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Background: Neoadjuvant chemotherapy (NAC) improves survival for patients with muscle-invasive bladder cancer (MIBC) treated with radical cystectomy. Studies on the potential benefit of NAC before radiation-based therapy (RT) are conflicting., Objective: To evaluate the effect of NAC on patients with MIBC treated with curative-intent RT in a real-world setting., Design, Setting, and Participants: The study cohort consisted of 785 patients with MIBC (cT2-4aN0-2M0) who underwent RT at academic centers across Canada. Patients were classified into two treatment groups based on the administration of NAC before RT (NAC vs no NAC)., Outcome Measurements and Statistical Analysis: The inverse probability of treatment weighting (IPTW) with absolute standardized differences (ASDs) was used to balance covariates across treatment groups. The impact of NAC on complete response, overall, and cancer-specific survival (CSS) after RT in the weighted cohort was analyzed., Results and Limitations: After applying the exclusion criteria, 586 patients were included; 102 (17%) received NAC before RT. Patients in the NAC subgroup were younger (mean age 65 vs 77 yr; ASD 1.20); more likely to have Eastern Cooperative Oncology Group performance status 0-1 (87% vs 78%; ASD 0.28), lymphovascular invasion (32% vs 20%; ASD 0.27), higher cT stage (cT3-4 in 29% vs 20%; ASD 0.21), and higher cN stage (cN1-2 in 32% vs 4%; ASD 0.81); and more commonly treated with concurrent chemotherapy (79% vs 67%; ASD 0.28). After IPTW, NAC versus no NAC cohorts were well balanced (ASD <0.20) for all included covariates. NAC was significantly associated with improved CSS (hazard ratio [HR] 0.28; 95% confidence interval [CI] 0.14-0.56; p < 0.001) and overall survival (HR 0.56; 95% CI 0.38-0.84; p = 0.005). This study was limited by potential occult imbalances across treatment groups., Conclusions: If tolerated, NAC might be associated with improved survival and should be considered for eligible patients with MIBC planning to undergo bladder preservation with RT. Prospective trials are warranted., Patient Summary: In this study, we showed that neoadjuvant chemotherapy might be associated with improved survival in patients with muscle-invasive bladder cancer who elect for curative-intent radiation-based therapy., (Copyright © 2024 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: The choice of urinary diversion at cystectomy is a life altering decision. Patient decision aids are clinical tools that promote shared decision making by providing information about management options and helping patients communicate their values. We sought to develop and evaluate a patient decision aid for individuals undergoing cystectomy with urinary diversion., Materials and Methods: We used the IPDAS (International Patient Decision Aids Standards) to guide a systematic development process. A literature review was performed to determine urinary diversion options and the incidence of outcomes. We created a prototype using the Ottawa Decision Support Framework. A 10-question survey was used to assess patient decision aid acceptability among patients, allied health professionals and urologists. The primary outcome was acceptability of the patient decision aid., Results: Ileal conduit and orthotopic neobladder were included as primary urinary diversion options because they had the most evidence and are most commonly performed. Continent cutaneous diversion was identified as an alternative option. Outcomes specific to ileal conduit were stomal stenosis and parastomal hernia. Outcomes specific to neobladder were daytime and nighttime urinary incontinence and urinary retention. Acceptability testing was completed by 8 urologists, 9 patients and 1 advanced practice nurse. Of the respondents 94% reported that the language was appropriate, 94% reported that the length was adequate and 83% reported that option presentation was balanced. The patient decision aid met all 6 IPDAS defining criteria, all 6 certification criteria and 21 of 23 quality criteria., Conclusions: We created a novel patient decision aid to improve the quality of decisions made by patients when deciding among urinary diversion options. Effectiveness testing will be performed prospectively.

