Cleveland Clinic

Novel machine learning algorithms can make predictions about treatment outcomes in patients with overactive bladder (OAB) that are similar to — or even more precise — than those of a specialist. This was the chief finding from a recent Cleveland Clinic-led 

, that tested trained algorithms on the largest OAB datasets available and compared them to predictions from human experts. The study investigators also recently presented these data at the American Urological Association annual meeting in New Orleans.

OAB is a common urologic diagnosis that affects about 1 in 6 patients. Patients with severe refractory symptoms may be candidates for onabotulinumtoxinA (OBTX-A) and sacral neuromodulation (SNM), similarly effective interventions.

But a certain subgroup of patients does not respond to these treatments, and predicting those who will not respond is an “open question in the field,” says Glenn Werneburg, MD, PhD, lead author of the study and a resident in Cleveland Clinic’s Department of Urology.

Dr. Werneburg and coauthors developed neural networks using a series of novel approaches. They then applied them to the prediction problem in OAB using datasets from the ROSETTA (Refractory Overactive Bladder: Sacral NEuromodulation v. BoTulinum Toxin Assessment) study, a trial that randomized patients to either OBTX-A or SNM interventions. Alongside this, blinded expert urologists also predicted outcomes.

Remarkably, the algorithms demonstrated outstanding accuracy in predicting treatment response (OBTX‐A: AUC 0.95; SNM: 0.88), the authors report.

“Our algorithms were extremely accurate in predicting treatment response to both modalities. In fact, they could correctly predict which patient was a responder and which patient was a non-responder about 90% of the time in patients they had never seen before,” says Dr. Werneburg.

Additionally, he explains, the algorithms generally outperformed human experts in prediction.

“At first glance, this was somewhat surprising, but we have to be careful with how we interpret this finding. The design of the study, which was the most optimal way to test the algorithms at this early stage, favored algorithms over humans. Essentially, we gave the algorithms the ‘home-field advantage’ here by asking the humans to predict based on spreadsheets of data,” he explains.

“And certainly that’s not how prediction is done in the clinical sense. So while both the algorithms and the humans have the same data to start with, the next step is to validate these results in the more natural clinical setting.”

Data from the ROSETTA study, a National Institute of Child Health and Development-sponsored trial and one of the most complete datasets in the field, was important for this type of analysis. The multicenter, open-label randomized trial included 381 women with refractory urgency incontinence across nine different U.S. centers to compare the two interventions. These findings were published in 

Sandip Vasavada, MD, an investigator on the ROSETTA trial and senior author of the study conducted with Dr. Werneburg, says the datasets generated by this work are valuable for a study like this.

“There isn’t anything at this scale that exists for this type of analysis, so we were pleased to be able to utilize this robust data for identification of these types of parameters in the context of machine learning,” he says.

The clinician-patient relationship is nuanced

Will this technology supplant patient counseling? Put simply, no, the physicians say.

“Many aspects of the physician-patient interaction are not computable. For example, a patient may have a particular treatment preference in mind; in other cases, a complex socioeconomic situation might preclude repeat office visits or certain other comorbidities that lead to shared decision between the patient and the urologist regarding an optimal treatment,” says Dr. Werneburg.

Ultimately, the physicians are hopeful that these algorithmic approaches will complement clinical expertise and judgment.

“At the end of the day, the patient decides their course of treatment with their physician. But in select patients, a machine learning approach might help guide patient decision-making, helping them make a more educated and informed decision about their care,” Dr. Vasavada concludes.

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“Our algorithms were extremely accurate in predicting treatment response to both modalities. In fact, they could correctly predict which patient was a responder and which patient was a non-responder about 90% of the time in patients they had never seen before,” said Glenn Werneburg, MD, PhD. 

Study shows machine learning is predicting outcomes in overactive bladder

Urologists at Cleveland Clinic and the University of Virginia are partnering on a prospective clinical trial designed to better understand urogynecologic complications following female cystectomy. With these data, they hope to improve patient counseling and tease out possible modifiable factors.

