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Koller CR, Greenberg JW, Natale C, Krane LS. Assessing the safety of bladder-preserving therapy as an alternative to surgical intervention in elderly patients with muscle invasive bladder cancer. Urologia 2024:3915603241265828. [PMID: 39058262 DOI: 10.1177/03915603241265828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
BACKGROUND There is interest in using bladder-preserving therapy as an alternative definitive therapy for muscle invasive bladder cancer in certain high-risk groups such as the elderly. OBJECTIVE To determine if bladder-preserving therapy represents a safer alternative to surgical intervention in elderly patients with muscle invasive bladder cancer. METHODS We surveyed the Surveillance, Epidemiology and End Results database (SEER) for cases of non-metastasized malignant bladder cancer in patients aged 80+. Survival outcomes with radical cystectomy (RC) with or without chemotherapy were compared to those after chemotherapy and radiation without cystectomy. We performed log-rank tests and Kaplan-Meier and cox regression and hazard analyses before and after propensity score matching. RESULTS A total of 2995 patients were identified, with 49.98% treated with RC only, 8.65% treated with RC/chemotherapy, and 41.37% treated with chemotherapy and radiation without RC. Median overall survival for the RC only, RC/chemotherapy and chemotherapy/radiation groups were 31.4, 44.1, and 24.6 months, respectively. On multivariate analysis, hazard ratios (reference: RC/chemotherapy group) were RC Only (HR = 1.408 (95% CI 1.188-1.669), p < 0.0001) and chemotherapy/radiation (HR = 1.650 (95% CI 1.390-1.959), p < 0.0001). After matching the chemotherapy/radiation and RC/chemotherapy groups, the former continued to show survival hazard (HR = 1.744 (95% CI 1.414-2.155), p < 0.0001). CONCLUSIONS Octogenarians should be offered definitive local therapy for their localized bladder cancer including RC and chemotherapy. Bladder-sparing alternatives should be reserved for patients unfit for surgery.
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Affiliation(s)
- Christopher R Koller
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Jacob W Greenberg
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Caleb Natale
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - L Spencer Krane
- Southeast Louisiana Veterans Health Care System, Department of Surgery, New Orleans, LA, USA
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2
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Kang N, Feng Y, Lin K, Chen Y, Ho C, Yang C. Comparative survival analysis of bladder preservation therapy versus radical cystectomy in muscle-invasive bladder cancer. Cancer Med 2024; 13:e6972. [PMID: 38379322 PMCID: PMC10844988 DOI: 10.1002/cam4.6972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Bladder preservation therapy is an alternative to radical cystectomy in patients with muscle-invasive bladder cancer (MIBC). The purpose of this study is to compare survival outcomes between bladder preservation therapy and radical cystectomy in MIBC patients using an Asian nationwide cancer registry database. METHODS From the Taiwan Cancer Registry database and the Taiwan National Health Insurance Research Database, we identified bladder cancer patients from 2008 to 2018. The patients with urothelial carcinoma and clinical stage T2-T4aN0-1 M0 were included. Propensity score matching by age, gender, clinical stage, cT classification, and Charlson Comorbidity Index score was used between those receiving bladder preservation therapy or radical cystectomy. Overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS) were compared using the Kaplan-Meier method. Multivariate Cox regression models were used to determine the predictive factors of OS, CSS, and DFS. RESULTS Following the propensity score matching, 393 MIBC patients were analyzed, 131 (33.3%) receiving bladder preservation therapy and 262 (66.7%) receiving radical cystectomy. After 5 years of the follow-up period the overall duration was with a median of 15.6 months. The treatment groups did not differ significantly in OS, CSS, and DFS (p = 0.2681, 0.7208, and 0.3616, respectively). In multivariable Cox regression models, bladder preservation therapy remained non-inferior to radical cystectomy in OS (adjusted hazard ratio [aHR] 1.08; 95% confidence interval [CI], 0.77-1.50; p = 0.6689), CSS (aHR, 1.06; 95% CI, 0.72-1.57; p = 0.7728), and DFS (aHR, 0.76; 95% CI, 0.46-1.27; p = 0.2929). Additionally, among patients ≥80 years, the use of bladder preservation therapy compared with radical cystectomy resulted in an equivalent OS, CSS and DSS. CONCLUSION In Asian populations, bladder preservation therapy yielded similar survival outcomes as radical cystectomy in MIBC patients. Based on the results, it is evident that a multidisciplinary approach and shared decision-making are recommended for bladder cancer treatment.
