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1.
Supportive interventions to improve physiological and psychological health outcomes among patients undergoing cystectomy: a systematic review.
Quirk, H, Rosario, DJ, Bourke, L
BMC urology. 2018;(1):71
Abstract
BACKGROUND Our understanding of effective perioperative supportive interventions for patients undergoing cystectomy procedures and how these may affect short and long-term health outcomes is limited. METHODS Randomised controlled trials involving any non-surgical, perioperative interventions designed to support or improve the patient experience for patients undergoing cystectomy procedures were reviewed. Comparison groups included those exposed to usual clinical care or standard procedure. Studies were excluded if they involved surgical procedure only, involved bowel preparation only or involved an alternative therapy such as aromatherapy. Any short and long-term outcomes reflecting the patient experience or related urological health outcomes were considered. RESULTS Nineteen articles (representing 15 individual studies) were included for review. Heterogeneity in interventions and outcomes across studies meant meta-analyses were not possible. Participants were all patients with bladder cancer and interventions were delivered over different stages of the perioperative period. The overall quality of evidence and reporting was low and outcomes were predominantly measured in the short-term. However, the findings show potential for exercise therapy, pharmaceuticals, ERAS protocols, psychological/educational programmes, chewing gum and nutrition to benefit a broad range of physiological and psychological health outcomes. CONCLUSIONS Supportive interventions to date have taken many different forms with a range of potentially meaningful physiological and psychological health outcomes for cystectomy patients. Questions remain as to what magnitude of short-term health improvements would lead to clinically relevant changes in the overall patient experience of surgery and long-term recovery.
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Impact of Sarcopenia as a Prognostic Biomarker of Bladder Cancer.
Fukushima, H, Takemura, K, Suzuki, H, Koga, F
International journal of molecular sciences. 2018;(10)
Abstract
Sarcopenia, the degenerative and systemic loss of skeletal muscle mass, indicates patient frailty and impaired physical function. Sarcopenia can be caused by multiple factors, including advanced age, lack of exercise, poor nutritional status, inflammatory diseases, endocrine diseases, and malignancies. In patients with cancer cachexia, anorexia, poor nutrition and systemic inflammation make the metabolic state more catabolic, resulting in sarcopenia. Thus, sarcopenia is considered as one of manifestations of cancer cachexia. Recently, growing evidence has indicated the importance of sarcopenia in the management of patients with various cancers. Sarcopenia is associated with not only higher rates of treatment-related complications but also worse prognosis in cancer-bearing patients. In this article, we summarized metabolic backgrounds of cancer cachexia and sarcopenia and definitions of sarcopenia based on computed tomography (CT) images. We conducted a systematic literature review regarding the significance of sarcopenia as a prognostic biomarker of bladder cancer. We also reviewed recent studies focusing on the prognostic role of changes in skeletal muscle mass during the course of treatment in bladder cancer patients. Lastly, we discussed the impact of nutritional support, medication, and exercise on sarcopenia in cancer-bearing patients.
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3.
Enhanced recovery after surgery for radical cystectomy with ileal urinary diversion: a multi-institutional, randomized, controlled trial from the Chinese bladder cancer consortium.