While men are three times more likely than women to receive a bladder cancer diagnosis, women make up a sizeable portion—approximately 17,500—of annual cases. Radical cystectomy in women involves removal of the bladder in addition to pelvic organs, such as ovaries, fallopian tubes, uterus, and the anterior vaginal wall.

There is increasing evidence in the literature that bladder cancer rarely affects these organs, but removing them can worsen quality of life by causing sexual dysfunction and pelvic organ prolapse.

Jacqueline Zillioux, MD, urology fellow at Cleveland Clinic is leading the study along with Sandip Vasavada, MD, Urologic Director, Center for Female Urology and Reconstructive Pelvic Surgery at Cleveland Clinic. Dr. Zillioux says, “We know that, in general, cystectomy in women can disrupt pelvic floor support and innervation, as well as hormonal and sexual function, but there are no good prospective data to help us fully understand pelvic floor complications following the procedure.”

The authors say that most studies have examined post-cystectomy function and disorders in male patients, but they’re hopeful that this study, and others like it, will contribute to the growing momentum into female-specific quality-of-life outcomes following bladder cancer treatment.

“Traditionally, female-centered research examining the sexual function and pelvic floor health would fall exclusively in the domain of the female pelvic medicine and reconstruction specialty,” she says. “But this study is a true collaboration between our urologic oncology and female urology teams.”

This is important because previous literature has existed largely within the subspecialty: oncology or female urology. Cleveland Clinic is well-suited for a study like this, she says. The Department of Urology has a robust female pelvic medicine and reconstructive surgery program. In 2021, the service completed nearly 1,250 surgical cases. It’s also a high-volume center for female cystectomy.

The study authors say this collaborative approach is important and, ultimately, provides a better service to the patient. Byron Lee, MD, PhD, urologic oncologist and co-investigator, explains, “About half of women who undergo radical cystectomy are sexually active, but not many receive preoperative counseling on how sex changes after cystectomy. The most common problems after cystectomy are pain with sexual activity, decreased desire for sex, and vaginal dryness.”

He continues, “We hope this study will answer key quality-of-life questions for women undergoing radical cystectomy that will ultimately improve preoperative counseling, better characterize rates of postoperative sexual dysfunction and pelvic organ prolapse, and support novel approaches to mitigate the risk of negative functional impact after surgery.”

Data collection: Pelvic exam and questionnaire

A female pelvic reconstructive surgeon conducts a pelvic exam on the patient prior to the cystectomy to establish baseline measurements, including vaginal length and prolapse evaluation. Patients also fill out a preoperative questionnaire about their pelvic floor symptoms and sexual function. After surgery, at various intervals, the team repeats the exam and will again administer the questionnaire.

After the first year, the team will continue collecting the data annually for up to five years.

Radical cystectomy is a complex surgery, and there are significant considerations when it comes to counseling patients about postoperative outcomes and managing their cancer care. Investigators hope this study adds a new layer to the patient-provider conversation.

“We absolutely cannot overlook the negative effect these complications can have on sexual and pelvic floor health,” says Dr. Zillioux. “At the very least, we should be consistently counseling our patients and managing expectations — and hopefully one day we can identify modifiable factors to minimize risks altogether.”

“We know that, in general, cystectomy in women can disrupt pelvic floor support and innervation, as well as hormonal and sexual function, but there are no good prospective data to help us fully understand pelvic floor complications following the procedure,” said Jacqueline Zillioux, MD.

Study aims to improve understanding of sexual and pelvic floor health after female cystectomy

On this episode of Cleveland Clinic’s Cancer Advances podcast, host Dale Shepard, MD, PhD, talks with Christopher Weight, MD, about discuss how high-intensity focused ultrasound (HIFU), a type of focal therapy for treating localized prostate cancer, is emerging as an alternative to more traditional treatments, such as surgery and radiation for select patients.

