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. PurposeMultidisciplinary 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. MethodsData 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, carcinom...

Bladder Cancer and Debate on Trimodal Therapy (Tmt) for Bladder Preservation

“…The gold standard treatment for Invasive Bladder Cancer is still the Radical Cystectomy (RC), but using Neoadjuvant Chemotherapy before the surgical procedure. [1][2][3][4][5][6][7] The Transurethral Bladder Tumor Resection (TUBTR) gives prognosis, is diagnostic and often therapeutic in some circumstances, but after an initial TUR, many patients (34% to 76%) will have residual disease present due to non-resection of the tumor in its entirety, increasing the risk of recurrence and progression. 1 In non-invasive tumor, the minimum goal of bladder cancer treatment is to eliminate the tumor, prevent disease recurrence and a possible progression to invasive muscle disease.…”

“…1 For invasive muscle tumor, RC is still the standard gold treatment, performing the radical surgical procedure as soon as possible, since the delay of this approach implies a lower survival due to the progression of the disease with the presence of micrometastases. [1][2][3][4][5][6][7] Hospitals that perform a high volume of radical cystectomies have lower mortality rates and complications than low volume centers. 1 In men, the standard RC is the removal of the bladder, prostate, vesicles Seminal and distal ureters, where as in women, RC removes bladder, urethra, vagina, uterus and ureters.…”

“…1,4,7 When the bladder is to be preserved, the treatment of invasive tumor is performed with Trimodal Therapy (TMT), which determines a surgical approach with radical TUR, radiotherapy and chemotherapy, selecting well the patients who should undergo this therapeutic line for a correct comparative study with the other therapies. 3,4,6,7,8 Patients with tumor-related hydronephrosis, flat lesions such as CIS, locally advanced disease (T4), presence of urethral obstruction and lymph node involvement are poor candidates for preservation of the bladder and are generally excluded from TMT. 3,4 Tumors eligible for preservation of the bladder are those with low volume T2 disease without hydronephrosis, CIS; Single tumors less than three centimeters and of usual histology; And patients who can't or don't want to undergo RC.…”

“…4 The similarity in survival between patients who undergo RC and TMT is probably due to the rapid use of rescue cystectomy in cases of recurrence in the bladder preservation series. 5,6,8…”

Nur die Chirurgie? Multimodalkonzepte mit kurativer Intention für das Urothelkarzinom der Harnblase

“…In einer Studie von Kulkarini et al wurde zum ersten Mal für alle wichtigen onkologischen Parameter ein entsprechendes Matching durchgeführt (Geschlecht, cT und cN Status, ECOG und Charlson-Score, Alter, CIS, Hydronephrose). Im Anschluss zeigte sich kein signifikanter Unterschied zwischen RC und TMT bei allerdings relativ geringer Patientenzahl (n = 121)[79].…”