Prognosis is deteriorating for upper tract urothelial cancer: data for England 1985–2010

Abstract

Objective To ascertain current trends in the incidence and mortality rates for upper tract urothelial cancer (UTUC) and identify any relationship with age, stage at presentation, social deprivation and treatment method. Patients and Methods We used national databases to collect the data: incidence, stage and survival data from the National Cancer Data Repository (NCDR) and British Association of Urological Surgeons (BAUS) audit database; mortality data from the Office for National Statistics (ONS); and treatment method data from the Hospital Episodes Statistics (HES). Results The incidence of UTUC is increasing (from 1985 to 2009 it increased by 38% in men and 77% in women). It affects mainly those aged >60 years, and diagnoses are increasingly made in those aged >80 years. Diagnoses at advanced stage have increased from 45 to 80%. Mortality has risen faster than incidence; the overall 5‐year survival rate has dropped from 60 to 48%. Survival is worst in stage IV disease and in patients aged ≥80 years; when analysed by age or stage group, survival rates are unchanged. Nephroureterectomy has increased by 75%, but endoscopic treatment, which only became available part way through the study period, now accounts for 11% of surgical interventions for UTUC, mainly in stage I disease and in the elderly. Conclusions Despite sharing its risk factors with bladder cancer, current incidence and mortality trends for UTUC contrast with those in bladder cancer. Increasing use of cross‐sectional imaging may explain some of the identified increased incidence. Higher incidence specifically in people >80 years, together with stage migration to more advanced cancers, are likely to have caused at least some of the observed increased mortality. Further study is required to answer the questions of whether there are other hitherto unidentified aetiological or prognostic factors; whether less aggressive treatment of UTUCs in the elderly is always justified; and whether the rising frequency of minimally invasive treatment means suboptimum oncological management.

Trends in incidence and survival for upper tract urothelial cancer (UTUC) in the state of Victoria – Australia

“…This is highlighted by the fact that 41% of the patients in this study died of non-cancer related causes [17]. In England the 5-year overall survival for UTUC has disturbingly declined from 60% in 1985 to 48% in 2009 [11]. The same epidemiological data revealed an increasing trend for endoscopic procedures, particularly in the elderly and those with stage 1 disease.…”

“…Eylert et al speculated that this rise in mortality was somewhat explained by the sharp rise in incidence in those over 80 years of age, as well as the increased used of cross-sectional imaging which likely meant more deaths were being attributed to UTUC than before. This was supported by the age-specific mortality rates, which were unchanged over the study period, suggesting that increases in the diagnosis of UTUC in those aged over 80 years may be adversely affecting the unadjusted overallsurvival rates [11]. When organ-confined disease is present, nephroureterectomy with bladder-cuff excision remains the gold standard treatment for UTUC.…”

“…Table 2 summarises the key findings from some of the largest and most relevant UTUC epidemiological series to date. In England, the incidence of UTUC has increased since 1985 by 38% and 77% for men and women, respectively [11]. The United States has also seen a gradual rise in the incidence of UTUC [10].…”

“…The United States has also seen a gradual rise in the incidence of UTUC [10]. Eylert et al hypothesised that this rise in the incidence of UTUC might somewhat be a result of increased use of cross-sectional imaging [11]. However, the expected positive stage migration effect towards diagnosing earlier stage disease in the asymptomatic phase was not seen in this data; in fact there was an increasing trend to more advanced stage disease at diagnosis, implying that other factors may be at play.…”

“…UTUC present challenges to clinicians for a variety of reasons, including their potential for multifocal disease, local recurrence and metastatic spread [9]. In addition to these difficulties, the incidence of UTUC appears to be rising [7,[10][11][12]. This rising incidence is thought to be a result of a combination of improved imaging techniques, advances in endoscopic procedures and improved bladder cancer survival [7].…”