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Affiliation(s)
- Nai‐Wen Kang
- Division of Hematology and Oncology, Department of Internal MedicineChi Mei Medical CenterTainanTaiwan
| | - Yin‐Hsun Feng
- Division of Hematology and Oncology, Department of Internal MedicineChi Mei Medical CenterTainanTaiwan
| | - Kuei‐Li Lin
- Department of Radiation OncologyChi Mei Medical CenterTainanTaiwan
| | - Yi‐Chen Chen
- Department of Medical ResearchChi Mei Medical CenterTainanTaiwan
| | - Chung‐Han Ho
- Department of Medical ResearchChi Mei Medical CenterTainanTaiwan
- Department of Information ManagementSouthern Taiwan University of Science and TechnologyTainanTaiwan
| | - Ching‐Chieh Yang
- Department of Radiation OncologyChi Mei Medical CenterTainanTaiwan
- Department of PharmacyChia‐Nan University of Pharmacy and ScienceTainanTaiwan
- School of Medicine, College of MedicineNational Sun Yat‐sen UniversityKaohsiungTaiwan
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3
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Su X, Dong C, Liao W, Liu W. Oncological effectiveness of bladder-preserving trimodal therapy versus radical cystectomy for the treatment of muscle-invasive bladder cancer: a system review and meta-analysis. World J Surg Oncol 2023; 21:271. [PMID: 37641150 PMCID: PMC10464249 DOI: 10.1186/s12957-023-03161-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE Radical cystectomy (RC) is the gold standard treatment for muscle-invasive bladder cancer (MIBC). As a bladder-preservation option recommended in guidelines, trimodal therapy (TMT) has become increasingly popular in recent years. However, it is still uncertain whether TMT can provide comparable oncologic outcomes to RC. Therefore, it is imperative to evaluate whether TMT yields comparable outcomes to RC. METHODS We conducted a systematic search of Web of Science, MEDLINE, the Cochrane Library, and EMBASE databases up to June 2023 to identify studies that met our inclusion criteria. The primary outcome measures evaluated in this study were overall survival (OS) and cancer-specific survival (CSS). The study quality was evaluated independently by two authors, and data were extracted accordingly. RESULTS After excluding duplicates and ineligible articles, our meta-analysis included seven studies involving 3,489 and 13,877 patients in the TMT and RC groups, respectively. Short-term overall survival rates were comparable between the groups, but beyond 5 and > 10-years, the RC group had significantly higher overall survival rates compared to the TMT group. In terms of cancer-specific survival, there was no significant difference between the groups at 1-year follow-up, but from the second year onwards, including the 5-year and > 10-year nodes, the RC group had significantly better outcomes compared to the TMT group. CONCLUSION The treatment effect of RC is better than that of TMT. Unless the patient can't tolerate RC or has a strong desire to preserve the bladder, RC should be chosen over TMT in treatment, and patients undergoing TMT should be closely followed up.
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Affiliation(s)
- Xiaozhe Su
- Department of Urology, The Second Xiangya Hospital of Central South University, Changsha, China
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Caitao Dong
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wenbiao Liao
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wentao Liu
- Department of Urology, The Second Xiangya Hospital of Central South University, Changsha, China.
