Current urology reports
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Current urology reports · Oct 2018
ReviewPerformance Measurement and Quality Improvement Initiatives for Bladder Cancer Care.
Bladder cancer care is costly due to long surveillance periods for non-muscle-invasive bladder cancer (NMIBC) and comorbidities associated with the surgical treatment of muscle-invasive bladder cancer (MIBC). We reviewed current evidence-based practices and propose quality metrics for NMIBC and MIBC. ⋯ For patients with NMIBC, we propose four categories of candidate quality metrics: (1) appropriate use of imaging, (2) re-staging transurethral resection of bladder tumor, (3) perioperative intravesical chemotherapy, and (4) induction and maintenance BCG in high-risk NMIBC. For patients with MIBC, we propose eight candidate quality measures: (1) neoadjuvant chemotherapy, (2) multidisciplinary consultation, (3) urinary diversion teaching, (4) appropriate perioperative antibiotics, (5) venous thromboembolic prophylaxis, (6) lymphadenectomy, (7) monitoring of complications, and (8) inclusion of enhanced recovery after surgery protocols. Marked variation in evidence-based practice exists among patients with bladder cancer and represents opportunity for quality improvement. Regional and national physician-led collaboratives may be the best vehicle to achieve quality improvement in bladder cancer.
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Epigenetics refers to processes that alter gene expression without altering primary DNA. Over that past decade, there is a growing focus on epigenetic mechanisms in cancer research and its importance in cancer biology. This review summarizes epigenetic dysregulation in bladder cancer. ⋯ Epigenetic alterations are overall shared across various grades and stages of bladder cancer. High grade invasive tumors demonstrate a greater degree and intensity of methylation and may have a unique methylation pattern. Environmental exposures may influence epigenetic alterations directly independent of genomic change. Non-coding RNAs play an important role in cancer phenotype, especially in the context of integrative genomic analyses. DNA hypermethylation and non-coding RNAs have potential as robust bladder cancer biomarkers; however, they require further study and validation. Changes in chromatin and histone modification are attractive targets for therapy and are currently in clinical trials. Epigenetic dysregulation may be an important key in improving the understanding of bladder cancer pathogenesis, especially through integrative genomic analyses. Deeper understanding of these pathways can help identify clinically relevant biomarkers and therapeutic targets to validate for diagnosis, monitoring, prognosis, and treatment for bladder cancer.