Intravesical gemcitabine for non‐muscle invasive bladder can | Figure 1

%27%3e%3cg%20id=%27Group-14%27%20transform=%27translate(13.000000,%20103.176124)%27%3e%3cg%20id=%27Group-Copy-5%27%20transform=%27translate(0.000000,%20182.676124)%27%3e%3crect%20id=%27Rectangle-8%27%20fill=%27%23E2E0DE%27%20x=%270%27%20y=%270%27%20width=%2736%27%20height=%2736%27%20rx=%2718%27%3e%3c/rect%3e%3cpath%20d=%27M28,27.6503435%20C28,22.127496%2023.5228474,17.6503435%2018,17.6503435%20C12.4771525,17.6503435%208,22.127496%208,27.6503435%20M18,16.3472505%20C20.8165136,16.3472505%2023.099749,14.0640151%2023.099749,11.2475015%20C23.099749,8.43098783%2020.8165136,6.1477524%2018,6.1477524%20C15.1834863,6.1477524%2012.9002509,8.43098783%2012.9002509,11.2475015%20C12.9002509,14.0640151%2015.1834863,16.3472505%2018,16.3472505%20Z%27%20id=%27Combined-Shape%27%20fill=%27%23FFFFFF%27%20fill-rule=%27nonzero%27%3e%3c/path%3e%3c/g%3e%3c/g%3e%3c/g%3e%3c/g%3e%3c/svg%3e)

Deleted account

Some actions are only available when you log in.

Report case

Report this to our moderators

Intravesical gemcitabine for non‐muscle invasive bladder cancer

You can view up to 4 cases without signing up Sign up for unlimited access

Review question

In people with tumors of the superficial layer of the urinary bladder (namely non‐muscle invasive bladder cancer [NMIBC]), how does gemcitabine that is put into the bladder compare to other medicines after the tumor has been removed?

Background

NMIBC can be taken out of the bladder using small instruments and a light source (called transurethral surgery). However, these tumors often come back (recurrence) with an aggressive feature such as spread into the deep layers of the bladder. To prevent this, we can put various medicines into the bladder. In this review, we wanted to know whether gemcitabine (a chemotherapy medication) was better or worse than other medicines.

Study characteristics

The evidence is current to 11 September 2020. We included only studies in which chance determined whether people received gemcitabine or other medicines. We found seven studies with 1222 participants. Two studies compared gemcitabine versus saline. One study compared gemcitabine versus mitomycin (a chemotherapy medication). Three studies compared gemcitabine versus BCG (Bacillus Calmette‐Guérin; a medicine used to help keep cancer from growing). One study compared gemcitabine versus one‐third dose BCG.

Key results

Gemcitabine may reduce the risk of recurrence over time, but may have a similar effect on progression (cancer getting worse) and severe unwanted effects compared to saline. Gemcitabine may prevent recurrence and progression compared to mitomycin. We are very unsure about the effect of gemcitabine on the severe unwanted effects compared to mitomycin. In people who had a high‐risk NMIBC with the cancer coming back after one course of treatment with BCG, gemcitabine may cause less tumor recurrence and progression compared to giving BCG again. We are very unsure about the effect of gemcitabine on the severe unwanted effects compared to BCG retreatment. The review also includes information on how gemcitabine compares to BCG and how it compares to one‐third dose BCG.

Reliability of the evidence

The reliability of the evidence was low or very low for most of the treatments we compared, meaning that we were often uncertain about whether the findings were true. Further research will likely change these findings.

Read the full Cochrane Review here:

Comment

Sign up to add a comment

More about this case

Resolved

Why you should join Figure 1

Sign up to explore now

Similar cases

\ \ Cochrane Review; eight trials (1699 participants); five compared the scheduled use of phosphodiesterase inhibitors to either no treatment or a placebo; Two compared the use of phosphodiesterase inhibitors either as a daily prescription or as needed. One compared the daily use of either a phosphodiesterase inhibitor or a medicine called prostaglandin E1 that is placed into the tip of the penis like a suppository.\ Key results\ We found that the men who used these medicines on a scheduled basis may have had similar self‐reported erections and quality of erections (based on questionnaires they filled out) as men who took no medication regularly or use it as needed. They also had similar rates of serious unwanted side effects and similar rates of stopping the drug before the end of the treatment duration. However, we are very uncertain of these findings. We were unable to research whether these results would be different in different groups of men based on whether the surgeon tried to preserve the nerves that help with erections or not, based on men's age and how good their erections were beforehand because we found no studies.\ Reliability of evidence\ The quality of evidence was very low for most main outcomes. That means we are very uncertain of the results of this review. Further research will likely change these findings.](https://app.figure1.com/case-detail/056f90b2-f8ba-4413-9671-3c2c1b5ae4e5)

