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Bladder-preservation therapy associated with worse survival
Bladder-preservation therapy appeared associated with worse OS compared with radical cystectomy among patients with stage II to stage III urothelial carcinoma, according to study data.
“Trimodal bladder-preservation therapy with maximal transurethral resection, chemotherapy and radiotherapy is an alternative treatment option in appropriately selected patients who are unfit or unwilling to undergo radical cystectomy,” David B. Cahn, DO, MBS, urologic oncology fellow at Fox Chase Cancer Center, and colleagues wrote. “Advantages of bladder-preservation therapy include avoiding the short-term and long-term morbidity of a complex operation, maintaining the patients’ native bladder and improved quality of life. Although well-designed studies have demonstrated improved 10-year locoregional control when comparing chemoradiotherapy with radiotherapy alone, to the best of our knowledge no prospective or randomized controlled trials have been performed to date comparing survival outcomes of patients treated with bladder-preservation therapy with those of patients receiving radical cystectomy.”
Cahn and colleagues used the National Cancer Data Base to identify patients who had stage II to stage III urothelial carcinoma of the bladder from 2004 to 2013 (n = 32,300). The researchers stratified those who underwent bladder-preservation therapy as receiving any external-beam radiotherapy, definitive radiotherapy (50 Gy-80 Gy) and definitive radiotherapy with chemotherapy.
Overall, 9,620 patients received bladder-preservation therapy, whereas 22,680 underwent radical cystectomy.
Slightly more than one-fourth (26.4%; n = 2,540) of those who received bladder-preservation therapy underwent definitive radiotherapy, and 15.5% (n = 1,489) received chemoradiotherapy.
Compared with patients who received bladder-preservation therapy, those treated with radical cystectomy demonstrated significantly better OS, according to unadjusted, multivariate and matched propensity score-adjusted analyses (P < .0001 for all).
However, this difference attenuated when the researchers adjusted with more rigorous statistical models that controlled for confounders and used more restrictive cohorts for bladder-preservation therapy in multivariate analysis (any radiotherapy, HR = 2.11; 95% CI, 2.04-2.18; definitive radiotherapy, HR = 1.87; 95% CI, 1.77-1.97; chemoradiotherapy, HR = 1.57; 95% CI, 1.47-1.69) and propensity score analysis (any radiotherapy, HR = 2; 95% CI, 1.87-2.15; definitive radiotherapy, HR = 1.6; 95% CI, 1.45-1.77; chemoradiotherapy, HR = 1.4; 95% CI, 1.23-1.6).
In an accompanying editorial, Ananya Choudhury, MA, PhD, MRCP, FRCR, of University of Manchester in the U.K., and Peter J. Hoskin, MD, PhD, of Mount Vernon Hospital Cancer Center in Northwood, U.K., pointed out “inherent difficulties” of the National Cancer Data Base, such as a lack of specific information on chemotherapy drugs and the sequencing of chemotherapy and radiotherapy.
Patients treated with radical cystectomy tend to be younger and fitter than those who receive bladder-preservation therapy, Choudhury and Hoskin wrote.
“To the best of our knowledge, there are currently no validated biomarkers with which to identify those patients who may have more or less radiosensitive tumors,” Choudhury and Hoskin wrote. “Retrospective analyses of big datasets may be the best that we have. It is crucial to be aware of the weaknesses and finer nuances of each database so that appropriately weighted conclusions can be drawn. Overinterpretation or extrapolation should be avoided and careful attention to the age, comorbidities and performance status is essential.” – by Andy Polhamus
Disclosures: Cahn reports no relevant financial disclosures. One author reports a grant from Pfizer for work outside of the study. Choudhury reports grants from AstraZeneca, Bayer, Cancer Research UK, Elekta AB, Medical Research Council UK, NIH research UK and Prostate Cancer UK, as well as honoraria from Janssen. Hoskin reports no relevant financial disclosures.