBMC) in patients with NMIBC treated with intravesical BCG. 
    Published July 31, 2018
  • Late Recurrences of Bladder Cancer - Expert Commentary

    Patients with muscle-invasive and high-risk non-muscle invasive urothelial carcinoma of bladder who undergo radical cystectomy (RC) and lymphadenectomy are closely monitored for recurrence.  The risk of disease recurrence is highest during the first few years. Defining late recurrence patterns is critical for designing optimal surveillance and management strategies.
    Published October 22, 2019
  • Mental Health Problems are Common in Bladder Cancer Patients - Expert Commentary

    Bladder cancer takes an enormous physical, emotional and economic toll on patients. Psychological distress can be caused by the diagnosis, the associated high risk of recurrence, and the stress from major surgery and the possible loss of sexual and urinary function. In the literature, little attention is paid to the impact of both pre- and post- treatment mental health of bladder cancer on clinical outcomes.
    Published March 12, 2019
  • Microfluidic Analysis of Captured Urinary Exfoliated Tumor Cells - Expert Commentary

    Due to the very high risk of recurrence, bladder cancer patients require periodic screening and monitoring. Due to the invasiveness and cost of the currently used tools like cystoscopy, the low sensitivity of urine cytology and the lack of sensitivity and specificity of the recent molecular techniques (BTA and NMP22), there is an unmet clinical need for less invasive and more sensitive and specific methods to detect UBC. 
    Published August 6, 2018
  • Mismatch Repair Gene Alterations and Microsatellite Instability in Upper Tract Urothelial Carcinoma - Expert Commentary

    Lynch Syndrome (LS) is a common hereditary cancer syndrome that is characterized by mutations in the mismatch repair (MMR) genes. The three most common malignancies in LS patients are colorectal, endometrial and upper tract urothelial carcinoma (UTUC). Unlike colorectal and endometrial carcinoma, universal MMR immunohistochemistry (IHC) and microsatellite instability (MSI) testing are not routinely performed in all the UTUC cases.
    Published September 27, 2018
  • Molecular Alterations in Urothelial Carcinoma Using CLIA-certified Genomic Testing - Expert Commentary

    Defining the genomic landscapes that characterize the different disease states of urothelial carcinoma is an important area of investigation. A recent study by Nassar et al. recently published in Clinical Cancer Research characterized the molecular changes across the clinical spectrum of urothelial carcinoma (UC).
    Published May 15, 2019
  • Monthly Maintenance Intravesical Combination Gemcitabine/Docetaxel for Non Muscle-invasive Bladder Cancer - Expert Commentary

    Bacillus Calmette-Guerin shortage is a critical access issue for patients with non-muscle-invasive bladder cancer (NMIBC). Defining the efficacy of alternative intravesical treatments is an active area of investigation.
    Published November 11, 2019
  • Mutational Analysis Reveals the Relationship Between Upper Tract and Lower Tract Urothelial Carcinomas - Expert Commentary

    Although urothelial carcinomas of the bladder and upper tract urothelial carcinoma (UTUC) can have similar histology, they significantly differ in prevalence and risk factors. A recent paper published by Audenet et al. in Clinical Cancer Research explored the genetic relatedness between UTUC and urothelial carcinomas of the bladder. The cohort included 195 UTUC patients and 454 urothelial carcinomas of the bladder patients with no prior history of UTUC. The investigators analyzed matched tumor and germ-line DNA by using targeted NGS platform (MSK-IMPACT). 
    Published March 7, 2019
  • Outcomes of Partial Cystectomy for Selected Bladder Cancer Patients - Expert Commentary 

    Radical cystectomy (RC) is currently the gold standard operative treatment for localized (T2-T4a) muscle-invasive bladder cancer (MIBC) or recurrent high-risk non-MIBC. However, RC can be associated with several complications and can affect the patients’ quality of life. Partial cystectomy (PC) is an important alternative treatment for selected patients, but there is insufficient data on the outcomes of PC as an alternative treatment for MIBC patients. Assessing the effectiveness and complications of PC is critical to establish guidelines for its proper utilization.  
    Published October 12, 2018
  • Outcomes of Patients with Renal Carcinoma and Sarcomatoid Dedifferentiation Treated with Nephrectomy and Systemic Therapies: Comparison between the Cytokine and Targeted Therapy Eras: Expert Commentary

    Though nephrectomy is the gold standard treatment for renal cell carcinoma, 20%-40% of patients have a recurrence and 20-30% of patients present with metastatic disease1. Sarcomatoid dedifferentiation is found in approximately 5% of all RCC and can be an associated feature with any RCC histological subtype. But they are historically associated with a poor prognosis and a median overall survival of 4 to 9 months2-4. The objective of this study was to then analyze the outcome of patients with metastatic sRCC in different therapeutic eras and explore factors associated with patient survival.
    Published November 15, 2017
  • Photoimmunotherapy: A New Method for Targeting EGFR in Bladder Cancer - Expert Commentary