\ \ Review question\ In people with cancer of the inner lining of the bladder, how do two different medicines, that are called Bacillus Calmette‐Guérin (BCG) and mitomycin (MMC), that are put into the bladder, after the tumour is taken out, compare?\ Background\ Tumours of the superficial layers of the bladder, so‐called non‐muscle‐invasive bladder cancer, are treated by putting small instruments into the bladder and shaving them out. This works well but these tumours often come back. When they do come back they can be more aggressive and advanced than before. Different types of medicines put into the bladder afterwards can make that happen less often, with BCG and MMC being those used most often. We are not sure how the two treatments compare when it comes to wanted and unwanted effects.\ Study characteristics\ The content of this review is current to September 2019. We included only studies where chance determined what treatment people in the study would get.\ Key results\ We found 12 studies including 2932 people who matched our question.\ We found that BCG may lead to similar risk of dying from any cause over time (low‐quality evidence), but may increase the risk of serious unwanted effects (low‐quality evidence), although it is possible that it does not make a difference.\ BCG may reduce the risk that the tumour comes back over time (low‐quality evidence), although it is possible that it does not make a difference.\ BCG may have little or no effect on the risk that the tumour gets worse over time (low‐quality evidence).\ We found no data on quality of life.\ Quality of the evidence\ The quality of the evidence was consistently rated as low, meaning that our confidence is limited, and future research may change these findings.](https://app.figure1.com/case-detail/23b5def6-0f1d-4593-b628-e9e7be563f76)

\ \ Review question\ How effective is targeted drug treatment for patients with kidney cancer which has spread compared with other targeted drug treatments?\ Background\ Kidney cancer which has spread was treated over the last decade with a group of drugs called targeted therapy which act specifically on molecular pathways. However, the last few years have seen the emergence of a promising, newer group of drugs called immune checkpoint inhibitors which exploit the immune system (hence called immunotherapy). Some of these drugs are currently used in combinations. This review assesses how effective targeted therapies are in comparison with different targeted therapies, immune checkpoint inhibitors or different combinations of these drugs.\ Study characteristics\ We included only studies in which chance determined whether people got a targeted drug or other targeted drug, and which were reported in medical literature up to 18 June 2020. Most of the studies examined the effects on kidney cancer growth (called progression), survival (life expectancy) and serious unwanted effects.\ Key results\ We found 18 studies that answered our review question. Participants included in these trials had metastatic (cancer that has spread to other parts of the body) or advanced cancer that could not be removed by surgery. We reported up‐to‐date comparisons that are most important to doctors and participants.\ \

  1. Pazopanib versus sunitinib (targeted therapy versus targeted therapy)\ Pazopanib may make little to no difference in progression, survival, and serious unwanted effects compared to sunitinib.\
  2. Sunitinib versus avelumab and axitinib (targeted agent versus immunotherapy + targeted agent)\ Sunitinib probably results in more progression but may make little to no difference on death and serious unwanted effects compared to avelumab and axitinib.\
  3. Sunitinib versus pembrolizumab and axitinib (targeted agent versus immunotherapy + targeted agent)\ Sunitinib probably results in more progression and death but may slightly reduce serious unwanted effects compared to pembrolizumab and axitinib.\
  4. Sunitinib versus nivolumab and ipilimumab (targeted therapy versus combinations of immunotherapy)\ Sunitinib may result in more progression and serious unwanted effects compared to nivolumab and ipilimumab. Sunitinib results in more deaths compared to combinations.\ Certainty of the evidence\ The certainty of the evidence for most outcomes was low to high, meaning that there is some uncertainty regarding the findings. Nevertheless, there is sufficient data for us to make definitive conclusions regarding how these drugs should be used in the management of patients with kidney cancer which has spread.](https://app.figure1.com/case-detail/49c1b1a2-46a0-4da1-be06-e01fa4b815f7)

