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The European Association of Urology (EAU) 2021 prognostic model for non–muscle-invasive bladder cancer (NMIBC) is based on the World Health Organization (WHO) 1973 and/or WHO 2004/2022 grading systems for patients who did not receive bacillus Calmette-Guérin (BCG) instillations and is widely used to assess the risk of progression. The estimated risk of progression affects the type of adjuvant intravesical instillation (chemotherapy or BCG), with primary radical cystectomy recommended for patients with the highest risk of progression. We applied the EAU 2021 prognostic model in a population-based setting for 3392 patients with primary NMIBC diagnosed in 2013–2014 according to the BladderBaSe 2.0 database. We assessed the model calibration by comparing the 5-yr progression probability observed in our cohort with the predicted progression probability assigned for the risk groups in the original EAU study, and evaluated the discrimination according to Harrell’s C index. At 5-yr follow-up, 394 patients had experienced disease progression. The progression probability observed was 4.9% (95% confidence interval [CI] 3.5–6.3%), 8.6% (95% CI 6.9–10%), 25% (95% CI 22–28%), and 23% (95% CI 14–30%) for the low-, intermediate-, high-, and very high-risk groups, respectively. The discrimination at 5 yr was 0.72 (95% CI 0.69–0.78) for the overall cohort and 0.74 (95% CI 0.70–0.80) in the group excluding the 811 patients who received BCG instillations. Showing moderate predictive ability, the EAU 2021 prognostic model has clinical utility in population-based settings despite underestimation of the observed progression risk in the low- and high-risk groups in the current study.

Patient summary

We looked at how well a model predicted the risk of progression of non–muscle-invasive bladder cancer using results for a group of Swedish patients. Approximately one in four patients in the high-risk category progress to more advanced disease within 5 yr. Doctors and patients need to consider the probability of progression in the high-risk category when making shared decisions on which treatment is best for an individual patient.

Background: Guidelines recommend neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). Current recommendations do not consider genomic profiles, although the Basal/Squamous (Ba/Sq) subtype is less likely to respond to NAC compared to Urothelial-like (Uro) and Genomically Unstable (GU) subtypes. The aim of this study is to perform cost-effectiveness analyses of a de-escalated use of NAC in patients with Ba/Sq tumors and MIBC.

Methods: A cost-effectiveness analysis was performed using a decision analytic Markov model using a healthcare provider perspective. Treatment and prognosis probabilities originated from the Bladder Cancer Data Base, Sweden (BladderBaSe) 2.0. Information on molecular subtype and outcomes was retrieved from published studies, and quality-adjusted life year (QALY) data were obtained from the iROC trial. Costs were collected from the regional healthcare registers in Sweden, utility values were obtained from the literature, and outcomes are presented as incremental cost-effectiveness ratio (ICER). Scenario analyses, along with several one-way and probabilistic sensitivity analyses were performed to capture uncertainties.

Results: At a 5-year time horizon, the model predicts that molecular subtype-based treatment has an ICER of 4,964 Euro/QALY (66,766 Swedish Krona/QALY), which is deemed cost-effective in the Swedish setting. At €7,427 (100,000 SEK) willingness-to-pay threshold, the molecular subtype-based treatment has a 65% probability of being cost-effective. The results were not sensitive to uncertainty analyses.

Conclusion: Molecular subtype-based treatment of MIBC, i.e., refraining from administering NAC to patients with Ba/Sq tumors, is cost-effective compared to the current treatment practices in Sweden.

Objective To estimate the probability of vaginal events (diagnosis and/or surgery) following radical cystectomy (RC) and explore possible risk factors in a nationwide population-based observational registry based study. Patients and Methods Women undergoing RC for urinary bladder cancer in Sweden, from 1 January 1997 to 31 December 2019, were identified within national registries. Women with any postoperative vaginal event (PVE), either a diagnosis or surgical repair related to a vaginal complication, were identified using diagnostic and treatment codes. The probability of developing a PVE was estimated based on the cumulative incidence proportion using a competing risk model. Additionally, a multivariable Cox proportional hazards model was used to explore the risk factors for PVEs. Subgroup analysis was performed in patients operated from 2011 to 2019, where additional perioperative variables were registered. Results The study encompassed 1914 women with a median age of 69 years at the time of bladder cancer diagnosis. The 5-year cumulative risk of PVEs in the entire cohort was 11% (95% confidence interval [CI] 9.5-12.5%). Subgroup analysis showed that robot-assisted RC and a body mass index (BMI) >30 kg/m(2) were more often associated with PVEs after RC (hazard ratio [HR] 2.82, 95% CI 1.81-4.40; and HR 1.71, 95% CI 1.05-2.79, respectively). Conclusions A clinically relevant cumulative incidence of PVEs following RC was identified. An association between robot-assisted RC or high BMI with increased risk of a PVE indicate the need for further studies on risk assessment of vaginal complications.