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Comparing Long-Term Survival Outcomes for Muscle-Invasive Bladder Cancer Patients Who Underwent with Radical Cystectomy and Bladder-Sparing Trimodality Therapy: A Multicentre Cohort Analysis. JOURNAL OF ONCOLOGY 2022; 2022:7306198. [PMID: 35607328 PMCID: PMC9124076 DOI: 10.1155/2022/7306198] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/18/2022]
Abstract
Background Although radical cystectomy (RC) is the clinical practice guideline-recommended treatment of muscle-invasive bladder cancer (MIBC), bladder-sparing trimodality therapy (TMT) has emerged as a valid treatment option. Findings comparing the survival outcomes for MIBC patients who underwent RC and TMT are inconclusive. Objective We designed a large hospital-based multicohort study to compare the effectiveness of TMT with RC. Methods Information on deaths was jointly retrieved from EMR (electronic medical record), cause of death registry, and chronic disease surveillance as well as study-specific questionnaire. To avoid the systematical difference between patients who received two modalities, RC-MIBC cohort was propensity score-matched to TMT-MIBC cohort, and the Cox proportional hazard regression was used to calculate the overall survival (OS) and disease-specific survival (DSS). Results There were 891 MIBC patients treated with RC and another 891 MIBC patients who underwent with TMT in the propensity score matching. Comparable effectiveness between two modalities was observed for DSS (HR, 1.20; 95% confidence interval (CI), 0.94 to 1.49) and OS (HR, 1.17; 95% CI, 0.91 to 1.43) according to multiple adjustment after a median follow-up of approximately 9.3 years. However, a relatively higher mortality rate around 5 years after TMT treatment was found compared to RC (HR, 1.26; 95% CI, 1.01 to 1.53). The respective 5-year OS rates were 69% and 73% for TMT cohort and RC cohort, respectively. Conclusions Our findings supported that MIBC patients with TMT yielded survival outcomes comparable to MIBC patients who underwent RC overall. Treatment options should be suggested considering patients' age and willingness.
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5
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Lockhart KR, Carroll R, Tiu A, Blatt A. Does the introduction of pre‐operative cardiopulmonary exercise testing in radical cystectomy delay or alter surgical care? BJUI COMPASS 2021; 3:238-242. [PMID: 35492226 PMCID: PMC9045571 DOI: 10.1002/bco2.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/18/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives To assess if the introduction of routine pre‐operative cardiopulmonary exercise testing (CPET) in radical cystectomy has delayed surgical intervention. Materials and Methods A prospective database of patients undergoing radical cystectomy in our local health network was maintained. A retrospective analysis of two years (2018–2020) included 38 patients. Of these, 15 patients had CPET pre‐operatively, and a direct comparison was performed. Results The mean time from diagnosis to cystectomy was 95 days in patients who did not have CPET compared to 110 days for those who did (p = 0.32), with comparable rates of neoadjuvant chemotherapy (NAC) (62.5% and 64.29%). Average length of stay was 18.6 days compared with 13.87 (p = 0.16), favouring the CPET group. The CPET group also had a lower readmission rate within 30 days (13.33% compared with 21.05%, p = 0.35). Cause‐specific mortality within 90 days was 10.2% and within the study timeframe was 36.84% (estimated 5‐year mortality rate 43–65%). Within the CPET group, eight had an anaerobic threshold (AT) of <11 ml/kg/min (range 6.3–10.5): Of these, 50% had Clavien‐Dindo complications of grade 2 or higher and the 90‐day mortality rate was 37.5% (cf. 0% in those with AT > 11 ml/kg/min in this series). Conclusion CPET is a valuable risk evaluation tool. This study suggested that CPET contributed to a minor non‐significant delay to surgery, however was associated with reduced length of stay and readmission rates, and was a valuable risk evaluation tool. We found that CPET AT <11 ml/kg/min is associated with higher rates of patient morbidity and perioperative mortality.
