Contemporary use trends and survival outcomes in patients undergoing radical cystectomy or bladder‐preservation therapy for muscle‐invasive bladder cancer

Cahn, David; Handorf, Elizabeth A.; Ghiraldi, Eric; Ristau, Benjamin T.; Geynisman, Daniel M.; Churilla, Thomas M.; Horwitz, Eric M.; Sobczak, M.L.; Chen, David Y.T.; Viterbo, Rosalia; Greenberg, Richard E.; Kutikov, Alexander; Uzzo, Robert G.; Smaldone, Marc C.

doi:10.1002/cncr.30900

Cited by 75 publications

(72 citation statements)

References 34 publications

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“…24,25 Previous studies show 5-year overall survival for radiotherapy ranging from 21% to 30% and for RC from 36% to 47%, 24,25 and most relative risk estimates of all-cause death using standard multivariable adjustments are in the range of 1.4-1.5, 25,26 with an exception of a recent study with an estimate of 2. 27 The relative risk estimates in our study increased with time from diagnosis. Previous studies have reported evidence of nonproportional hazards over time.…”

Section: Discussionsupporting

confidence: 46%

Survival after radiotherapy versus radical cystectomy for primary muscle‐invasive bladder cancer: A Swedish nationwide population‐based cohort study

et al. 2019

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Background Studies of survival comparing radical cystectomy (RC) and radiotherapy for muscle‐invasive bladder cancer have provided inconsistent results and have methodological limitations. The aim of the study was to investigate risk of death after radiotherapy as compared to RC. Methods We selected patients with muscle‐invasive urothelial carcinoma without distant metastases, treated with radiotherapy or RC from 1997 to 2014 in the Bladder Cancer Data Base Sweden (BladderBaSe) and estimated absolute and relative risk of bladder cancer death and all‐cause death. In a group of patients, theoretically eligible for a trial comparing radiotherapy and RC, we calculated risk difference in an instrumental variable analysis. We have not investigated chemoradiotherapy as this treatment was not used in the study time period. Results The study included 3 309 patients, of those 17% were treated with radiotherapy and 83% with RC. Patients treated with radiotherapy were older, had more advanced comorbidity, and had a higher risk of death as compared to patients treated with RC (relative risks of 1.5‐1.6). In the “trial population,” all‐cause death risk difference was 6 per 100 patients lower after radiotherapy at 5 years of follow‐up, 95% confidence interval −41 to 29. Conclusion(s) Patient selection between the treatments make it difficult to evaluate results from conventionally adjusted and propensity‐score matched survival analysis. When taking into account unmeasured confounding by instrumental variable analysis, no differences in survival was found between the treatments for a selected group of patients. Further clinical studies are needed to characterize this group of patients, which can serve as a basis for future comparison studies for treatment recommendations.

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Section: Discussionsupporting

confidence: 46%

Survival after radiotherapy versus radical cystectomy for primary muscle‐invasive bladder cancer: A Swedish nationwide population‐based cohort study

et al. 2019

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“…When matched based on analytic stage, the finding that patients treated with radical cystectomy had better overall survival than chemoRT was in agreement with a published report using the NCDB . Cahn et al.…”

Section: Discussionsupporting

confidence: 88%

“…This report provides a possible explanation as to why prior large database analyses have shown better overall survival for bladder cancer patients treated with cystectomy/ chemo compared to definitive chemoRT whereas prospective multi-institution radiotherapy trials have shown overall survival comparable to radical cystectomy-use of analytic stage instead of clinical stage in prior NCDB matched pair analyses. [17][18][19][20]22,24 Given that only clinical stage is available to the patient and oncologists prior to definitive local therapy, clinical stage represents a more accurate comparison between the two treatment approaches. One advantage of NCDB compared to SEER is that clinical and pathologic stages are coded separately, which allowed for separate matching based on clinical or pathologic stage and the ability to account for upstaging.…”

Section: Discussionmentioning

confidence: 99%

National Cancer Database Comparison of Radical Cystectomy vs Chemoradiotherapy for Muscle‐Invasive Bladder Cancer: Implications of Using Clinical vs Pathologic Staging

Lin

Kernen

et al. 2018

Cancer Medicine

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PurposeTo test the hypothesis that bladder preservation therapy consisting of definitive chemoradiotherapy (chemoRT) results in similar overall survival rates to radical cystectomy/chemotherapy when balancing baseline patient characteristics and initial (preoperative) clinical stage.Materials/methodsA total of 7,322 patients with stage II‐IV, M0 bladder cancer who were treated with cystectomy/chemo (N = 5,664) or definitive chemoRT (N = 1,658) were identified from the National Cancer Database. Baseline patient characteristics were compared using Pearson's chi‐square, Fisher's exact test, and Wilcoxon's rank sum tests. Cox regressions were used to investigate for variables significantly correlated with overall survival (OS). OS was compared between cystectomy/chemo vs chemoRT before and after propensity score matched pair analyses using Kaplan‐Meier curves and log‐rank tests.ResultsPatients who underwent cystectomy/chemo were significantly younger than ones treated with definitive chemoRT (mean age 63.7 vs 75.2; P < 0.001). Age, race, Charlson/Deyo Comorbidity Score (CDCS), clinical stage, insurance status, and type of facility significantly correlated with OS (P < 0.05 for all covariates). Patients treated with cystectomy/chemo were younger, healthier with better CDCS, and more likely treated at academic facilities. Before matched pair analyses, OS was significantly better when treated with cystectomy/chemo (3 year 56.4%; 5 year 45.9%) compared to chemoRT (3 year 47.3%; 5 year 33.2%) (P < 0.001); 28.6% of patients undergoing cystectomy were upstaged at the time of surgery. After matched pair analyses matching age, race, sex, CDCS, clinical (presurgical) stage, insurance, and facility type (N = 1,750), OS was no longer significantly different between cystectomy/chemo (3 year 52.1% and 5 year 41.0%) vs chemoRT (3 year 53.3% and 5 year 40.1%) (P = 0.5).ConclusionsPatients treated with cystectomy/chemo were significantly younger and healthier compared to those treated with chemoRT. Once these factors were accounted for in propensity score matched pair analyses using clinical stage, overall survival was not significantly different between cystectomy/chemo and an organ‐sparing approach with definitive chemoRT.

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“…6,7 The study by Cahn et al compared overall survival (OS) in patients undergoing radical cystectomy (22,680 patients) with that of patients undergoing bladder preservation therapy (9620 patients). 6 Patients treated with radiotherapy (RT) were stratified by those receiving radical RT alone (dose > 50 grays; 2540 patients) or chemoradiotherapy (1489 patients). Improved OS was observed for those patients receiving surgery in all age groups.…”

Section: Introductionmentioning

confidence: 99%

Bladder cancer and the National Cancer Data Base: New insight or misinformation?

Choudhury

Hoskin

2018

Cancer

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Contemporary use trends and survival outcomes in patients undergoing radical cystectomy or bladder‐preservation therapy for muscle‐invasive bladder cancer

Cited by 75 publications

References 34 publications

Survival after radiotherapy versus radical cystectomy for primary muscle‐invasive bladder cancer: A Swedish nationwide population‐based cohort study

Survival after radiotherapy versus radical cystectomy for primary muscle‐invasive bladder cancer: A Swedish nationwide population‐based cohort study

National Cancer Database Comparison of Radical Cystectomy vs Chemoradiotherapy for Muscle‐Invasive Bladder Cancer: Implications of Using Clinical vs Pathologic Staging

Bladder cancer and the National Cancer Data Base: New insight or misinformation?

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