Editorial Comment on: Clinical Outcome in a Contemporary Series of Restaged Patients with Clinical T1 Bladder Cancer

Abstract

The authors report on 523 clinical T1 (cT1) patients seen in a 17-yr period that had restaging transurethral resection [1]. Upstaged patients had a higher diseasespecific mortality compared to patients with T1 tumors or lower. Of 417 true cT1 patients, 84 underwent immediate cystectomy; of the remaining 333 patients, 59 had delayed cystectomy. Cystectomy was 2.4 times more frequent in those restagedwith T1 tumors than in those restaged with tumors lower than T1. Apart from restaging, characteristics of those with and without immediate cystectomy were similar. Survival was similar for patients after immediate versus delayed cystectomy. The authors conclude that restaging of cT1 patients improves staging accuracy, and T1 tumors on restaging should be considered for early cystectomy. Although this patient cohort is large, the final numbers of progression and death are limited. Furthermore, this patient cohort is clearly selected; it is difficult to estimate how representative these results are for general practice. Other significant limitations are the retrospective nature of the study and the long inclusion period. Treatments, follow-up intervals, and so forth were up to the treating physician. This makes this patient group relatively heterogeneous and, again, limits the power of the results. There were no differences in survival between the immediate cystectomy and surveillance groups, due in part to the small number of events. The authors state that ‘‘there was an imbalance between the two groups: 30% of the patients with cT1 tumors at restaging underwent immediate cystectomy versus 10% for the rest.’’ They assume this could explain the similar survival outcomes, but because this finding is not prospectively proven, other aspects, like conserved quality of life in patients with delayed cystectomy, should be kept in mind. In all, the limited number of events, the retrospective nature, and the heterogeneous material andmethods urge me to be careful with the conclusions suggested by the authors.