Weight is Center Director of Urologic Oncology at Cleveland Clinic and Shephard is a medical oncologist at Cleveland Clinic who oversees the Taussig Phase I and Sarcoma Programs.

Cancer Advances, a Cleveland Clinic Podcast for medical professionals. Exploring the latest, innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic, overseeing our Taussig Phase I and Sarcoma Programs. Today, I'm happy to be joined by Dr. Christopher Weight. Dr. Weight is the Center Director for Urologic Oncology. He's here today to talk to us about High-Intensity Focused Ultrasound for the treatment of prostate cancer. So welcome Chris.

So maybe you could start by telling us a little bit about your role here at Cleveland Clinic.

Great. So I'm the Center Director for Urologic Oncology. That means I help oversee the main missions of the clinic as a whole, kind of the educational aspects, the research aspects, and the clinical care with regards to urologic oncology. And so, for those of you who don't know what that means, I didn't say neurologic, which my mom thought that's what I said when I told her I was going to do urology. But that means prostate cancer, bladder cancer, and kidney cancer, which are the three most common, and then some other rare cancers.

I guess we're going to focus today on focal therapies for prostate cancer, and specifically, about ultrasound and High-Intensity Focused Ultrasound. So, maybe you could just give us a really broad background about what kind of focused therapies there are, and then maybe a little bit about the newer technologies.

You know prostate cancer is a very common cancer, and it affects hundreds of thousands of men a year. But most prostate cancer is not immediately life-threatening, may never become life-threatening, but there still is some that is quite aggressive and we still lose 25,000, or so men a year. There've been radical therapies that have been successful for years in preventing death from prostate cancer, but they've also been associated with a lot of side effects. And so, that really allowed a space for people to try to figure out a way to treat this cancer but do it in a way that minimize the side effects that could really have devastating effects on quality of life. And that's where focal therapy has really started many years ago, but now more recently, as we've improved our diagnostic techniques, our biopsy techniques and imaging techniques, it's finding a broader role. And focal therapy could be any sort of therapy that just treats part of the prostate, rather than the entire gland.

The two most common are really High Frequency Ultrasound or HIFU, and Cryotherapy or a freezing and thawing of the prostate tissue, but there are many others, there are some laser focal therapies. There's some gold nanoparticle therapies that are heated up by laser as well. So there is an active area of research and exploration as we've gotten better at identifying where the prostate cancer is, within the gland itself. I'm trying to strike that happy medium of a good cancer treatment that prevents death from prostate cancer, but while simultaneously maintaining a good quality of life.

So we think about the ultrasound technique you mentioned, we'll refer to as HIFU. This is something that's been around for quite a while, is that right?

Yeah. I mean, ultrasound is, we've used in medicine for years and years and years, that most people are probably familiar with ultrasound use for prenatal diagnosis and seeing the baby before the baby is born. So it's been used in imaging for quite a long time. And it was realized that these waves could also be focused into a very fine point and that you can really raise the temperature of those cells if you overlap them. And so that has been used also to treat a variety of things, a variety of tumors. But the prostate is a very good candidate for it because you can get very close access to it through the rectal wall, and focus those waves into a really fine pinpoint area. The early attempts with HIFU were really whole-gland treatments actually, not it wasn't thought as a focal therapy and the whole gland was treated.

And when you treat the whole gland, you still get some of the side effects that you'd get with whole-gland treatment such as surgery or radiation. And there are also some limitations, the waves cannot penetrate to a certain depth, so a larger prostates weren't candidates for it. And there were some other limitations, but I think more recently the excitement has been, as we've gotten again better at imaging, and diagnosing and pinning down where the tumors are, of just treating that particular area. And when we do that, then the side effect profile is really pretty minimal. And yet we still, at least in the short and intermediate term follow up studies of these more focal treatments, seem to be pretty good. They're pretty comparable to standard treatments.

So when we think about candidates for this type of therapy, we're primarily thinking about patients that have prostate cancer, relatively low Gleason scores, is that right? Fairly low volume disease. What are the characteristics of patients who would be good candidates?