Lin, T, Li, K, Liu, H, Xue, X, Xu, N, Wei, Y, Chen, Z, Zhou, X, Qi, L, He, W, et al
World journal of urology. 2018;(1):41-50
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) has played an important role in recovery management for radical cystectomy with ileal urinary diversion (RC-IUD). This study is to evaluate ERAS compared with the conventional recovery after surgery (CRAS) for RC-IUD. METHODS From October 2014 and July 2016, bladder cancer patients scheduled for curative treatment from 25 centers of Chinese Bladder Cancer Consortium were randomly assigned to either ERAS or CRAS group. Primary endpoint was the 30-day complication rate. Secondary endpoints included recovery of fluid and regular diet, flatus, bowel movement, ambulation, and length of stay (LOS) postoperatively. Follow-up period was 30-day postoperatively. RESULTS There were 144 ERAS and 145 CRAS patients. Postoperative complications occurred in 25.7 and 30.3% of the ERAS and CRAS patients with 55 complications in each group, respectively (p = 0.40). There was no significant difference between groups in major complications (p = 0.82), or type of complications (p = 0.99). The ERAS group had faster recovery of bowel movements (median 88 versus 100 h, p = 0.01), fluid diet tolerance (68 versus 96 h, p < 0.001), regular diet tolerance (125 versus 168 h, p = 0.004), and ambulation (64 versus 72 h, p = 0.047) than the CRAS group, but similar time to flatus and LOS. CONCLUSIONS ERAS did not increase 30-day complications compared with CRAS after RC. ERAS may be better than CRAS in terms of bowel movement, tolerance of fluid and regular diet, and ambulation.
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An open label, single-arm, phase II multicenter study of the safety and efficacy of CG0070 oncolytic vector regimen in patients with BCG-unresponsive non-muscle-invasive bladder cancer: Interim results.
Packiam, VT, Lamm, DL, Barocas, DA, Trainer, A, Fand, B, Davis, RL, Clark, W, Kroeger, M, Dumbadze, I, Chamie, K, et al
Urologic oncology. 2018;(10):440-447
Abstract
OBJECTIVES CG0070 is a replication-competent oncolytic adenovirus that targets bladder tumor cells through their defective retinoblastoma pathway. Prior reports of intravesical CG0070 have shown promising activity in patients with high-grade non-muscle invasive bladder cancer (NMIBC) who previously did not respond to bacillus Calmette-Guérin (BCG). However, limited accrual has hindered analysis of efficacy, particularly for pathologic subsets. We evaluated interim results of a phase II trial for intravesical CG0070 in patients with BCG-unresponsive NMIBC who refused cystectomy. PATIENTS AND METHODS At interim analysis (April 2017), 45 patients with residual high-grade Ta, T1, or carcinoma-in-situ (CIS) ± Ta/T1 had evaluable 6-month follow-up in this phase II single-arm multicenter trial (NCT02365818). All patients received at least 2 prior courses of intravesical therapy for CIS, with at least 1 being a course of BCG. Patients had either failed BCG induction therapy within 6 months or had been successfully treated with BCG with subsequent recurrence. Complete response (CR) at 6 months was defined as absence of disease on cytology, cystoscopy, and random biopsies. RESULTS Of 45 patients, there were 24 pure CIS, 8 CIS + Ta, 4 CIS + T1, 6 Ta, 3 T1. Overall 6-month CR (95% CI) was 47% (32%-62%). Considering 6-month CR for pathologic subsets, pure CIS was 58% (37%-78%), CIS ± Ta/T1 50% (33%-67%), and pure Ta/T1 33% (8%-70%). At 6 months, the single patient that progressed to muscle-invasive disease had Ta and T1 tumors at baseline. No patients with pure T1 had 6-month CR. Treatment-related adverse events (AEs) at 6 months were most commonly urinary bladder spasms (36%), hematuria (28%), dysuria (25%), and urgency (22%). Immunologic treatment-related AEs included flu-like symptoms (12%) and fatigue (6%). Grade III treatment-related AEs included dysuria (3%) and hypotension (1.5%). There were no Grade IV/V treatment-related AEs. CONCLUSIONS This phase II study demonstrates that intravesical CG0070 yielded an overall 47% CR rate at 6 months for all patients and 50% for patients with CIS, with an acceptable level of toxicity for patients with high-risk BCG-unresponsive NMIBC. There is a particularly strong response and limited progression in patients with pure CIS.
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5.
The Diagnostic Performance of MRI for Detection of Lymph Node Metastasis in Bladder and Prostate Cancer: An Updated Systematic Review and Diagnostic Meta-Analysis.
