A propensity score analysis of radical cystectomy versus bladder-sparing trimodal therapy in the setting of a multidisciplinary bladder cancer clinic

Abstract

Purpose Multidisciplinary management improves complex treatment decision making in cancer care, but its impact for bladder cancer (BC) has not been documented. Although radical cystectomy (RC) currently is viewed as the standard of care for muscle-invasive bladder cancer (MIBC), radiotherapybased, bladder-sparing trimodal therapy (TMT) that combines transurethral resection of bladder tumor, chemotherapy for radiation sensitization, and external beam radiotherapy has emerged as a valid treatment option. In the absence of randomized studies, this study compared the oncologic outcomes between patients treated with RC or TMT by using a propensity score matched-cohort analysis. Methods Data from patients treated in a multidisciplinary bladder cancer clinic (MDBCC) from 2008 to 2013 were reviewed retrospectively. Those who received TMT for MIBC were identified and matched (for sex, cT and cN stage, Eastern Cooperative Oncology Group status, Charlson comorbidity score, treatment date, age, carcinoma in situ status, and hydronephrosis) with propensity scores to patients who underwent RC. Overall survival and disease-specific survival (DSS) were assessed with Cox proportional hazards modeling and a competing risk analysis, respectively. Results A total of 112 patients with MIBC were included after matching (56 who had been treated with TMT, and 56 who underwent RC). The median age was 68.0 years, and 29.5% had stage cT3/cT4 disease. At a median follow-up of 4.51 years, there were 20 deaths (35.7%) in the RC group (13 as a result of BC) and 22 deaths (39.3%) in the TMT group (13 as a result of BC). The 5-year DSS rate was 73.2% and 76.6% in the RC and TMT groups, respectively (P = .49). Salvage cystectomy was performed in 6 (10.7%) of 56 patients who received TMT. Conclusion In the setting of a MDBCC, TMT yielded survival outcomes similar to those of matched patients who underwent RC. Appropriately selected patients with MIBC should be offered the opportunity to discuss various treatment options, including organ-sparing TMT.

Contemporary use trends and survival outcomes in patients undergoing radical cystectomy or bladder‐preservation therapy for muscle‐invasive bladder cancer

“…Two comparative effectiveness publications also have supported the use and future prospective study of BPT. A Canadian‐based group performed a matched propensity score‐adjusted analysis in a smaller cohort (112 patients), and demonstrated comparable 5‐year disease‐specific survival rates in the RC (73.2%) and trimodal BPT (76.6%) cohorts …”

Survival after radiotherapy versus radical cystectomy for primary muscle‐invasive bladder cancer: A Swedish nationwide population‐based cohort study

“…RC entails high risk of re‐operations, long hospital‐stays, long‐term sequelae, and even postoperative mortality . A contemporary bladder‐sparing treatment alternative to RC is chemoradiotherapy . There is no evidence from randomized controlled trials to support superiority of RC over radiotherapy with respect to survival.…”

Selective tetramodal bladder‐preservation therapy, incorporating induction chemoradiotherapy and consolidative partial cystectomy with pelvic lymph node dissection for muscle‐invasive bladder cancer: oncological and functional outcomes of 107 patients

“…Bladder-sparing strategies for patients with MIBC have been explored to overcome these innate limitations of RC. Supported by a growing body of evidence, multimodal bladder-sparing therapy has recently been acknowledged as an important treatment option along with RC [6][7][8][9][10][11][12][13][14]. Most of the currently existing protocols for bladder preservation are trimodal therapies, which comprise maximal transurethral resection of bladder tumour (TURBT) and chemoradiotherapy (CRT) [10][11][12][13][14].…”

“…Supported by a growing body of evidence, multimodal bladder-sparing therapy has recently been acknowledged as an important treatment option along with RC [6][7][8][9][10][11][12][13][14]. Most of the currently existing protocols for bladder preservation are trimodal therapies, which comprise maximal transurethral resection of bladder tumour (TURBT) and chemoradiotherapy (CRT) [10][11][12][13][14]. Recently the published literature has shown that trimodal bladder-sparing therapy yields survival outcomes similar to those of RC [12]; however, a significant number of patients experienced MIBC recurrences in the preserved bladders after receiving trimodal bladder-sparing therapy [10][11][12][13][14].…”