This is a question we get a lot. What are their... I would say shortcoming of the early HIFU studies was that they treated these very low risk men with prostate cancer. And, and we know now that most of those men probably should be watched. So we don't want to treat the lowest risk, but we really want to treat as you transition from the low risk, so that would be a Gleason score of six on the old scoring system or a Grade Group 1 on the newer scoring system. Those, we still prefer to do observation or active surveillance as it is called, unless there are other factors that indicate that this may not just be that low risk stuff and that could be for example, a high-risk Genomic score or certain patterns that are seen under the microscope, or other details along those lengths.

But the real sweet spot for this treatment is as you move into the low intermediate risk, and it's a small volume but intermediate risk tumor, that would be a Gleason score of 7 or 3+4, or a Grade Group 2 on the new scoring system. And the ideal one is actually one that has a corresponding MRI. This shows that the same area that we found on the biopsy corresponds to an area on the MRI, because then we can also observe the treatment effect in the follow-up. And those are the people that seem to do really well, we have more confidence that we treated the area of concern. We have more confidence in follow-up that that treatment was successful because that area undergoes change on MRI that we can appreciate.

How are we incorporating things like Oncotype DX or these sort of predictive tools into selection of patients?

One way is similar to what I referred to earlier, just in briefly is that if you have a low risk appearing tumor on histology, under the microscope it doesn't look low risk, but under the Genomics profile like Oncotype DX, or decipher Polaris, there are many that are approved now in this space. If that conveys a high risk, then we think that there's probably more risk in that tumor than we anticipated at, by histology alone. And so that's a good option. And, we were actually really interested in trying to use Genomics as well as potentially Artificial Intelligence to try to re stratify these patients into, identify those that really only have one dominant tumor. Many prostate cancers are multifocal. You may have a dominant lesion over on the left side, but you could also have a smaller lesion on the right side.

But not all of them are that way. And so we think Genomics may play a role in that, as well as potentially radiomics, meaning using artificial intelligence to look at that MRI and trying to sort which ones are truly unifocal and would really benefit from a focal treatment, or those that may be more likely to have a multifocal tumor and maybe would just benefit from a whole-gland treatment.

And so at this point, if...you look at a MRI, there are two small lesions, maybe one's on the left, one's on the right, not considering this type of therapy or those that are still maybe under consideration because you have something visible and you still think that there's some discrete lesions.

They could be considered. It would be very dependent, also on what the biopsy shows, but they would be considered. We have a group where we evaluate each person who wants to pursue focal therapy. This way, we're trying to keep it rigorous and make sure we're offering the appropriate treatment to patients. So anyone who wants to be considered for focal therapy at Cleveland clinic, we will take the results and evaluate them. We have kind of an ideal candidate, which I referred to initially. And then we have kind of extended criteria candidates that we will consider and under the right circumstances, under the right findings, based a lot on what the biopsy shows we could consider someone in that situation.

A scenario that we feel even more comfortable with is if you have two lesions, but they're both on the same side, then we could do a Hemi-gland treatment, which is still associated with fairly few side effects. But then we have more confidence that we're treating most of that cancer there, if not all of the cancer that we can find. We really want to demonstrate success. And, I mean we believe it should work just as well on high-risk tumors, but we just don't want to be cavalier about deploying this technology until we understand it a little bit better and make sure we're deploying it in the safest way for our patients.

When you talk about side effects, clearly people that get radiation therapy, men that have a prostatectomy are at risk for things like incontinence and erectile dysfunction. Is there the ability to focus the ultrasound therapy? Are there areas of the prostate that you stay away from to minimize those things that are more toward the edges of the prostate, or is it really focal enough that you don't have to worry about that?

