Poor prognosis of bladder cancer patients with occult lymph node metastases treated with neoadjuvant chemotherapy.

OBJECTIVES: To characterise the outcomes of neoadjuvant chemotherapy (NAC) pre-treated patients found to be lymph node (LN)-positive at the time of radical cystectomy and pelvic lymph node dissection (RC/PLND) for urothelial carcinoma of the bladder (UCB). PATIENTS AND METHODS: Of 1484 patients treated with RC/PLND for UCB from 2000 to 2010, we analysed 198 patients with clinically non-metastatic (cN0M0) muscle-invasive UCB who were found to be LN-positive at RC/PLND. As patients not receiving perioperative chemotherapy were significantly older and comorbid, we compared LN-positive patients previously treated with NAC (32 patients) to LN-positive patients treated with adjuvant chemotherapy (AC, 49 patients) using Cox proportional hazards models. A sensitivity analysis was designed to account for the additional time to RC in NAC patients. RESULTS: The 3-year recurrence-free survival estimate for LN-positive NAC patients was 26%, compared with 60% for LN-positive AC patients. LN-positive patients treated with NAC had significantly higher risks of disease recurrence and cancer-specific mortality in univariate analyses (hazard ratio [HR] 2.86, 95% confidence interval [CI] 1.58-5.19, P = 0.001 and HR 2.50, 95% CI 1.34-4.65, P = 0.004, respectively) and multivariable analyses adjusting for pathological stage and LN density (HR 3.11, 95% CI 1.59-6.07, P = 0.001 and HR 3.05, 95% CI 1.46-6.35, P = 0.003, respectively). Sensitivity analyses similarly demonstrated worse outcomes for NAC pre-treated LN-positive patients. CONCLUSION: LN-positive patients previously treated with NAC have a poor prognosis, significantly worse than LN-positive patients subsequently treated with AC, and should be considered for protocols using sandwich chemotherapy approaches or novel agents. These results should be considered in the interpretation of and stratification for clinical trials.

Reflex fluorescence in situ hybridization assay for suspicious urinary cytology in patients with bladder cancer with negative surveillance cystoscopy.

OBJECTIVE: To assess the ability of reflex UroVysion fluorescence in situ hybridization (FISH) testing to predict recurrence and progression in patients with non-muscle-invasive bladder cancer (NMIBC) with suspicious cytology but negative cystoscopy. PATIENTS AND METHODS: Patients under NMIBC surveillance were followed with office cystoscopy and urinary cytology every 3-6 months. Between March 2007 and February 2012, 500 consecutive patients with suspicious cytology underwent reflex FISH analysis. Clinical and pathological data were reviewed retrospectively. Predictors for recurrence, progression and findings on subsequent cystoscopy (within 2-6 months after FISH) were evaluated using univariate and multivariate Cox regression. RESULTS: In all, 243 patients with suspicious cytology also had negative surveillance cystoscopy. Positive FISH was a significant predictor of recurrence (hazard ratio [HR] = 2.35, 95% confidence interval [CI]: 1.42-3.90, P = 0.001) in multivariate analysis and for progression (HR = 3.01, 95% CI: 1.10-8.21, P = 0.03) in univariate analysis, compared with negative FISH. However, positive FISH was not significantly associated with evidence of tumour on subsequent surveillance cystoscopy compared with negative FISH (odds ratio = 0.8, 95% CI: 0.26-2.74, P = 1). CONCLUSIONS: Positive FISH predicts recurrence and progression in patients under NMIBC surveillance with suspicious cytology but negative cystoscopy. However, there was no association between the FISH result and tumour recurrence in the immediate follow-up period. Reflex FISH testing for suspicious cytology might have limited ability to modify surveillance strategies in NMIBC.

Automating Treatment Summary Development Using Electronic Billing Information: A Pilot Study of Survivors of Head and Neck Cancer.

PURPOSE: Although the provision of a treatment summary (TS) is a quality indicator in oncology, routine delivery of TSs remains challenging. Automatic TS generation could facilitate use, but data on accuracy are lacking in complex cancers such as head and neck cancer (HNC). We developed and evaluated an electronic platform to automate TS generation for HNC. METHODS: The algorithms autopopulated TSs using data from billing records and an institutional cancer registry. A nurse practitioner used the medical record to verify the accuracy of the information and made corrections electronically. Inaccurate and missing data were considered errors. We described and investigated reasons for errors in the automatically generated TSs. RESULTS: We enrolled a heterogeneous population of 43 survivors of HNC. Using billing data, the information on primary site, lymph node status, radiation, and chemotherapy use was accurate in 93%, 95%, 93%, and 95% of patients, respectively. Billing data captured surgery accurately in 77% of patients; once an omitted billing code was identified, accuracy increased to 98%. Chemotherapies were captured in 90% of patients. Using the cancer registry, month and year of diagnosis were accurate in 91% of cases; stage was accurate in 28% of cases. Reprogramming the algorithm to ascertain clinical stage when pathologic stage was unavailable resulted in 100% accuracy. The algorithms inconsistently identified radiation receipt and treating physicians from billing data. CONCLUSION: It is feasible to automatically and accurately generate most components of TSs for HNC using billing and cancer registry data, although clinical review is necessary in some cases.

Incidence and Effect of Thromboembolic Events in Radical Cystectomy Patients Undergoing Preoperative Chemotherapy for Muscle-invasive Bladder Cancer.

BACKGROUND: We evaluated the incidence and effect of thromboembolic events (TEEs) in patients with muscle-invasive bladder cancer treated with preoperative chemotherapy (POC) and radical cystectomy (RC) with pelvic lymph node dissection (PLND). PATIENTS AND METHODS: We performed a retrospective review of all patients who had undergone POC followed by RC plus PLND for muscle-invasive bladder cancer from June 2000 to January 2013 (n = 357). The chemotherapy type (neoadjuvant vs. induction), incidence and timing of TEE diagnosis (preoperatively vs. ≤ 90 days postoperatively), and effect of TEEs on clinical outcomes were recorded. RESULTS: Overall, 79 patients (22%; 95% confidence interval [CI], 18%-27%) experienced a TEE: 57 (16%) occurred during POC and 22 (6.2%) were diagnosed postoperatively. Forty patients (11%; 95% CI, 8.1%-15%) required an inferior vena cava filter. We found no significant differences in neoadjuvant versus induction chemotherapy and the risk of TEEs (difference, 3.3%; 95% CI, -5% to 12%; P = .5). No significant difference were found in the rates of POC completion according to the presence of a TEE (difference, 1.0%; 95% CI, -11% to 13%; P = .9). The occurrence of TEE did not significantly affect other perioperative outcomes. The risk of recurrence and overall survival were not associated with TEE on multivariable analysis. CONCLUSION: We found a high incidence of TEEs (22%) in patients undergoing POC before RC plus PLND, with a 16% incidence in the preoperative period. TEEs in the POC setting leads to invasive procedures; however, we did not find a significant effect on POC completion or postoperative complication risk. Further research is required to determine whether preventative TEE measures during POC can improve clinical outcomes.