The Role of Adjuvant Radiation Therapy in Locally Advanced Bladder Cancer

Abstract

Background:The standard of care for locally advanced bladder cancer (LABC) is neoadjuvant chemotherapy followed by cystectomy. However, the role of adjuvant therapy for locally advanced bladder cancer is unclear.Objective:The purpose of this study was to evaluate the outcomes of adjuvant radiation therapy (RT) for patients with LABC, and to determine which risk factors best predict for patients who may best benefit from adjuvant RT.Methods:The National Cancer Data Base (NCDB) was queried (2004– 2013) for patients with newly-diagnosed pT3-4N0-3M0 urothelial carcinoma of the bladder that received neoadjuvant chemotherapy and cystectomy. Patients were divided into two groups based on the adjuvant therapy they received: RT or observation. Statistics included multivariable logistic regression to determine factors predictive of receiving adjuvant RT, Kaplan-Meier analysis to evaluate overall survival (OS), and Cox proportional hazards modeling to determine variables associated with OS.Results:Altogether, 1,646 patients met inclusion criteria; 59 (3.6%) patients received adjuvant RT, while 1,587 (96.4%) were observed. Patients treated with adjuvant RT were more likely to be female, have positive surgical margins, and receive treatment at a non-academic facility. There was no difference in median overall survival (OS) between patients treated with RT when compared to patients observed (17.7 months vs. 23.5 months; p = 0.085). However, an improvement in median OS with the use of adjuvant RT was observed among patients with positive surgical margins (20.3 months vs. 13.1 months; p = 0.032). On multivariate analysis, advancing age, pT4 stage, positive N stage, positive margins, and lower socioeconomic status were associated with worse OS.Conclusions:In the largest study to date evaluating efficacy of adjuvant radiotherapy in patients with locally advanced bladder cancer, use of RT was not associated with OS in all patients, while RT was associated with improvemed OS among patients with positive surgical margins. Prospective studies are recommended to confirm these findings.

EAU-ESMO Consensus Statements on the Management of Advanced and Variant Bladder Cancer—An International Collaborative Multistakeholder Effort†

“…Patients with urothelial carcinoma with squamous and/or glandular differentiation are more likely to have pT3-T4 tumours (70% vs 38%, p < 0.0001) and pN+ disease (20% vs 15%, p = 0.05) than those with pure urothelial carcinoma, confirming the observation that they are more likely to die of local than of distant metastatic disease [23]. This would provide a strong argument to consider improving local control by adjuvant radiotherapy, especially in cases of positive margins at areas amenable for radiotherapy [24,25].…”

EAU–ESMO consensus statements on the management of advanced and variant bladder cancer—an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees

“…Patients with urothelial carcinoma with squamous and/or glandular differentiation are more likely to have pT3-T4 tumours (70% versus 38%, P < 0.0001) and pNþ disease (20% versus 15%, P ¼ 0.05) than those with pure urothelial carcinoma, confirming the observation that they are more likely to die of local than distant metastatic disease [23]. This would provide a strong argument to consider improving local control by adjuvant radiotherapy especially in cases of positive margins at areas amenable for radiotherapy [24,25].…”

The impact of molecular status on survival outcomes for invasive micropapillary carcinoma of the breast

“…The NCDB is a national hospital‐based cancer registry that is cosponsored by the American College of Surgeons (ACoS) and the American Cancer Society. It houses data from more than 1500 hospitals with ACoS‐accredited cancer‐treatment programs, accounting for almost 70% of all newly diagnosed cancer cases in the United States . A case list of patients with biopsy‐proven IMPC diagnosed between January 2007 and December 2012 was retrieved from the NCDB.…”