Woo, S, Suh, CH, Kim, SY, Cho, JY, Kim, SH
AJR. American journal of roentgenology. 2018;(3):W95-W109
Abstract
OBJECTIVE The purpose of this article is to review the diagnostic performance of MRI for the detection of pelvic lymph node (LN) metastasis in patients with bladder and prostate cancer. MATERIALS AND METHODS MEDLINE and EMBASE were searched up to January 13, 2017. We included diagnostic accuracy studies that used MRI for pelvic LN detection in patients with bladder or prostate cancer, using histopathologic analyses published since 2000 as the reference standard. Two independent reviewers assessed the methodologic quality using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Sensitivity and specificity of all studies were calculated. Per-patient and per-LN results were pooled and plotted in a hierarchic summary ROC plot. Metaregression, sensitivity, and subgroup analyses were performed. RESULTS Twenty-four studies (2928 patients) were included. Pooled per-patient sensitivity (n = 21) was 0.56 (95% CI, 0.42-0.69) with a specificity of 0.94 (95% CI, 0.90-0.96). Per-LN pooled estimates (n = 9) showed consistent results: sensitivity of 0.57 (95% CI, 0.29-0.82) and specificity of 0.97 (95% CI, 0.94-0.98). At metaregression analysis, type of cancer, magnet field strength, and use of ultrasmall superparamagnetic particles of iron oxide (USPIO) were significant factors affecting heterogeneity (p ≤ 0.01). Sensitivity analyses showed that specificity estimates were comparable (range, 0.87-0.95), but sensitivity estimates showed significant differences. Studies that used USPIO (n = 4) had higher sensitivity (0.86; 95% CI, 0.62-0.96) than did those not using USPIO (n = 17; 0.46; 95% CI, 0.35-0.58). CONCLUSION MRI shows high specificity but poor and heterogeneous sensitivity for detecting pelvic LN metastasis in patients with bladder and prostate cancer. Using USPIO can improve sensitivity.
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Prehabilitation for major abdominal urologic oncology surgery.
Jensen, BT, Lauridsen, SV, Jensen, JB
Current opinion in urology. 2018;(3):243-250
Abstract
PURPOSE OF REVIEW Whether prehabilitation in radical cystectomy adds to the effort of reducing postoperative morbidity and impairments in the survivorship phase has until recently received limited attention. This narrative review aims to summarize the current evidence base on prehabilitaion interventions focusing on the efficacy of procedure-specific interventions and the influence on postoperative outcomes. RECENT FINDINGS Given the oncological risk, there is a relative short window to intervene and proactively optimize the patient before radical cystectomy. Preliminary results are however promising and a single-center randomized controlled trial (RCT) has shown that home-based short-term physical prehabilitation is feasible and effective and significantly improves early mobilization, time to perform activities of daily living and health-related quality of life (HRQoL). No significant impact on length of stay or complications was found. Limited evidence support preoperative nutritional interventions in cancer surgery, although evidence suggests improved outcome if malnourished individuals are adequately fed 7-10 days before surgery. No RCTs have evaluated the effect of smoking or alcohol cessation interventions on complications or HRQoL in radical cystectomy. Patient education interventions focusing on stoma care improve significantly self-efficacy in regards to independently change of stoma-appliance up to 1 year postoperatively. Currently, there is no evidence of early intervention considering psychological well being, sexual health or shared decision-making. SUMMARY Published data indicate that a group of preoperative multiprofessional interventions including physical exercises, supportive nutritional care and stoma education can postoperatively improve early mobilization, self-efficacy and HRQoL. No evidence for further reduction of length of stay or complications was found.
