Survival Outcomes in Elderly Patients with Muscle Invasive Bladder Cancer: A Population Based Analysis

Abstract

Radical cystectomy (RC) remains the standard of care for muscle-invasive bladder cancer (MIBC). However, many elderly patients are medically inoperable or at high risk for complications following RC. Chemoradiation therapy (CRT) is an alternative treatment approach with less morbidity and mortality than RC, but this combined modality treatment remains widely under-utilized with many elderly patients receiving chemotherapy (CT) or radiation therapy (RT) alone. In this population-based analysis, we hypothesized that CRT would have similar overall survival (OS) to RC and improved OS compared to CT or RT alone in octogenarians with MIBC. We queried the National Cancer Database (NCDB) for all newly diagnosed muscle-invasive (cT2-T4a N0 M0) bladder cancer cases in patients aged 80 years or older from 2004 to 2013. All included patients underwent TURBT followed by RC, RT alone, CT alone, CRT, or no further treatment. Only patients receiving definitive radiation doses (>= 50Gy) were included for analysis as receiving RT. Kaplan-Meier, log-rank test, and multivariate Cox proportional hazards regression was performed with OS as the primary outcome. A total of 10,055 patients aged >= 80 years with complete treatment information were identified. 1,588 underwent radical cystectomy, 839 received RT alone, 1,013 received CT alone, 1,035 had CRT, and 5,580 had no further treatment. Mean age was 85.1 years (range, 80-90). 82.1% of patients had Stage II disease. Mean follow-up was 27.6 months (range, 0-137.8). Mean survival of the entire cohort was 28.0 months (95% CI, 27.2-28.8) and 21.4 months (95% CI, 25.0-26.6) for those receiving TURBT only. Mean survival was 43.8 months (95% CI, 41.2-46.3) for patients undergoing radical cystectomy and 40.8 months (95% CI, 38.2-43.3) for those undergoing CRT (P = 0.85). Mean survival was 29.1 months (95% CI, 26.8-31.4) and 30.7 months (95% CI, 28.2-33.2) for patients receiving RT alone vs. CT alone, respectively (P <0.0001 for both RC and CRT comparisons). The 5-year OS for CT alone, RT alone, CRT, and RC was 15.7%, 15.1%, 24.0% and 29.6%, respectively. Multivariate analysis adjusting for age, year of diagnosis, gender, race, treatment location, treatment facility, insurance status, comorbidity (Charlson/Deyo Score), grade, and stage demonstrated an OS benefit in favor of CRT (Hazard Ratio (HR) for death 0.70; 95% CI, 0.63-0.77; P<0.0001) and RC (HR 0.69; 95% CI, 0.63-0.76; P<0.0001). For elderly patients with MIBC, CRT has similar OS compared to RC. Both RC and CRT were associated with improved OS compared to CT or RT alone. In elderly patients who are candidates for CRT, this treatment should be preferred rather than CT or RT alone for bladder preservation.