Background and purpose: The Measure of Case-Discussion Complexity (MeDiC) tool was created to gauge case complexity at multidisciplinary team meetings (MDTM) forcase selection and prioritization. We aimed to assess applicability and association with MeDiC score and non-compliance with national guideline-recommendations for MDTM referral in a bladder cancer setting.

Material and methods: A modified MeDiC scoring system was applied in 8955 subjects with localized (T1-T4N0M0) or metastasized disease as per the Bladder Cancer Data Base Sweden (BladderBaSe) 2.0. Association between MeDiC score and not being discussed at MDTM was investigated by multivariable logistic regression, and further explored in relation to calendar time period, healthcare region, age at diagnosis and hospital volume.

Results and interpretation: Median total MeDiC score was lower in individuals not being discussed at an MDTM (7.0 Inter Quartile Range [IQR] 6.0-9.0) compared to those who were (8.0 IQR 6.0-10.0). Adjusted odds ratio for not being discussed at an MDTM was 2.1 (95% confidence interval [CI] 1.8-2.4) for a MeDiC score in the lower quartile, as compared to the highest quartile, with higher estimates when performing stratified analyses in later calendar years and in specific healthcare regions. Our data indicate that the MeDiC score is applicable in bladder cancer patients, and we identified an association between lower MeDiC score and not being discussed at an MDTM.

ObjectivesTo investigate the risk of upper urinary tract urothelial carcinoma (UTUC) in patients with non-muscle-invasive bladder cancer (NMIBC), in relation to the primary NMIBC tumour risk categories, calendar time trends and intravesical Bacillus Calmette-Guerin (BCG) treatment.Patient and methodsAll patients with primary NMIBC diagnosed 1997-2019 registered in Bladder Cancer Data base Sweden (BladderBaSe) 2.0 were included in the study. Risk of UTUC was calculated by cumulative incidence proportion using competing risk analysis. Associations with risk of UTUC by tumour stage category, calendar time, and intravesical BCG treatment was estimated by hazard ratios from multivariable Cox regression analyses.ResultsOf 36 038 NMIBC patients, 537 (1.5%) were diagnosed with UTUC during a mean time of 7 years in follow-up. The risk of UTUC within 10 years from NMIBC diagnosis was 1.7% (95% 1.6-1.9) with highest estimates for TaG3/CIS. Stage T1 and TaG3/CIS, as compared with TaG1-2 was associated to risk, with stronger associations during later calendar times. Within high-risk NMIBC patients (CIS/TaG3/T1), intravesical BCG treatment was associated with higher risk of UTUC.ConclusionsThis large study of more than 36 000 patients with NMIBC found 1.7% (95% 1.6-1.9) risk of UTUC within 10 years of diagnosis. Differences by tumour stage category indicate the need for refined studies accounting for tumour characteristics, location in the bladder and given treatment to optimise follow-up routines in NMIBC.

We synthesized life-long trends for outcome measures following radical prostatectomy or watchful waiting in the SPCG-4 trial, which randomized 695 patients with early prostate cancer to radical prostatectomy (RP) or watchful waiting (WW) from 1989 to 1999. We estimated trends in the relative risk of prostate cancer death, absolute risk reduction (ARR), number needed to treat (NNT), life-years gained, and changes in comorbidity following RP versus WW in the intention-to-treat population. During follow-up after randomization, cumulative prostate cancer mortality increased from 2.9% at 5 yr to 25.9% at 30 yr in the RP arm, and from 4.6% at 5 yr to 42.9% at 30 yr in the WW arm, with a corresponding increase in ARR from 1.7% to 17.0%. NNT to avert one prostate cancer death decreased from 58 to 6. Life-years were gained when follow-up was conditioned on being alive up to 20 yr after randomization. At 10-15 yr of follow-up, the WW arm had higher comorbidity than the RP arm. Treatment choices for early prostate cancer have lifelong consequences. Trial outcomes in a disease with long natural history are highly time-dependent.

