National Cancer Database Comparison of Radical Cystectomy vs Chemoradiotherapy for Muscle-Invasive Bladder Cancer: Implications of Using Clinical vs Pathologic Staging.

Hong‐Yiou Lin,Hong Ye,Kenneth M Kernen,Daniel J Krauss,Jason M Hafron

doi:10.1002/cam4.1684

Hong‐Yiou Lin, Hong Ye + Show 3 more

Open Access

https://doi.org/10.1002/cam4.1684

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Journal: Cancer medicine	Publication Date: Oct 10, 2018
Citations: 13	License type: CC BY 4.0

Affiliation: Beaumont Health, Michigan Institute of Urology

Abstract

PurposeTo test the hypothesis that bladder preservation therapy consisting of definitive chemoradiotherapy (chemoRT) results in similar overall survival rates to radical cystectomy/chemotherapy when balancing baseline patient characteristics and initial (preoperative) clinical stage.Materials/methodsA total of 7,322 patients with stage II‐IV, M0 bladder cancer who were treated with cystectomy/chemo (N = 5,664) or definitive chemoRT (N = 1,658) were identified from the National Cancer Database. Baseline patient characteristics were compared using Pearson's chi‐square, Fisher's exact test, and Wilcoxon's rank sum tests. Cox regressions were used to investigate for variables significantly correlated with overall survival (OS). OS was compared between cystectomy/chemo vs chemoRT before and after propensity score matched pair analyses using Kaplan‐Meier curves and log‐rank tests.ResultsPatients who underwent cystectomy/chemo were significantly younger than ones treated with definitive chemoRT (mean age 63.7 vs 75.2; P < 0.001). Age, race, Charlson/Deyo Comorbidity Score (CDCS), clinical stage, insurance status, and type of facility significantly correlated with OS (P < 0.05 for all covariates). Patients treated with cystectomy/chemo were younger, healthier with better CDCS, and more likely treated at academic facilities. Before matched pair analyses, OS was significantly better when treated with cystectomy/chemo (3 year 56.4%; 5 year 45.9%) compared to chemoRT (3 year 47.3%; 5 year 33.2%) (P < 0.001); 28.6% of patients undergoing cystectomy were upstaged at the time of surgery. After matched pair analyses matching age, race, sex, CDCS, clinical (presurgical) stage, insurance, and facility type (N = 1,750), OS was no longer significantly different between cystectomy/chemo (3 year 52.1% and 5 year 41.0%) vs chemoRT (3 year 53.3% and 5 year 40.1%) (P = 0.5).ConclusionsPatients treated with cystectomy/chemo were significantly younger and healthier compared to those treated with chemoRT. Once these factors were accounted for in propensity score matched pair analyses using clinical stage, overall survival was not significantly different between cystectomy/chemo and an organ‐sparing approach with definitive chemoRT.

Highlights

Bladder cancer is the 6th most common cancer in the United States with an estimated 79,030 new cases responsible for 16,870 deaths in 2017.1 Internationally, bladder cancer is a major cause of morbidity and mortality as the 9th most common malignancy.[2]
Bladder preservation therapy consisting of transurethral resection of bladder tumor (TURBT) followed by combination chemoradiotherapy is an alternative treatment to cystectomy for muscle-invasive bladder cancer.[6,8]
While there has not been a prospective randomized trial comparing neoadjuvant chemotherapy followed by radical cystectomy with the organ-sparing approach, multiple prospective randomized and nonrandomized definitive chemoRT trials have shown overall survival rates that are comparable to radical cystectomy trials.[9-15]

Summary

Introduction

Bladder cancer is the 6th most common cancer in the United States with an estimated 79,030 new cases responsible for 16,870 deaths in 2017.1 Internationally, bladder cancer is a major cause of morbidity and mortality as the 9th most common malignancy.[2]. According to the NCCN, category 1 recommendation for the treatment of muscle-invasive bladder cancer is neoadjuvant cisplatin- based combination chemotherapy followed by radical cystectomy with bilateral pelvic lymph node dissection and urinary diversion.[6]. Radical cystectomy is associated with significant perioperative morbidity and mortality with 67% of patients experiencing complications and up to 2% death rate within 90 days of surgery.[7]. Bladder preservation therapy consisting of transurethral resection of bladder tumor (TURBT) followed by combination chemoradiotherapy (chemoRT) is an alternative treatment to cystectomy for muscle-invasive bladder cancer.[6,8]. While there has not been a prospective randomized trial comparing neoadjuvant chemotherapy followed by radical cystectomy with the organ-sparing approach, multiple prospective randomized and nonrandomized definitive chemoRT trials have shown overall survival rates that are comparable to radical cystectomy trials.[9-15]. In the absence of prospective randomized trials comparing cystectomy with definitive radiotherapy, investigators have used both institutional and large national databases including Surveillance, Epidemiology, and End Results (SEER) and the National Cancer Database (NCDB) to compare treatment outcomes

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