Aims: We undertook a systematic evaluation of the prognostic value of numerous histological factors in 165 radical cystectomies (RCs) of patients with invasive urothelial carcinoma (UC) who underwent surgery after neoadjuvant chemotherapy (NAC)., Methods and Results: Tumour regression grade (TRG) and therapy-related stromal and epithelial changes were also recorded. Locally advanced disease (≥pT2 and/or pN+) was present in 64% of patients, 22% had no evidence of residual carcinoma (pT0 + pN0), and 28% had no evidence of residual muscle-invasive carcinoma (≤pT1 + N0). TRG1, TRG2 and TRG3 were found in 32%, 15% and 50% of patients, respectively. Histological variants of UC were reported in 25% of cases. The most common therapy-related stromal change was fibroblastic reaction (78%), and the most common epithelial change in residual UC was smudgy and poorly preserved chromatin (28%). Prominent stromal and epithelial changes were noted in 41% and 5% of RCs, respectively. Progression was found in 45% of patients, and cancer-related deaths occurred in 30%. Multivariate analysis showed that the only independent prognostic parameters for progression were T stage, N stage, lymphovascular invasion, and margin status. Similarly, only T stage, N stage and margin status correlated with cancer-related deaths. Neither TRG nor any of the stromal-related or epithelial-related variables correlated with outcome., Conclusions: We confirm that the traditional and routinely reported histological parameters in RC post-NAC remain the most powerful prognosticators of disease course. The significance of TRG in the bladder remains unconfirmed., (© 2018 John Wiley & Sons Ltd.)

Background: Survival in patients with bladder cancer has only moderately improved over the past 2 decades. A potential reason for this is nonadherence to clinical guidelines and best practice, leading to wide variations in care. Common quality indicators (QIs) are needed to quantify adherence to best practice and provide data for benchmarking and quality improvement., Objective: To produce an evidence- and consensus-based list of QIs for the management of bladder cancer., Methods: A modified Delphi method was used to develop the indicator list. Candidate indicators were extracted from the literature and rated by a 27-member Canadian expert panel in several rounds until consensus was reached on the final list of indicators. In rounds with numeric ratings, a frequency analysis was performed., Results: A total of 86 indicators were rated, 52 extracted from the literature and 34 suggested by the panel. After iterative rounds of ratings and discussion, a final list of 60 QIs spanning several disciplines and phases of the cancer care continuum was developed., Conclusions: This is the first study to comprehensively produce common QIs representing structure, process, and outcome measures in bladder cancer management. Though developed in Canada, these indicators can be used in other countries with slight modifications to track performance and improve care., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Prolonged surgical wait times have significant effects on a patient's psychological well-being and a negative impact on quality of life but the effect on long-term cancer control is controversial. We conducted a systematic review of the bladder cancer literature to examine the best available evidence addressing the following key questions: What is the reported time interval for bladder cancer patients from the decision to operate until the day of bladder cancer surgery? Are there recommendations/guidelines in the urological cancer literature and, if so, how do the Canadian times compare? Is there a known association between duration of wait time beyond the recommended standard and clinical outcome (i.e., recurrence-free survival, overall survival)?, Methods: A structured literature search PubMed, Embase, the Cochrane Database and Google Scholar from January 1965 to January 2006 was conducted for published studies and international guidelines/consensus documents that evaluated surgical wait times for bladder cancer. Data extracted from eligible studies included median time to bladder cancer surgery from diagnosis and key patient outcomes, such as survival rate or adjusted hazard ratios (HR)., Results: Eighteen studies evaluating wait times for bladder cancer surgery were identified, ten of which measured the association between prolonged waiting time and overall survival or tumor grade. Differences in study data availability, method of analysis and wait time definitions precluded statistical pooling of the findings. Median wait times from various points of patient contact ranged from 29 days (urologist consultation to transurethral resection) to 164 days (general practitioner referral to surgery). In the lone Canadian epidemiological study, which focused on all types of urological cancer, median wait time was 64 days from referral to surgery. This was in contrast to national and international guidelines, which recommended a maximum wait time between 2 and 4 weeks for all cancer surgeries. The association between surgical delay and overall survival remained controversial with some studies reporting a reduced overall survival in patients with prolonged delays, while others failed to find such associations. However, the three studies that measured the association between a delay of (3) 3 months and tumor grade reported that patients in the prolonged delay groups had an overall poorer tumor grade., Conclusions: In Canada, it appears that current wait times for urological surgeries, such as for bladder cancer, are beyond the threshold recommended by national and international expert bodies. Even though the association between surgical delay and overall survival remains inconclusive, there is evidence to suggest that prolonged delays are associated with an overall poorer tumor grade. To provide the necessary guidance and recommendations on these issues to the federal and provincial governments, the surgical wait times (SWAT) initiative was developed. Through a partnership of the key stakeholders, it is the vision of SWAT to ultimately improve the care and quality of life of bladder cancer patients and their families.