Background and objective: It has been suggested that urinary tract infections (UTIs) are associated with delayed diagnosis of bladder cancer (BC). Our aim was to investigate prediagnostic treatments related to UTI and the relation to BC diagnostic delay, reflected by advanced disease at diagnosis. Methods: We used data from the BladderBaSe 2.0 with data of treatments related to UTI up to 3 yr before BC diagnosis (2008-2019) for BC patients in comparison to a matched reference population. We investigated the association between UTI treatments and more advanced disease at diagnosis in the BC cohort. We used generalized ordered logistic regression to calculate odds ratios (ORs) for more advanced disease as an ordered outcome: non-muscle-invasive BC (NMIBC), muscle-invasive BC (MIBC), and metastatic BC (MBC). Key findings and limitations: The study population included 29 921 BC patients and 149 467 matched reference subjects. The proportions of individuals receiving UTI treatment were higher in the patient groups than in the corresponding reference groups, with the greatest differences observed for the MIBC and MBC subgroups. The OR for the risk of more advanced disease (MIBC or MBC) with at least one UTI treatment versus none was 1.28 (95% confidence interval [CI] 1.19-1.37) for men and 1.42 (95 % CI 1.27- 1.58) for women. The association to risk of more advanced disease increased with the number of UTI treatments for both sexes. Conclusions and clinical implications: Further studies on the effects of treatments related to UTI in combination with other factors are needed to identify reasons for possible delays in the BC diagnostic pathway. Patient summary: We found that for patients with bladder cancer, previous antibiotic treatment for a urinary tract infection was linked to more advanced disease at diagnosis. Further studies are needed to identify reasons for possible delays in the diagnosis of bladder cancer. (c) 2024 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license (http://creativecommons.

Objectives: To investigate the association between waiting time and outcomes in patients with upper tract urothelial carcinomas (UTUC).

Patients and methods: We studied a population-based cohort of 858 patients in BladderBaSe 2.0 subjected to extirpative surgery for UTUC 2015-2019 in Sweden. Diagnostic waiting time (from referral to diagnosis, reference <1 week), treatment waiting time (from diagnosis to surgery, reference <5 weeks) and total waiting time (reference <10 weeks) were investigated in relation to disease-specific (DSS) and overall survival (OS) by multivariable Cox regression models. To further explore these associations, stage progression from preoperatively recorded clinical tumour stage to pathological tumour stage in the extirpated specimen was assessed by logistic regression.

Results: Total waiting time was not associated with DSS, OS or stage progression. A diagnostic waiting time between 1 and 4 weeks was associated with better DSS (HR 0.57 [95% CI 0.35-0.94]) and OS (HR 0.60 [95% CI 0.41-0.87]). In the strata of patients with UTUC in the renal pelvis, a diagnostic waiting time > 4 weeks was associated with stage progression (OR 2.44 [95% CI 1.00-5.95]), and in patients with UTUC in the ureter, a treatment waiting time between 5 and 10 weeks was associated to worse DSS (HR 2.85 (95% CI 1.03-7.89).

Conclusions: In general, shorter care pathways were linked to beneficial survival estimates, yet some estimates may be influenced by selection bias due to prioritizing short waiting times for patients with advanced and/or overt symptomatic tumours. Stage progression with increased waiting time may indicate an underlying causal mechanism.

Introduction: Observational studies suggest that breast conserving surgery (BCS) and radiotherapy (RT) offers superior survival compared to mastectomy. The aim was to compare patient and tumour characteristics in women with invasive breast cancer <= 30 mm treated with either BCS or mastectomy, and to explore the underlying reason for choosing mastectomy.

Methods: Women registered with breast cancer <= 30 mm and <= 4 positive axillary lymph nodes in the Swedish National Breast Cancer Register 2013-2016 were included. Logistic regression analyses were performed to assess the association of tumour and patient characteristics with receiving a mastectomy vs. BCS.

Results: Of 1860 breast cancers in 1825 women, 1346 were treated by BCS and 514 by mastectomy. Adjuvant RT was given to 1309 women (97.1 %) after BCS and 146 (27.6 %) after mastectomy. Variables associated with receiving a mastectomy vs. BCS included clinical detection (Odds Ratio (OR) 4.15 (95 % Confidence Interval (CI) 3.35-5.14)) and clinical stage (T2 vs. T1 (OR 3.68 (95 % CI 2.90-4.68)), N1 vs. N0 (OR 2.02 (95 % CI 1.38-2.96)). Women receiving mastectomy more often had oestrogen receptor negative, HER2 positive tumours of higher histological grade. The most common reported reason for mastectomy was large or multifocal tumours (53.5 %), followed by patient preference (34.5 %).

Conclusion: Choice of surgery is strongly associated with key prognostic factors among women undergoing BCS with RT compared to mastectomy. Failure to control for all relevant confounders may bias results in outcome studies in favour of BCS.