These nerves that run on the outside of the prostate, we thought as a specialty, we thought it was part of the prostate for probably the first 70 years of doing the radical prostatectomy, we just took them with them all the time because there's that close. They look like they're part of the prostate. They're on the bottom lateral side of the prostate, so on the outside edge, as you were kind of referred to, and it is fairly pinpoint, the area of the ablation zone is kind of one by two millimeters. So it's pretty small. But there can be some thermal spread, so we do try to be cautious in that very peripheral lateral zone, right close to the neurovascular bundles of not giving a large dose there. And for someone who has a large tumor in that space, we just counsel the patient that there may be a little bit higher chance that that particular bundle is going to take a little bit of heat quite literally, and may experience some diminished erection function.

And afterwards, when we look at the results from radiation and surgery, when you're treating the whole gland. It's very dependent on your preoperative function that's very dependent on your age, but it's about 50 to 60% will have their sexual function preserved with those treatments. But it's closer to 90% with HIFU, because it is much more focused and we're often able to treat only one part of the gland. So the other side, for example, may be completely untreated and should function completely normally, as it did before. And with that one to two millimeter margin, if we can have some confidence that that tumor is not budding those nerves, and we can leave just that little zone untreated, and that also translates into better preservation of erections.

What does this look like for a patient? How do you describe what it's like to get this therapy, timeframe, recovery times, things like that?

So a patient experiencing this, they actually experienced very little discomfort. This is an outpatient procedure, it is not a surgical procedure. So there are no incisions made. This probe goes in the rectum after they're fully anesthetized and relaxed. And the rectum has to be dilated a little bit to get the probe to fit in. It's kind of like a large bowel movement, a little bit bigger than a finger exam.

And the main thing that a patient experiences is that there is a little bit of swelling associated with this that may block the urethra off. So we have to leave a catheter in place, for anywhere from as few as two to three days. If the zone of ablation is quite away from the urethra, and we don't have to dissipate a lot of swelling, to as many as five to seven days if they have a very large gland and we have to treat a lot of that prostate, and especially if the area we have to treat is quite close to the urethra. But they go home the next day, and very few patients have blood in the urine and they may have a day or so of a little bit of blood when you have your first bowel movements. But many people are back to their normal activities, barring, having a catheter in place within a few days with not a lot of setback or a timeout for a recovery after this kind of treatment.

And success rates so far, you certainly don't have the duration of experiences we do with the other techniques, but how comparable is it?

The overall and cancer specific survival are equivalent in the five-year timeframe. We know, in prostate cancer that's an insufficient timeframe. Most studies need to demonstrate 10 year survival to really show that it's better than not treatments. But quite comparable, at least in the intermediate term, in the historical series, it's been around as we talked earlier for 15 to 20 years. You know, when they were doing whole gland, it was not as successful. If the recurrence free survival, I guess, is what we would call it, was more like 80 to 90%. Whereas surgeon radiation were more like 95 to 99%. But in this more focal treatment, when we're a little bit more selective about who we're treating, we anticipate we're going to see a similar success rate, but we don't have that data yet. So we're really kind of in the five-year timeframe.

When we think about this procedure, you mentioned some other focal therapies, things like laser ablation and things like that. Does this an advantage in some way, based on the patient characteristics or the tumor characteristics, or how do you compare those other therapies to the HIFU?

Yeah, so this has a real significant advantage, I think over cryoablation, which is again that the freezing and thawing of the prostate. That one is very difficult to control the ice ball. That is so you create an internalized ball with cryotherapy, and is really hard, it doesn't stop along planes. It can go, and that one had actually a very high rate of erectile dysfunction afterwards, even the higher than surgery actually, and radiation. So that one was sort of reserved for people who didn't want to undergo a surgical procedure where radiation wanted a one-time treatment, but weren't really concerned about erections.

Laser therapy is newer and I think still we have yet to see if it will pan out to do quite as well as other focal therapies like HIFU. We have a clinical trial that we're evaluating a laser in conjunction with these gold link nanoparticles. So I would say, the laser is a little bit more experimental than the HIFU, we have a little bit less experience to tell us whether it's going to give us as durable of a result.