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A Stratified Meta-Analysis of the Association between Exposure to Environmental Tobacco Smoke during Childhood and Adulthood and Urothelial Bladder Cancer Risk.
van Osch, FHM, Jochems, SHJ, Wesselius, A, van Schooten, FJ, Bryan, RT, Zeegers, MP
International journal of environmental research and public health. 2018;(4)
Abstract
Background: Active smoking is a major risk factor for urothelial bladder cancer (UBC). However, the evidence that exposure to environmental tobacco smoke (ETS) either in childhood or adult life is also associated with UBC risk is ambiguous. With this meta-analysis, we aim to summarise how exposure to ETS is associated with UBC risk. Methods: In total, 11 studies (3 cohort studies, 8 case-control studies) were included in this meta-analysis and summary odds ratios (SORs) for UBC risk were calculated for never smokers who were exposed to ETS during childhood at home, during adulthood at home, or during adulthood in a work environment compared to never smokers who were never exposed to ETS. Sensitivity analyses were conducted to test the robustness of findings. Results: Never smokers exposed to ETS during childhood (SOR = 1.04, 95% confidence interval (CI) = 0.82-1.26), during adulthood at work (SOR = 0.98, 95% CI = 0.78-1.18) or at home (SOR = 0.99, 95% CI = 0.83-1.15) were at a similar risk of UBC compared to never smokers who were never exposed to ETS. Results for males and females were similar. Also, when pooling all estimates during both childhood and adulthood, no effect was observed (SOR = 1.00, 95% CI = 0.89-1.10). Conclusions: Although measurement of exposure to ETS was imprecise, there does not seem to be an association between UBC risk and exposure to ETS during childhood or adulthood. However, the current body of evidence mostly overlooks the duration and intensity of exposure to ETS.
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8.
Is folic acid safe for non-muscle-invasive bladder cancer patients? An evidence-based cohort study.
Tu, H, Dinney, CP, Ye, Y, Grossman, HB, Lerner, SP, Wu, X
The American journal of clinical nutrition. 2018;(2):208-216
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Abstract
BACKGROUND Patients with cancer are highly concerned about food choices and dietary supplements that may affect their treatment outcomes. Excess folic acid (synthetic folate) from supplements or fortification can lead to accumulation of unmetabolized folic acid in the systemic circulation and urine and may promote cancer growth, especially among those with neoplastic alterations. OBJECTIVE We investigated the prospective association between synthetic compared with natural folate intake and clinical outcomes in non-muscle-invasive bladder cancer (NMIBC), which is a highly recurrent disease. DESIGN In a cohort of 619 NMIBC patients, folate intake at diagnosis was assessed with a previously validated food-frequency questionnaire and categorized according to tertiles. After a median follow-up of 5.2 y, 303 tumor recurrence and 108 progression events were documented from medical record review. Multivariable Cox proportional hazards and logistic models were used to estimate adjusted HRs and ORs with 95% CIs. RESULTS Synthetic folic acid intake was positively associated with a risk of recurrence among NMIBC patients (medium compared with low intake-HR: 1.72; 95% CI: 1.20, 2.48; P = 0.003; high compared with low intake-HR: 1.80; 95% CI: 1.14, 2.84; P = 0.01). Patients with a higher folic acid intake were more likely to have multifocal tumors at diagnosis (medium or high compared with low-OR: 2.08; 95% CI: 1.08, 4.02; P = 0.03). In contrast, natural folate intake tended to be inversely associated with the risk of progression (medium or high compared with low-HR: 0.68; 95% CI: 0.44, 1.04; P = 0.08). CONCLUSIONS A high intake of synthetic folic acid, in contrast to the natural forms, is associated with an increased risk of recurrence in NMIBC and multifocal tumors at diagnosis, which suggests that folic acid may be unsafe for NMIBC patients. These findings provide some evidence for nutritional consultation with regard to folate intake among NMIBC patients.
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Perioperative Immunonutrition Modulates Inflammatory Response after Radical Cystectomy: Results of a Pilot Randomized Controlled Clinical Trial.
