Clinical Outcomes in cN+M0 Bladder Cancer Patients: Can Bladder be Spared?

Abstract

<h3>Purpose/Objective(s)</h3> Optimum management of patients initially presenting with clinically node positive non-metastatic (cN+M0) bladder cancer is a topic of debate with significant variation in practice worldwide. In the UK, fit patients are offered – after platinum-based chemotherapy - either radical cystectomy (RC) or radical radiotherapy (RadRT) – a bladder preserving treatment. There is a paucity of evidence to guide clinician and patient decision making on choice of treatment. A multi-center UK retrospective analysis was undertaken to assess clinical outcomes for cN+M0 bladder cancer. <h3>Materials/Methods</h3> A multicenter retrospective analysis was conducted on patients from four large UK Oncology Centers. Patients initially presenting with cN+M0 bladder cancer between 2012 and 2021 were identified. Data was collected on treatment received, clinical outcomes and patient and tumor factors. Overall survival (OS) was calculated as time from initial diagnosis of bladder cancer. Univariable and multivariable analysis was performed on patients receiving radical treatment using the variables; age, performance status (PS), T and N stage, primary chemotherapy and radical treatment received. <h3>Results</h3> 288/292 patients with cN+M0 bladder cancer identified had survival data available for analysis. Median OS of the whole analyzed cohort (n=288) was 1.54 years (95% CI 1.35-1.82). 163/288 patients received a treatment with radical intent. OS was significantly higher in the radical vs palliative treatment group (log-rank test, p<0.0001). Median OS in the radical and palliative groups were 2.41 years (95% CI,1.92-2.78) and 0.89 year (95% CI, 0.68-1.07) respectively. Patients treated radically received either RC (n=76) or RadRT (n=87) with no difference is OS between the two groups (log-rank test p=0.5). Median OS for those receiving RadRT was 2.53 years (95% CI, 2.02-3.44) vs 2.09 years (95% CI, 1.79-3.13) for RC. In a univariable analysis of patients receiving radical treatment, improved OS was positively associated with lower PS (HR 0.61 (95% CI 0.41-0.91) p=0.02), lower T stage (HR 0.59 (95% CI 0.37-0.95) p=0.03) and receiving primary chemotherapy (HR 0.6 (95% CI 0.4-0.9) p=0.01). No variables retained significance on multivariable analysis. <h3>Conclusion</h3> This multi-center retrospective analysis of survival outcomes gives real-world data on a large cohort of patients with cN+M0 bladder cancer. A limitation of our data is the risk of confounders when comparing retrospective cohorts. Overall survival unfortunately remains poor in this cohort but was significantly longer in patients who received radical-intent treatment. There was no difference in overall survival between patients receiving RC and RadRT. Given the equivalent survival outcomes in these patients whose overall prognosis remains poor, our data would support wider use of radiotherapy to avoid risks from major surgery in node-positive patients.