Re: Sharma AP, Singh PP, Chauhan R, Panda I, Devana SK, Bora GS, et al. Clinical study of steroid receptors in nonmuscle invasive bladder cancer: A domain worth revisiting. Indian J Urol 2024;40:127-32

Dear Sir, We read this original article on steroid receptors in nonmuscle invasive bladder cancer (NMIBC) by Sharma et al. with great interest and would like to make certain observations.[1] The study claims that the Indian subpopulation has a starkly different demographic distribution as compared to the Western population and the data on the expression of steroid receptors in patients with NMIBC from this population is not available. We would like to highlight the study by Shrivastava et al., which correlated the expression of androgen and estrogen receptors with the clinicopathological features in 132 specimens of bladder cancer obtained from Indian patients, including 87 with nonmuscle invasive, 42 with muscle-invasive, and 3 with metastatic disease.[2] They found that the estrogen receptor beta expression was associated with small unifocal tumors and superior disease-free survival; however, an association between the expression of estrogen receptor beta and androgen receptor and the clinicopathological features of bladder cancer could not be found. Although we appreciate the efforts by Sharma AP et al., in evaluating the role of steroid receptors in NMIBC, the study has a few limitations that need elaboration. The authors have clubbed all the grades, stages, and risk categories of NMIBC, including the low and the high-grade NMIBC together for the survival analysis, and since there would be obvious differences in the survival of the patients in the different categories of NMIBC, conducting a separate survival analysis for different risk categories or different grades and stages of NMIBC would have been more appropriate. The expression of steroid receptors, in the study population, has not been compared with the expression of similar receptors in the control population, which would have given a better insight into the differential expression of steroid receptors in patients with malignancy. Furthermore, the data on the differential expression of sex steroid receptors in the epithelial or the stromal cells is lacking and some of the previous studies have performed such a characterization.[3] The survival analysis is only based on the expression of the steroid receptors and the data on the association of the results of survival analysis with other tumor and patient-related characteristics such as size, multiplicity, tumor grade, and stage is lacking. A multivariate analysis should have been performed to assess whether the expression of the steroid receptors is an independent predictor of survival in patients with NMIBC or not. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.