Hamilton-Reeves, JM, Stanley, A, Bechtel, MD, Yankee, TM, Chalise, P, Hand, LK, Lee, EK, Smelser, W, Mirza, M, Wyre, H, et al
The Journal of urology. 2018;(2):292-301
Abstract
PURPOSE Poor preoperative nutritional status is associated with a higher complication rate after radical cystectomy in patients with bladder cancer. Given the short interval between diagnosis and radical cystectomy, we compared the effect of short-term specialized immunonutrition to that of a standard oral nutritional supplement on the acute inflammatory response and arginine status in patients treated with radical cystectomy. MATERIALS AND METHODS In this prospective, randomized study in 29 men 14 received specialized immunonutrition and 15 received oral nutritional supplement. Each group drank 3 cartons per day for 5 days before and 5 days after radical cystectomy. The Th1-Th2 balance, plasma interleukin-6 and plasma amino acids were measured at baseline, intraoperatively and on postoperative days 2, 14 and 30. Body composition was measured by dual energy x-ray absorptiometry at baseline and on postoperative days 14 and 30. Differences in outcomes were assessed using the generalized linear mixed model. RESULTS In the specialized immunonutrition group there was a 54.3% average increase in the Th1-Th2 balance according to the tumor necrosis factor-α-to-interleukin-13 ratio from baseline to intraoperative day, representing a shift toward a Th1 response. In the oral nutritional supplement group the Th1-Th2 balance decreased 4.8%. The change in the Th1-Th2 balance between the specialized immunonutrition and oral nutritional supplement groups significantly differed (p <0.027). Plasma interleukin-6 was 42.8% lower in the specialized immunonutrition group compared to the oral nutritional supplement group on postoperative day 2 (p = 0.020). In the specialized immunonutrition group plasma arginine was maintained from baseline to postoperative day 2 and yet the oral nutritional supplement group showed a 26.3% reduction from baseline to postoperative day 2 (p = 0.0003). The change in appendicular muscle loss between the groups was not statistically significant. CONCLUSIONS Th1-to-Th2 ratios, peak interleukin-6 levels and plasma arginine suggest that consuming specialized immunonutrition counteracts the disrupted T-helper balance, lowers the inflammatory response and prevents arginine depletion due to radical cystectomy.
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The Effect of Daily Fluid Management and Beverages Consumption on the Risk of Bladder Cancer: A Meta-analysis of Observational Study.
Hong, X, Xu, Q, Lan, K, Huang, H, Zhang, Y, Chen, S, Chi, Z, Lin, J, Zhou, Y, Wu, W, et al
Nutrition and cancer. 2018;(8):1217-1227
Abstract
Epidemiological studies have evaluated the risk of bladder cancer (BCa) in relation to total fluid intake, as well as specific type of beverages consumption, with controversial results. The aim of this study was to further explore the potential relationship by conducting a meta-analysis. Fifty-four articles involving more than 43,000 BCa patients were included in this meta-analysis. A positive, though not statistically significant, association was found between total fluid intake and risk of BCa comparing the highest with lowest intake (SRRE: 1.16, 95%CI: 1.00-1.36). By conducting dose-response meta-analysis, we found that each 500 ml/day increase in total fluid intake was associated with 3.3% increased risk of BCa (RR: 1.03, 95%CI: 1.00-1.07). Pronounced increase in risk of BCa was detected when total fluid intake was more than 3000 ml/day. Meta-analyses of specific type of beverages showed increasing intake of coffee (RR: 1.03, 95%CI: 1.02-1.05) were risk factors for BCa. On the contrary, increasing intake of milk appeared to be a potential protective factor for BCa (RR: 0.90, 95%CI: 0.83-0.98). The risk of BCa was not significantly related to intake of water (RR: 1.01, 95%CI: 0.98-1.03), alcohol (RR: 1.01, 95%CI: 0.97-1.05), tea (RR: 1.01, 95%CI: 0.97-1.05) and soft drinks (RR: 1.04, 95%CI: 0.96-1.11).