\ \ Why are people sick after an operation?\ Feeling sick (nausea) or being sick (vomiting) is a common unwanted effect of general anaesthesia—medicine that makes people unconscious and unresponsive so they don't move or feel pain during an operation.\ Most unwanted effects of general anaesthesia, including feeling or being sick, happen immediately and stop after a few hours, although some people may continue to feel sick for up to a day. If people carry on feeling or being sick, they might have to stay in hospital longer than expected and may experience other unwanted effects or complications.\ Women are more likely to be sick after an operation, as are people taking opioid painkillers, those who have had motion sickness, and those who have been sick after previous operations.\ Medicines to prevent people from being sick\ Medicines called antiemetics are given to prevent people from feeling or being sick. These medicines may be given before or during anaesthesia.\ Antiemetic medicines are grouped into six main classes based on how they act. Combining medicines from different classes sometimes makes them work better.\ Why we did this Cochrane Review\ We wanted to find out which medicines work best to prevent people from being sick after an operation and cause the fewest unwanted effects. Some unwanted effects of antiemetic medicines include headache, constipation, movement disorders such as tremors, sleepiness, irregular heartbeat, and wound infection.\ What did we do?\ We searched for studies that looked at the use of antiemetic medicines in adults having general anaesthesia to prevent people from being sick afterwards.\ \ We looked for randomized controlled studies, in which the treatments people received were decided at random. This type of study usually gives the most reliable evidence about the effects of a treatment.\ Search date\ We included evidence published up to November 2017; in April 2020, we found another 39 studies, which are not yet included in the analysis.\ What we found\ We found 585 studies in 97,516 people who were given antiemetic medicines before or during general anaesthesia. People included in the studies were more likely to be sick after anaesthesia, as 83% were women and 88% were taking opioid painkillers. Most studies were conducted in Asia, Europe, or North America.\ These studies either measured how many people were sick in the first 24 hours after their operation or how many unwanted effects were reported, or both of these outcomes. Most studies compared medicines (given alone or in combination) with a dummy (placebo) treatment.\ We compared all antiemetic medicines with each other using a mathematical method called network meta‐analysis.\ What were our main results and how reliable are these results?\ Compared with placebo treatment, 10 out of 28 single medicines and 29 out of 36 combinations of medicines prevented people from being sick in the first 24 hours after their operation (282 studies). Combinations of antiemetic medicines generally worked better than single medicines given alone. However, aprepitant, casopitant, and fosaprepitant worked as well alone as most combinations of antiemetics. The single medicine that worked best in the ranking of all medicines was fosaprepitant, followed by casopitant, aprepitant, ramosetron, granisetron, dexamethasone, tropisetron, ondansetron, dolasetron, and droperidol.\ We are confident that aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron prevent people from being sick. We are moderately confident about how well fosaprepitant and droperidol work, but this finding may change when further evidence becomes available. We are uncertain about how well casopitant, tropisetron, and dolasetron work.\ Not all studies looked at serious, life‐threatening unwanted effects. We are uncertain how many of these effects were reported when taking an antiemetic medicine and whether serious, life‐threatening unwanted effects occur at a similar rate or are reduced compared to placebo (28 studies).\ Of the best medicines with most reliable evidence for preventing being sick, granisetron and ondansetron probably made little to no difference in the occurrence of unwanted effects compared to placebo, whereas dexamethasone and droperidol may cause fewer unwanted effects than placebo. We are uncertain about unwanted effects with aprepitant and ramosetron (61 studies). We found no studies looking at unwanted effects for fosaprepitant.\ We are less confident about unwanted effects of other antiemetic medicines because we found little reliable evidence about this. Our results for unwanted effects are likely to change when further evidence is available.\ Conclusions\ For people at higher risk, we found that some antiemetic medicines work well to prevent them from being sick after general anaesthesia. The best antiemetic medicines with reliable evidence were aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron, followed by fosaprepitant and droperidol.\ However, we did not find enough reliable evidence about potential unwanted effects to rank these medicines reliably according to how well they are tolerated.](https://app.figure1.com/case-detail/691082ff-4cbb-4670-8ce2-3f7f9aa8a0be)

Trending now

\ \ A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis.\ He had a history of hypertension, long-term smoking, and a sedentary lifestyle.\ On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.](https://app.figure1.com/case-detail/ae0fe999-6875-4474-94f0-ad823dbb9b3a)

\ \ A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets.\ Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.](https://app.figure1.com/case-detail/c271070f-2bc7-4052-9895-635277e1a7d5)

\ \ A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.](https://app.figure1.com/case-detail/48f41642-b9db-4089-b120-a94ee52328de)

\ \ patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family, are there any features in this ekg that would warrant further work-up or is this just a pediatric ekg?](https://app.figure1.com/case-detail/2af390e1-ace8-40ed-ba1c-98fb2d72f4c5)