Enhancing bladder cancer care through the multidisciplinary clinic approach.

INTRODUCTION: To report the impact of our 25-year multidisciplinary care delivery model experience on patients with muscle invasive bladder cancer treated at our National Cancer Institute (NCI)-designated Sidney Kimmel Cancer Center at Jefferson University. To our knowledge, our multidisciplinary genitourinary cancer clinic (MDC) is the longest continuously operating center of its kind at an NCI Cancer Center in the United States. MATERIALS AND METHODS: We selected a recent group of patients with cT2-4 N0-1 M0 bladder cancer seen in the Sidney Kimmel Cancer Center Genitourinary Oncology MDC from January 2016 to September 2019. These patients were identified retrospectively. SEER-18 (Surveillance, Epidemiology, and End Results) database, November 2019 submission was queried to obtain patients with similarly staged disease diagnosed between 2015 and 2017. Completion rates of radical cystectomy, use of neoadjuvant therapies, and survival outcomes were compared between the two cohorts. RESULTS: Ninety-one patients from the MDC form this time period were identified; 65.9% underwent radical cystectomy and 71.8% received neoadjuvant therapy in the form of chemotherapy, immune checkpoint inhibition or a combination of the two - higher than reported national trends for neoadjuvant therapies. Progression of disease was seen in 24.2% of patients. A total of 8675 patients met inclusion criteria in the SEER database. Rates of radical cystectomy were significantly higher in MCD patients when compared to SEER derived data (65.9% vs. 37.7%, p =< 0.001). MCD patients had significantly better cancer-specific survival (mean 20.4 vs. 18.3 months p = 0.028, median survival not reached). CONCLUSION: Our long term experience caring for patients with genitourinary malignancies such as bladder cancer in a uniform multidisciplinary team results in a high utilization of neoadjuvant therapies. When compared to a contemporary SEER-derived cohort, multidisciplinary patients were more likely to undergo radical cystectomy and had longer cancer-specific survival.

DNA analysis for prostate specimen verification: How I Do It.

Prostate cancer is the most common malignancy affecting men. Prostate biopsy remains the key clinical tool for selecting appropriate treatment options. The process of specimen collection and diagnosis is multistep and vulnerable to human error along every stage. Specimen provenance testing (SPT) aims to provide certainty that biopsy results can be trusted when recommending life changing treatments and has emerged as a necessary tool in medicine to counteract human error and specimen contamination. In this study we report our practice's experience using the Know Error test to verify prostate biopsy specimens. In this study, we retrospectively reviewed the results of a specific SPT known as Know Error which is used in our institution for specimen verification during prostate biopsy. Over a period of 16 months, we identified 445 patients with a total of 921 specimens. The percentage of patients who had 1, 2 or 3 specimens analyzed was 29%, 38%, and 30%, respectively. Our cohort's rate of specimen verification was 92.8% with a 2.8% contamination rate. The pathology reports for 445 patients were then examined to determine Gleason Grade Group (GG) showing 180 GG1 and 148 GG2 patients. Cross reference of pathology reports and Know Error reports showed 8 GG1 and 9 GG2 patients had contaminated biopsy specimens. Specimen provenance complications such as contamination can negatively impact patient counselling and treatment modalities leading to unnecessary intervention and detrimental patient outcomes.

Prospective study to define the clinical utility and benefit of Decipher testing in men following prostatectomy.

BACKGROUND: Genomic classifiers (GC) have been shown to improve risk stratification post prostatectomy. However, their clinical benefit has not been prospectively demonstrated. We sought to determine the impact of GC testing on postoperative management in men with prostate cancer post prostatectomy. METHODS: Two prospective registries of prostate cancer patients treated between 2014 and 2019 were included. All men underwent Decipher tumor testing for adverse features post prostatectomy (Decipher Biosciences, San Diego, CA). The clinical utility cohort, which measured the change in treatment decision-making, captured pre- and postgenomic treatment recommendations from urologists across diverse practice settings (n = 3455). The clinical benefit cohort, which examined the difference in outcome, was from a single academic institution whose tumor board predefined "best practices" based on GC results (n = 135). RESULTS: In the clinical utility cohort, providers' recommendations pregenomic testing were primarily observation (69%). GC testing changed recommendations for 39% of patients, translating to a number needed to test of 3 to change one treatment decision. In the clinical benefit cohort, 61% of patients had genomic high-risk tumors; those who received the recommended adjuvant radiation therapy (ART) had 2-year PSA recurrence of 3 vs. 25% for those who did not (HR 0.1 [95% CI 0.0-0.6], p = 0.013). For the genomic low/intermediate-risk patients, 93% followed recommendations for observation, with similar 2-year PSA recurrence rates compared with those who received ART (p = 0.93). CONCLUSIONS: The use of GC substantially altered treatment decision-making, with a number needed to test of only 3. Implementing best practices to routinely recommend ART for genomic-high patients led to larger than expected improvements in early biochemical endpoints, without jeopardizing outcomes for genomic-low/intermediate-risk patients.

Intradetrusor onabotulinumtoxinA injection: how I do it.

Overactive bladder is a highly prevalent condition that may have significant impact on quality of life. This condition may be idiopathic or may have a neurogenic etiology. Antimuscarinics have long been the preferred agents for the treatment of this condition. OnabotulinumtoxinA, an injectible agent that prevents presynaptic release of acetylcholine at the neuromuscular junction, has emerged as an important option in the management of patients with urinary incontinence caused by refractory detrusor overactivity. This manuscript describes our technique for performing utilizing this therapy, describes key equipment needed and provides technical tips for avoiding common pitfalls.

Blue light cystoscopy for detection and treatment of non-muscle invasive bladder cancer.

In patients with non-muscle invasive bladder cancer, fluorescence cystoscopy can improve the detection and ablation of bladder tumors. In this paper we describe the technique and practical aspects of hexaminolevulinate (HAL) fluorescence cystoscopy, also known as "blue light cystoscopy".