    Clinically-localized bladder cancer is amenable to local treatments because of its accessibility. A team of investigators led by Dr. Piyush Agarwal at the National Institutes of Health developed a novel way to target bladder cancers that express epidermal growth factor receptor (EGFR). By combining infrared radiation with an anti-EGFR antibody panitumumab labeled with the photo-absorber, IR dye 700Dx.
    Published July 11, 2017
  • Racial Differences in Urinary Bladder Cancer in the United States - Expert Commentary

    To achieve progress against Urinary bladder cancer (UBC), studies are needed to understand to understand the racial differences in the incidence, presentation, outcomes, and biology of UBC. However, there is a lack of studies addressing this knowledge gap.
    Published October 1, 2018
  • Randomized Phase 1 Trial of Pembrolizumab with Sequential Versus Concomitant Stereotactic Body Radiotherapy in Metastatic Urothelial Carcinoma - Expert Commentary

    Radiotherapy has the potential to sensitize tumors to immune checkpoint blockade. A recent article published by Sundahl et al. in European Urology assessed the toxicity and efficacy of stereotactic body radiotherapy (SBRT) at different time points to patients who receive pembrolizumab for mUC.1 In this randomized phase 1 trial, the investigators enrolled 18 patients who received at least one dose of SBRT and at least one dose of pembrolizumab. Patients were randomly divided into two groups, arm A included patients who received SBRT before the first cycle of pembrolizumab and arm B who received SBRT before the third cycle of pembrolizumab.
    Published November 19, 2019
  • Recurrence Risk Prediction Nomogram for Non-muscle Invasive Bladder Cancer Patients - Expert Commentary

    Non-muscle invasive bladder cancers (NMIBC) represent the majority of new bladder cancer diagnoses. A high recurrence rate characterizes the natural history of the disease. Understanding the risk factors for recurrence is critical for predicting the individual recurrence risk of recurrence. 
    Published August 16, 2019
  • Response to Platinum Reintroduction After Immune Checkpoint Inhibitors for Metastatic Urothelial Carcinoma - Expert Commentary

    Immune checkpoints inhibitors (ICIs) are approved as a second line of treatment for metastatic urothelial carcinoma (mUC) patients with progression on cisplatin-based chemotherapy. Chemotherapy is rarely reintroduced in these patients after the ICI.
    Published March 8, 2019
  • Sarcopenia as a Predictor of Survival in Bladder Cancer Patients Receiving Radiotherapy - Expert Commentary

    There is not enough data on the prognostic value of sarcopenia and nutritional indices in bladder cancer patients who receive definitive radiotherapy. A recent paper by Stangl-Kremser et al. in Urologic Oncology studied the role of sarcopenia and nutritional indices in the overall survival for patients with high-risk urothelial carcinoma who are unfit to for chemotherapy or radical cystectomy. 
    Published May 15, 2019
  • Survival Benefit of Chemotherapy in Metastatic Upper Tract Urothelial Carcinoma - Expert Commentary

    Upper tract urothelial carcinoma (UTUC) is a distinct clinical entity with poor clinical outcomes. A recent paper published by Nazzani et al. in Clinical Genitourinary Cancer studied the efficacy of chemotherapy in treating non-surgically treated metastatic upper tract urothelial carcinoma (mUTUC) in a large cohort. The investigators identified 539 patients with non-surgically treated mUTUC within the Surveillance, Epidemiology, and End Results database (2004-2014). Of these, 277 (51.4%) received chemotherapy. The investigators compared the overall mortality and cancer-specific mortality in the group that received chemotherapy to the control group. 
    Published March 11, 2019
  • Testing A Novel Molecular Urine Assay in Patients with Equivocal Urine Cytology - Expert Commentary

    Urine cytology plays a critical role as a noninvasive tool in bladder cancer detection and surveillance. However, a substantial fraction of cytology tests is classified as atypical or indeterminate. A need for a minimally-invasive high sensitivity and specificity test that can early detect genetic alterations associated with bladder cancer in these patients is needed.
    Published December 9, 2019
  • The Efficacy of Immunotherapy and Carboplatin-Based Chemotherapy in Cisplatin-Ineligible Metastatic Urothelial Cancer Patients - Expert Commentary

    The optimal treatment for patients with metastatic urothelial carcinoma (mUC) patients who are unfit to receive the standard cisplatin-based chemotherapy is uncertain.