Very widely available in Europe, not very widely available in the United States. I think of the Focal One therapy machines available in the United States, which is the newest iteration of the HIFU device. Yeah, I think there are fewer than 20 around the country. There are more of the older machine called the Ablatherm, which has more limitations, has a less intuitive interface. It's less able to integrate with the MRI. And we feel like less able to target the areas of concern and so not widely available, but I think focal therapy really is going to, we're going to see a lot more of it in prostate cancer because of the benefits with side effect profile. And these are a lot due to the fact that we're getting better at really pinning down where the cancer is.

There can be, yes. It's a significant issue currently. We have, Medicare does cover it. Often, whatever Medicare decides to do, everybody else falls in line, but that's not been the case so far with HIFU. There are only a handful of insurance providers that cover HIFU for prostate cancer. And so that may be a challenge for patients if it's not covered.

So certainly access is going to be important and avail... Not only from coverage, but just availability, but what are the other gaps, what's going to be necessary to move this forward. And I guess the associated question is, what's the next big step? Where do we need to go from here?

Yeah, I think that really to get this right now, we estimate probably about 15 to 20% of people might be eligible for this. And I think a lot of it stems on the fact that we don't have good long-term data in the higher intermediate risk or the higher risk patients. So I think research showing us that it's also effective. We don't have any reason to believe that it wouldn't be able, kill a high risk cancer cell just as well as it can kill an intermediate risk cancer cell. So I think we need those kinds of studies. We also need studies to demonstrate that it's at least equivalent on cancer control or at least acceptably not inferior to the existing treatments. And so there are a couple of randomized trials going on right now, the largest one is in Great Britain. Where they're randomizing people to radiation or surgery or focal therapy like HIFU.

We really will be anxious to see those results, because we don't want to see a serious drop-off in cancer control, in exchange for a slightly better quality of life. So I think that's something that's important. And then the other key for HIFU really becoming widespread, I think, is really being able to pin down who are the candidates who are appropriate for it, and who are the candidates who are not appropriate for it. And I think that will come through a variety of enhanced imaging studies, potentially Genomics and maybe AI, helping us to really identify the appropriate candidates. I don't think we'll ever see prostate surgery go away, nor will I think we see radiation go away because they still are very effective treatments and they work really well. But I think as we get better at identifying the candidates who could be treated by focal therapy, and if we demonstrate that it's a really comparable cancer treatment, I think we'll really see it take off in the coming years.

This is great. Well, you've provided us with some great insight today and I really appreciate it. Thanks for being with us.

It's my pleasure. Great talking with you.

 This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, 

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On this episode of Cleveland Clinic’s Cancer Advances podcast, Christopher Weight, MD, discusses high-intensity focused ultrasound for treating patients with localized prostate cancer.

Dr. Christopher Weight discusses HIFU for localized prostate cancer

 found higher rates of mortality and worse oncologic outcomes in bladder cancer patients residing in more socioeconomically disadvantaged neighborhoods who underwent radical cystectomy.

The study utilized the area deprivation index (ADI) to assess the patients’ socioeconomic status and found that patients in the most disadvantaged quartile were more likely to die within 90 days of surgery and had worse oncologic outcomes including overall survival and recurrence-free survival.

“This study really shows the power of ADI in predicting postoperative and oncologic outcomes for bladder cancer patients undergoing radical cystectomy. ADI also allows us to systematically identify patients most at risk for adverse outcomes so that we can better serve them,” says Byron H. Lee, MD, PhD, Cleveland Clinic urologist and senior author of the study. Lee led the study along with Jacob Knorr, a medical student in the Cleveland Clinic Lerner College of Medicine and incoming urology resident.

ADI was first developed in 2002 to examine the link between census tract-based socioeconomic measures and mortality, and it has also been used to examine medical and surgical disparities.

In patients who are fit for surgery, radical cystectomy with or without chemotherapy remains the gold standard for the management of muscle invasive bladder cancer. However, radical cystectomy is a long and complex procedure that is often performed in older patients with many coexisting illnesses. Thus, this procedure is associated with high complication rates.

