Radiotherapy vs. Cystectomy for Treatment of Muscle Invasive Bladder Cancer in Very Elderly Patients

Abstract

Radical cystectomy (RC) has long remained the principal treatment of muscle invasive bladder cancer (MIBC). It is, however, associated with significant morbidity, long recovery, and reported worse overall and cancer specific survival, particularly for the very elderly (age > = 80). Bladder preservation with transurethral resection of bladder tumor (TURBT) followed by radiotherapy (RT) +/- concurrent chemotherapy (ChT) is regarded as a curative-intent alternative to RC in well-selected patients. The optimal treatment strategy remains unclear in very elderly patients. We hypothesize that outcomes following RT vs RC are clinically equivalent for treatment of MIBC in very elderly patients. Patients > = 80 years old with T2-T4 N0-N1 bladder cancer treated definitively with RT versus RC were included. Exclusion criteria included history of pelvic RT, prior cystectomy, or palliative treatment intent. Clinicopathologic and treatment-related details, as well as clinical outcomes and toxicities were retrospectively abstracted. Kaplan-Meier analyses were performed. At a median follow-up of 17 months (range 0.25-190), 47 patients received RT vs 83 patients who underwent RC with median age of 86 years (80-97) vs 83 years (range 80-91) (p<0.01), respectively. Median Charlson Comorbidity Index was similar between groups (p = 0.35) with median 7 for both cohorts, predicting 0% estimated 10y survival. Most patients had cT2 tumors (91% vs 99%, p = 0.06), cN0 nodal status (96% vs 100%, p = 0.06), and urothelial carcinoma histology (79% vs 90%, p = 0.22). Most RT patients received concurrent ChT (90%) and a minority of RC patients received neoadjuvant ChT (16%). 70% of RT pts had complete TURBTs prior to RT. Common RT regimens were 50-55 Gy in 20-25 fractions or 60-64.8 Gy in 30-36 fractions, using IMRT (89%) or 3D conformal (11%) technique. Overall survival for RT vs RC at 1- and 2- years was 79% vs 85% and 57% and 69%, respectively (p = 0.20). Locoregional control at 1- and 2-years was 73% vs 70% and 63% vs 66% (p = 0.59), respectively. Progression free survival at 1- and 2-years was 69% vs 66% and 52% vs 54% (p = 0.75), respectively. No RT patients went on to receive salvage cystectomy. Treatment complications are listed in Table 1; the Clavien Dindo classification system was used to describe acute surgical complications of RC and the Common Terminology Criteria for Adverse Events (CTCAE) Dictionary v5.0 was used for acute and late toxicity of RT. In the very elderly, RT (with or without concurrent ChT) offers survival and locoregional control rates comparable to RC, with a favorable side effect profile. RT should be offered for definitive management of non-metastatic MIBC as an alternative to RC in selected, well- informed, and compliant very elderly patients.