    A new study published by Feld et al. in European Urology1 compared the outcomes of carboplatin-based chemotherapy versus immunotherapy. The investigators used the Flatiron Health electronic health record–derived database to find patients with mUC who started first line of treatment. The study included 1530 mUC patients who received carboplatin-based treatment and 487 mUC patients who received immunotherapy between 2011 and 2018. The investigators compared the overall survival (OS) at 12 months and 36 months between the treatment groups. They used propensity score–based inverse probability of treatment weighting (IPTW) to adjust for confounding factors that could affect clinical outcomes.

    The investigators found that, at 12 months, the IPTW-adjusted OS of the immunotherapy group was lower than chemotherapy group (39.6% [95% confidence interval {CI} 34.0–45.3%] versus 46.1% [95% CI 43.4–48.8%]). On the other hand, at 36 months, the IPTW-adjusted OS of the immunotherapy group was higher than chemotherapy group (28.3% [95% CI 21.8–34.7%] vs. 13.3% [95% CI 11.1–15.5%]). Although immunotherapy showed higher hazard of death (HR 1.37, 95% CI 1.15–1.62, p < 0.001) than chemotherapy during the first 12 months, immunotherapy survival rates improved (HR 0.50, 95% CI 0.30–0.85, p= 0.01) for those who survived the one year after the first line.

    This interesting real-world data show temporal variations in patterns of response to different treatments for mUC patients who are ineligible for cisplatin-based chemotherapy. Prospective randomized trials comparing carboplatin-based treatment versus immunotherapy in this patient population is needed to validate this data. Pre-specified analyses should be planned to examine whether specific patient subgroups derive more clinical benefit from chemotherapy or immunotherapy.

    Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine

    1. Feld, Emily, Joanna Harton, Neal J. Meropol, Blythe JS Adamson, Aaron Cohen, Ravi B. Parikh, Matthew D. Galsky et al. "Effectiveness of First-line Immune Checkpoint Blockade Versus Carboplatin-based Chemotherapy for Metastatic Urothelial Cancer." European urology (2019).

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    Published September 9, 2019
  • The Impact of Bacillus Calmette-Guérin Shortage on Non-Muscle-Invasive Bladder Cancer Patients - Expert Commentary

    A shortage of the Bacillus Calmette-Guérin (BCG) Connaught strain occurred between 2013-2016. A recent paper published by Ourfali et al. in European Urology Focusinvestigated the medical and financial sequelae of BCG shortage on intermediate-risk and high-risk NMIBC patients between 2013 and 2016.
    Published August 8, 2019
  • The Relationship Between Uterosacral Ligament Laxity, OAB , Chronic Pain and Bowel Dysfunction - Expert Commentary

    This commentary outlines the anatomical basis for surgical cure of OAB as reported by Liedl et al., in a multicentre study (n=611) in the Central European Journal of Urology1. This is the first substantive study aimed to challenge the Integral Theory’s predictions that OAB and other pelvic symptoms are mainly caused by loose suspensory ligaments2, are a consequence of deficient collagen/elastin within them, and are potentially curable surgically, Table1, by use of a polypropylene tape to create a collagenous neoligament 3. The first application of this neoligament methodology 3 was reinforcement of damaged pubourethral ligaments 4 as part of the midurethral sling operation, ‘TVT’ 4 for cure of urinary stress incontinence.
    Published November 14, 2018
  • The Role of Aurora Kinase A in Bladder Cancer - Expert Commentary

    Aurora kinase A (AURKA) plays a vital role in several cancers, but little is known about its role in bladder cancer. A recent study published by Guo et al. in BMC Systems Biology investigated the relationship between AURKA expression, clinicopathologic characteristics and overall survival in patients with bladder cancer using sequential gene expression profiling.
    Published May 15, 2019
  • The Significance of Persistent Muscle Invasive After Neoadjuvant Chemotherapy - Expert Commentary

    Downstaging of muscle-invasive bladder cancer (MIBC) following neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) has been correlated with higher survival rates.  
    Published October 8, 2018
  • The Use of High-Resolution Micro-Ultrasound in Diagnosing and Staging Bladder Cancer - Expert Commentary

    High-resolution micro-ultrasound is a promising technology in the staging of prostate cancer but has not been well studied in bladder cancer patients. A recent paper published by Saita et al. in European Urologyevaluated the accuracy and feasibility of micro-ultrasound in detecting and staging bladder cancer. The investigators studied 23 bladder cancer patients using a micro-ultrasound system before the transurethral resection of their bladder tumors. They evaluated the accuracy of micro-ultrasound in identifying bladder wall layers, non-muscle-invasive bladder cancer, and muscle-invasive cancers in comparison to histopathological results.
    Published August 8, 2019

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