Bladder cancer experts at Cleveland Clinic have continuously refined their surgical technique and introduced care pathways to significantly reduce complication and readmission rates after radical cystectomy. Nonetheless, approximately 2%-3% of patients still die within 90 days of surgery.

The goal of the current study was to assess the factors associated with a higher risk of mortality after surgery.

“We wanted to figure out what are the determinants of mortality within the 90 days of surgery,” he says. “The hypothesis that we’re testing here is that not only is it dependent on the patients’ underlying health status, but also their socioeconomic position.”

Comparing radical cystectomy outcomes with socioeconomic position

The retrospective single-institution study analyzed the outcomes of 906 patients who underwent radical cystectomy for bladder cancer between 2011 and 2019. Investigators assessed the rates of major complications within 30 and 90 days of surgery, mortality, and overall and recurrence-free survival. ADI was used to assess the patients’ socioeconomic position.

“ADI is a composite measure that ranks neighborhoods by socioeconomic disadvantage using census block data. Some of the variables that are used to calculate a neighborhood’s ADI include measures of education, income, employment, household characteristics, and housing such as home values and percent housing units that are occupied,” Lee explained. “Interestingly, neighborhoods in the same zip code that are adjacent to each other may have vastly different ADI percentile ranks.”

In this study, Lee’s team divided the patient population into four ADI quartiles. Twenty percent of the patients were in the most disadvantaged quartile and 13% of patients were in the least disadvantaged quartile. The middle quartiles contained about two-thirds of the patients. The patients in the most disadvantaged quartile were more likely to be younger, African American, and active smokers.

“We also looked at other variables known to be associated with surgical outcomes such as medical comorbidities and nutrition levels, but did not find any differences among the four ADI quartiles,” said Lee. “Also, there were no significant differences in the care that the patients received. We found similar rates of neoadjuvant chemotherapy use and continent diversion choice. There were also no differences in the rates of open versus robotic surgery.”

Closer follow-up is needed in patients at high risk of poor outcomes

The study found that the patients belonging to the most disadvantaged ADI quartile were at highest risk for a poor outcome after radical cystectomy.

“Although none of the least disadvantaged patients died within 90 days of surgery, 6.5% of the most disadvantaged patients died within 90 days. This was three times the overall 90-day mortality rate of the entire population,” Lee said. “Half of all 90 day deaths occurred in patients from the most disadvantaged ADI.”

He notes that this finding was surprising and speculates that there are many factors contributing to higher 90-day mortality rates in patients from the most disadvantaged ADI quartile. His team examined each case individually and noted a trend toward longer time to first readmission in the most disadvantaged patients. They plan to investigate why there is a delay in obtaining care for these patients.

“The other important finding in this study is that the most disadvantaged patients also had worse cancer outcomes — overall survival and recurrence-free survival, mainly because their disease was more advanced and more aggressive at the time they presented to us,” he said.

“Moving forward, I think that one of the things that we need to do is formulate a strategy to incorporate and use ADI in perioperative care for patients undergoing radical cystectomy. For example, we may follow the most disadvantaged patients even more closely after surgery via phone calls or some other means. Outreach and education of the community physicians serving the socioeconomically disadvantaged areas would also be an important way to reduced mortality rates in this patient population,” Lee concluded.

1. Knorr JM, Campbell RA, Cockrum J, et al. Neighborhood socioeconomic disadvantage associated with increased 90-day mortality following radical cystectomy [published online ahead of print December 29, 2021]. 

“This study really shows the power of the area deprivation index in predicting postoperative and oncologic outcomes for bladder cancer patients undergoing radical cystectomy,” said Byron H. Lee, MD, PhD, Cleveland Clinic urologist and senior author of the study.

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Articles

Study shows machine learning is predicting outcomes in overactive bladder

Study aims to improve understanding of sexual and pelvic floor health after female cystectomy

Dr. Christopher Weight discusses HIFU for localized prostate cancer

Study links socioeconomic disadvantage with increased post-cystectomy mortality