Systematic Review of Comorbidity and Competing-risks Assessments for Bladder Cancer Patients

Abstract

Context Radical cystectomy continues to be associated with a significant risk of morbidity and all-cause mortality (ACM). Practice pattern data demonstrating underuse of surgery for patients with muscle-invasive and high-risk non–muscle invasive bladder cancer (BC) have been linked to the advanced age and higher comorbidity status of such patients, which suggests that rates of ACM as well as cancer-specific mortality should be incorporated into patient counseling and guideline recommendations. Objective To review the literature on risk assessment tools for preoperative comorbidity in BC that may aid in treatment decision-making. Evidence acquisition A systematic search was conducted using Ovid and Medline according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2017 reporting on comorbidity risk assessment (CRA) tools for BC. Prospective and retrospective studies were included. Evidence synthesis There are no published randomized control trials comparing CRA tools for BC. Patients undergoing radical cystectomy with combined high-risk comorbidity and performance scores may face up to a sevenfold greater risk of other-cause mortality compared to those with low scores. The Charlson Comorbidity Index is one of the most widely studied indices for 90-d perioperative mortality and overall and cancer-specific survival, with an area under the receiver operating characteristic curve of up to 0.810. Prospective studies of CRA tools for BC have consistently shown that patients with higher comorbidity have worse outcomes. While not specific for BC, comorbidity indices provide useful assessment of competing risks. Competing-risks assessment tools are lacking, with limited studies assessing the impact of these tools on treatment decision-making by patients and providers. We provide the impetus for incorporation of comorbidity risks into practice guidelines when discussing treatment options with patients. Conclusions CRA tools should be incorporated into preoperative treatment counseling and the assessment of postoperative outcomes. While retrospective evidence supports the use of CRA tools for BC, further comparative studies evaluating the effectiveness of these tools and identifying the patients most likely to benefit from a treatment according to competing-risks assessment are needed. Patient summary In this review we explored the clinical evidence for comorbidity risk assessment tools in bladder cancer. We found evidence to support incorporation of comorbidity risks into practice guidelines when discussing treatment options with patients.

Rates of other‐cause mortality after radical cystectomy are decreasing over time—A population‐based analysis over two decades

“…However, male patients were still at higher risk of OCM than females. In consequence, unmarried and male patients may represent prime targets for preventative measures aimed at OCM risk reduction, along with the elderly patients 20‐24 …”

Predictive Value of Different Parameters for Estimating the First 90-days and Long-term Survival Following Radical Cystectomy

“…There exists surplus of studies which pertain to the comorbidity index to be used in the prediction of the OS in the follow up in the long term and the perioperative mortality of 90 days for the patients on which radical cystectomy is planned due to bladder tumors (4,12,13,14). Different studies have shown that the elder age, angina pectoris, smoking history, chronic lung diseases and Diabetes Mellitus were used as independent prognostic factors to predict the 10-year mortality subsequent to cystectomy (13,15). However, instead of evaluating the comorbid conditions individually, it is thought to be more valuable to use nomograms that examine the total morbidity burden (2).…”

“…According to the updated guidelines of the European Association of Urology (EAU), it is suggested to make an evaluation for the morbidity of the potential patients who are to undergo radical cystectomy preoperatively (3). For this purpose, the widely used scoring systems are ACCI and ASA and it has been observed that they are much more beneficial for the prediction of the complications which may develop in the elder patients during the first 30 days after the operation and the cancer free mortality in the first 90 days (13,14). It has been reported that the prognostic value of ACCI may be higher in the estimation of five-year mortality due to all causes (12).…”

“…Hence, the patients and their families will be informed of the potential risks and the approaches to protect the bladder will perhaps be brought forward for the patients with higher morbidity. However, we come to an understanding that there exists no consensus for the nomogram or scoring system which may be the best for comorbidity of such patients, if we have a look at the literature (6).…”

Validation of a Questionnaire-Suitable Comorbidity Index in Patients Undergoing Radical Cystectomy

“…Comorbidity is an important risk factor for periop- erative and long-term mortality after radical cystectomy. There is, however, no consensus on the best way to measure it in this setting [3,4].…”