ABSTRACT
INTRODUCTION AND OBJECTIVE: In situation with the COVID-19 outbreak, the EAU guidelines Rapid Reaction Group provided recommendations to guide muscle invasive bladder cancer (MIBC) priorities, and they recommended that neoadjuvant chemotherapy should be considered omitted in T2/3 focal N0M0 MIBC patients. This meta-analysis aims to evaluate the efficacy of neoadjuvant chemotherapy compared to radical cystectomy alone in improving overall survival of T2-4aN0M0 MIBC patients. METHODS: Following the PRISMA guideline, PubMed, EMBASE, and Cochrane Library were searched up to September 2021. The articles were searched with keywords muscle-invasive bladder cancer, neoadjuvant chemotherapy, cystectomy, and overall survival. Participants, patients with T2-4aN0M0 MIBC;Interventions, T2- 4aN0M0 MIBC patients who underwent neoadjuvant chemotherapy;Outcomes, comparison of overall survival included for analysis. The overall survival was analyzed as hazard ratio (HR) and 95% confidence interval (CI) and presented in a forest plot. We also conducted a sub-analysis of only T2N0M0 MIBC patients. Quality assessments were performed independently by two reviewers using the Scottish Intercollegiate Guidelines Network. RESULTS: A total of 8 studies were included in the metaanalysis. 8 studies were intermediate risk for detection bias and there were no major problems. In T2-4aN0M0 MIBC patients, the overall survival was significantly better in the neoadjuvant chemotherapy + radical cystectomy group than in the radical cystectomy alone group (HR, 0.79;95% CI, 0.69-0.92;p=0.002) (Fig. 1A). A subgroup analysis was performed on only T2N0M0 MIBC patients and 5 studies were included. There was no difference in overall survival between the neoadjuvant chemotherapy + radical cystectomy group and the radical cystectomy alone group (HR, 0.83;95% CI, 0.69-1.02;p=0.06) (Fig. 1B). CONCLUSIONS: As recommended by the EAU guidelines Rapid Reaction Group, it is thought that patients with T2N0M0 MIBC should strongly consider omitting neoadjuvant chemotherapy until the end of the COVID-19 pandemic. Whether to omit neoadjuvant in T2- 4aN0M0 MIBC should be discussed further, and studies targeting only T2-3N0M0 MIBC are expected to proceed further.
ABSTRACT
Introduction & Objectives: During coronavirus disease 2019 (COVID-19) pandemic, EAU recommended intravesical bacillus Calmette-Guérin (BCG) therapy courses that have been ongoing for longer than 1 year can be safely terminated for high-risk non-muscle-invasive bladder cancer(NMIBC) patients. Thus, we conducted a systematic review and network meta-analysis according to EAU COVID-19 recommendation.Materials & Methods: Systematic review was performed following the PRISMA guideline. PubMed/Medline, EMBASE, and Cochrane Library weresearched up to Sep, 2021. We conducted a network meta-analysis to outcomes including only induction therapy group (No_M), 1-year (M1) andmore than 1 year (MM1) maintenance therapies groups for recurrence rate in patients with NMIBC. Participants, patients with NMIBC;Interventions,NMIBC patients who underwent intravesical BCG therapy;Outcomes, comparison of recurrence rate included for analysis. Quality assessmentswere performed independently by two reviewers using the Scottish Intercollegiate Guidelines Network.Results: Nineteen studies with a total of 3,957 patients were included for network meta-analysis. 19 studies were intermediate risk for detectionbias and there were no major problems. There was just two published studies between M1 and MM1. Five studies between No_M and M1 and 12articles between No_M and MM1 were identified. In node-split forest plot using Bayesian Markov Chain Monte Carlo (MCMC) modeling, there couldbe no difference between M1 and MM1 in recurrence rate (OR 0.95 (0.73-1.2)). However, recurrence rate in No_M group was higher than M1 (OR1.9 (1.5-2.5)) and MM1 (OR 2.0 (1.7-2.4)) groups (Fig. 1A). P-score test using frequentist method to rank treatments in network demonstrate MM1(P-score 0.8701) was superior to M1 (P-score 0.6299) and No_M groups (P-score 0). In the rank-probability test using MCMC modeling, MM1 had the highest rank, followed by M1 and No_M groups (Fig. 1B). (Figure Presented)(Figure Presented)Conclusions: In network meta-analysis, there could be no difference between 1-year and more than 1-year maintenance intravesical BCGtherapies in recurrence rate. In the rank test, more than 1-year therapy could be most effective. During COVID-19 pandemic, 1-year maintenancetherapy can be performed, however, after the COVID-19 pandemic, more than 1-year therapy will be decided
ABSTRACT
Background: With the COVID-19 pandemic, social isolation, increased personal stressors, and less access to addiction support services may be detrimental to persons with AUD, including those with alcohol-associated liver disease We hypothesized that utilization of AUD pharmaceuticals such as naltrexone might increase during this time period We characterized the patterns of naltrexone prescriptions for AUD, particularly in reference to 'shelter-in-place' orders, amongst patients in a large, urban safety-net hospital Methods: Naltrexone prescriptions for AUD from Jan-May in 2019 and 2020 were compared as the shelter-in-place order occurred in March 2020 Patient and prescriber characteristics were extracted from the medical records Liver disease was determined by diagnostic codes, imaging and calculated FIB- 4 Linear regression assessed trends in monthly prescription numbers Results: A total of 128 adults were prescribed naltrexone: 81 from Jan-May 2020 compared to 47 in the same period in 2019 (Figure) The cohort was 72% male, 75% Hispanic, mean age of 46 years, 70% had steatosis on imaging, 25% had a FIB-4 >3 and 15% had cirrhosis. Patients were similar by year, except for a higher proportion with FIB-4>3 in 2019 vs 2020 (80% vs 20%, p <0.03). In total, 77% received oral formulations (versus intramuscular) of naltrexone in a variety of care settings (78% primary care, 9% emergency room, 13% inpatient), with inpatient prescriptions higher but not statistically significant in 2020 versus 2019 (35% versus 0%, p=0 15) The number of prescriptions per month in January to March 2020 increased 2 2-3 3-fold over the same months in 2019 (Figure), reflecting a mean of 7 4 more naltrexone prescriptions per month in 2020 versus 2019 (p=0 04) Despite this, 2020 showed a mean decline of 5 3 prescriptions per month from February (the highest prescribing month) to May (p= 0 02) coinciding with the COVID-19 pandemic and county shelter-in-place orders Conclusion: A striking increase in naltrexone prescribing for AUD occurred in early 2020 and an increased proportion from inpatient settings, peaking with the onset of the 'shelter-inplace' order in the county An increase in patients with AUD, a lack of outpatient access to AUD services, or greater provider motivation/comfort with prescribing AUD pharmaceuticals may underlie this increase A subsequent decline in recent months may reflect fear of patients to access healthcare services during COVID-19, though other factors may be contributing Understanding these trends and factors can inform care of these patients during and beyond pandemic periods.