A propensity score analysis of radical cystectomy versus bladder-sparing trimodal therapy in the setting of a multidisciplinary bladder cancer clinic.

Girish S Kulkarni,Annette Erlich,Srikala S Sridhar,Robert G Bristow,Raj Satkunasivam,Yanliang Wei,Kathy Li,Arnoud J Templeton,Shaheena Bashir,Bimal Bhindi,Thomas Hermanns,Cynthia Kuk,Theodorus Van Der Kwast,Padraig Warde ,Peter J Boström ,Peter Chung ,Neil Fleshner ,Michael A.s Jewett ,Michael Milosevic ,Alexandre R Zlotta

doi:10.1200/jco.2017.35.15_suppl.e16003

Abstract

e16003 Background: Multidisciplinary management improves complex treatment decision making in cancer care, but its impact for bladder cancer (BC) has not been documented. While radical cystectomy (RC) is currently viewed as the standard of care for muscle-invasive bladder cancer (MIBC), radiotherapy-based, bladder-sparing trimodal therapy (TMT) combining transurethral resection of bladder tumor, chemotherapy for radiation sensitization and external beam radiotherapy has emerged as a valid treatment option. In the absence of randomized studies, we compared the oncological outcomes between patients managed by RC or TMT using a propensity-score matched cohort analysis. Methods: Patients seen in our multidisciplinary bladder cancer clinic (MDBCC) from 2008 to 2013 were retrospectively reviewed. Those who received TMT for MIBC were identified and matched (for gender, cT and cN stage, ECOG status, Charlson comorbidity score, treatment date, age, CIS, hydronephrosis) using propensity scores, to patients who underwent RC. Overall survival and disease-specific survival (DSS) were assessed with Cox Proportional hazards modeling and competing risk analysis, respectively. Results: 112 patients with MIBC were included after matching, 56 treated with TMT and 56 by RC. Median age was 68.0 years and 29.5% were cT3/cT4. At a median follow up of 4.51 years, there were 20 (35.7%) deaths (13 from BC) in the RC group and 22 (39.3%) deaths (13 from BC) in the TMT group. 5 year DSS was 73.2% and 76.6%, in the RC and TMT groups, respectively (p = 0.49). Salvage cystectomy was performed in 6/56 TMT patients (10.7%). Conclusions: In the setting of a MDBCC, TMT yielded survival outcomes similar to matched RC patients. Appropriately selected MIBC patients should be offered the opportunity to discuss various treatment options including organ-sparing TMT.

Highlights

Bladder cancer (BC) care can be complex
A total of 112 patients with muscle-invasive bladder cancer (MIBC) were included after matching (56 who had been treated with trimodal therapy (TMT), and 56 who underwent radical cystectomy (RC))
Recent data from many noncomparative single-arm series and Radiation Therapy Oncology Group protocols demonstrated that selected patients with MIBC experience excellent outcomes and experience preservation of a functioning bladder with trimodal therapy (TMT), which consists of debulking transurethral resection of bladder tumor (TURBT), chemotherapy for radiation sensitization, and external beam radiotherapy.[10,11,12,13]

Summary

Introduction

Variation in assessment of pathologic stage, grade, and histologic subtype, quality of care,[1,2] or utilization of perioperative chemotherapy[3,4] affect management and outcomes.[5] Multidisciplinary care (MDC) models have been shown to maximize outcomes by minimizing such variability, which reduces judgment errors and optimizes communication among physicians and between caregivers and patients.[6,7,8,9] MDC provides an opportunity for all treatment options to be discussed, which is important for BC care, in which multiple treatment options are available to patients regardless of the stage at presentation. The traditional treatment of muscle-invasive bladder cancer (MIBC) has been radical cystectomy (RC). A propensity score adjusted direct comparison of TMT to RC in MIBC has not been reported

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Discussion

Conclusion