Survival for patients with residual tumor at radical cystectomy following chemotherapy: A matched analysis to cystectomy-only patients.

Abstract

355 Background: While neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) improves survival compared to RC alone for urothelial carcinoma of the bladder (UCB), the bulk of this survival benefit has been attributed to patients who achieve ypT0 status at RC. The implications of having residual UCB (rUCB) at RC after NAC are less clear. As such, we evaluated whether the outcomes for patients with rUCB after NAC differ from stage-matched RC patients who did not receive NAC. Methods: Patients undergoing RC for UCB between 1981-2010 at Mayo Clinic were identified. All RC pathology was re-reviewed by a single genitourinary pathologist. Patients who received NAC were matched 1:2 to patients not exposed to NAC based on pT and pN-stage, margin status, and year of RC. Kaplan Meier and Cox regression analyses were used to evaluate the associations between NAC and cancer-specific (CSS) and overall survival (OS), stratified by presence of rUCB (i.e. (y)pT0N0 and non-(y)pT0N0). Results: We matched 111 patients who underwent NAC + RC to 222 RC-alone patients. Median age was 68 years (IQR 60,74); 59 (18%) were female. Median follow-up among survivors was 7.2 years (IQR 6,16). A total of 248 patients died; 148 died from UCB. In patients without rUCB at RC, there were no differences in 5-yr CSS (86% vs. 90%, p=0.85) or OS (82% vs. 84%, p=0.46) between patients who did and did not receive NAC. Moreover, on multivariable analysis, NAC exposure was not associated with CSS (HR=1.0; 95%CI 0.3-3.1; p=0.9) or OS (HR=0.9; 95%CI 0.4-1.9; p=0.8) in this subgroup. Among patients with rUCB, receipt of NAC was associated with significantly worse 5-yr CSS (32% vs. 56%, p<0.001) and OS (25% vs. 48%, p<0.001). NAC exposure remained independently associated with worse CSS (HR=2.2; 95%CI 1.6-3.1; p<0.001) and OS (HR=2.0; 95%CI 1.5-2.7; p<0.001) among these patients. Conclusions: While patients who achieve a complete response to NAC have excellent survival outcomes, patients with residual UCB at RC after NAC have a worse prognosis compared to stage-matched RC patients not exposed to NAC. Such patients should be considered for enrolment in novel adjuvant therapy trials.

Treatment of muscle‐invasive and advanced bladder cancer in 2020

“…Although cisplatin‐based chemotherapy followed by RC improves survival, for some patients, residual cancer remains. In fact, Bhindi et al, in a retrospective analysis of patients with MIBC who received either NAC plus RC or RC alone, among patients with residual cancer, those who received NAC had worse disease control and survival 105 . The aggressive nature of the disease in this subgroup of patients, who are refractory to NAC, calls for a need to optimize cisplatin‐based chemotherapy.…”

Immunotherapy in non-metastatic urothelial cancer: back to the ‘future’

“…Long term survival is directly proportional to the depth of response to neoadjuvant therapy. The pCR at RC after neoadjuvant therapy is a surrogate marker, which translates into equal survival as compared to stage matched controls undergoing upfront RC with ypT0N0/pT0N0 [47][48][49]. Can we omit RC in such patients is the question being addressed in bladder sparing trials on IO therapy.…”