Abstract
Clinical guidelines suggest neoadjuvant cisplatin-based chemotherapy prior to cystectomy in the setting of muscle-invasive bladder cancer (MIBC). A creatinine clearance (CrCl) >60 mL/min is frequently used to characterize cisplatin-eligible patients, and use of the CKD-EPI equation to estimate CrCl has been advocated. From a prospectively maintained institutional database, patients with MIBC who received cystectomy were identified and clinicopathologic information was ascertained. CrCl prior to surgery was computed using three equations: (1) Cockcroft-Gault (CG), (2) CKD-EPI, and (3) MDRD. The primary objective was to determine if the CG and CKD-EPI equations identified a different proportion of patients who were cisplatin-eligible, based on an estimated CrCl of >60 mL/min. Cisplatin-eligibility was also assessed in subsets based on age, CCI score and race. Actuarial rates of neoadjuvant cisplatin-based chemotherapy use were also reported. Of 126 patients, 70% and 71% of patients were found to be cisplatin-eligible by the CKD-EPI and CG equations, respectively (P = 0.9). The MDRD did not result in significantly different characterization of cisplatin-eligibility as compared to the CKD-EPI and CG equations. In the subset of patients age >80, the CKD-EPI equation identified a much smaller proportion of cisplatin-eligible patients (25%) as compared to the CG equation (50%) or the MDRD equation (63%). Only 34 patients (27%) received neoadjuvant cisplatin-based chemotherapy. Of the 92 patients who did not receive neoadjuvant chemotherapy, 64% had a CrCl >60 mL/min by CG. In contrast to previous reports, the CKD-EPI equation does not appear to characterize a broader span of patients as cisplatin-eligible. Older patients (age >80) may less frequently be characterized as cisplatin-eligible by CKD-EPI. The discordance between actual rates of neoadjuvant chemotherapy use and rates of cisplatin eligibility suggest that other factors (e.g., patient and physician preference) may guide clinical decision-making.
Highlights
Several therapeutic options are available to patients with muscle-invasive bladder cancer (MIBC)
Our findings suggest that the CKD-EPI equation may be less likely to deem patients cisplatin-eligible in patients age
We do take the added step of characterizing actuarial use of neoadjuvant chemotherapy in our cohort, which was comprised entirely of patients with MIBC (Tsao et al assessed a mixed cohort of patients with both localized and metastatic disease)
Summary
Several therapeutic options are available to patients with muscle-invasive bladder cancer (MIBC). For patients who opt to receive radical cystectomy, current guidelines strongly recommend consideration of neoadjuvant cisplatin-based chemotherapy.[1,2] These guidelines are predicated on randomized, phase III trials showing a survival benefit with this modality.[3,4] For instance, in Southwest Oncology Group (SWOG) 8710, a total of 307 patients with MIBC were randomized to receive either methotrexate, vinblastine, adriamycin and cisplatin (MVAC) followed by cystectomy or cystectomy alone.[4] Median survival was improved in those patients who received neoadjuvant MVAC (77 months v 46 months, P = 0.06). The efficacy of neoadjuvant therapy may be based on (1) cytoreduction of primary tumor, resulting in more complete and successful surgery, or (2) elimination of micrometastatic disease burden
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