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Affiliation(s)
| | | | - Albert Tiu
- John Hunter Hospital Newcastle New South Wales Australia
| | - Alison Blatt
- John Hunter Hospital Newcastle New South Wales Australia
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6
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[Locally advanced or oligometastatic bladder cancer-role of local treatment of the primary tumor and metastases]. Urologe A 2021; 60:1555-1560. [PMID: 34825935 PMCID: PMC8654709 DOI: 10.1007/s00120-021-01712-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/15/2022]
Abstract
Hintergrund Das muskelinvasive Blasenkarzinom stellt in seiner Behandlung eine besondere Herausforderung dar, da die Therapie mit signifikanten Nebenwirkungen und Komplikationsraten einhergeht, insbesondere bei Patienten mit relevanten Begleiterkrankungen. Im metastasierten Stadium besteht der Therapiezweck in der Palliation, wobei das Vorliegen einer Oligometastasierung eine gesonderte Rolle einnimmt. In diesem Stadium kann auch die Therapie des Primärtumors relevant sein, wenn die Metastasen neben einer systemischen Therapie ebenso lokal behandelt werden können – insbesondere auch in Hinblick auf die über die letzten Jahre die Therapielandschaft erweiternden neuen medikamentösen Möglichkeiten. Ziel der Arbeit In diesem Reviewartikel sollen die Einflüsse einer definitiven Therapie des Primärtumors bei Patienten mit oligometastasiertem Urothelkarzinom der Harnblase dargelegt werden. Material und Methoden Basierend auf einer nicht-systemischen Literaturrecherche soll ein Überblick über bestehende Ergebnisse zur Therapie des oligometastasierten Blasenkarzinoms in Hinblick auf den Einfluss der Therapie des Primärtumors geben, wobei die Daten meist auf retrospektiven Studien und Metaanalysen bestehen. Schlussfolgerung Eine Lokaltherapie des Primärtumors im Rahmen eines multimodalen Therapiekonzepts kann bei selektionierten Patienten mit lymphogen metastasiertem und oligometastasiertem Blasenkarzinom einen positiven Einfluss auf Überleben, Lebensqualität und Vermeidung von Lokalkomplikationen nehmen, wobei für die Wahl der lokalen Therapie dieselben Kriterien angewendet werden sollten wie im nicht-metastasierten Stadium.
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7
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Jiang DM, Gupta S, Kitchlu A, Meraz-Munoz A, North SA, Alimohamed NS, Blais N, Sridhar SS. Defining cisplatin eligibility in patients with muscle-invasive bladder cancer. Nat Rev Urol 2021; 18:104-114. [PMID: 33432181 DOI: 10.1038/s41585-020-00404-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 01/29/2023]
Abstract
The current treatment paradigm for muscle-invasive bladder cancer (MIBC) consists of cisplatin-based neoadjuvant chemotherapy followed by local definitive therapy, or local definitive therapy alone for cisplatin-ineligible patients. Given that MIBC has a high propensity for distant relapse and is a chemotherapy-sensitive disease, under-utilization of chemotherapy is associated with suboptimal cure rates. Cisplatin eligibility criteria are defined for patients with metastatic bladder cancer by the Galsky criteria, which include creatinine clearance ≥60 ml/min. However, consensus is still lacking regarding cisplatin eligibility criteria in the neoadjuvant, curative MIBC setting, which continues to represent a substantial barrier to the standardization of patient care and clinical trial design. Jiang and colleagues accordingly suggest an algorithm for assessing cisplatin eligibility in patients with MIBC. Instead of relying on an absolute renal function threshold, their algorithm emphasizes a multidisciplinary and patient-centred approach. They also propose mitigation strategies to minimize the risk of cisplatin-induced nephrotoxicity in selected patients with impaired renal function. This new framework is aimed at reducing the inappropriate exclusion of some patients from cisplatin-based neoadjuvant chemotherapy (which leads to under-treatment) and harmonizing clinical trial design, which could lead to improved overall outcomes in patients with MIBC.
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Affiliation(s)
- Di Maria Jiang
- Division of Medical Oncology, Department of Medicine, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shilpa Gupta
- Department of Hematologic and Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Abhijat Kitchlu
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Alejandro Meraz-Munoz
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Scott A North
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Nimira S Alimohamed
- Department of Medicine, Division of Medical Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Normand Blais
- Division of Medical Oncology and Hematology, Department of Medicine, Centre Hospitalier de l'Université de Montréal; Université de Montréal, Montreal, Quebec, Canada
| | - Srikala S Sridhar
- Division of Medical Oncology, Department of Medicine, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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8
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Polo-Alonso E, Kuk C, Guruli G, Paul AK, Thalmann G, Kamat A, Solsona E, Thalmann G, Urdaneta AI, Zlotta AR, Mir MC. Trimodal therapy in muscle invasive bladder cancer management. MINERVA UROL NEFROL 2020; 72:650-662. [PMID: 33263367 DOI: 10.23736/s0393-2249.20.04018-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Radical cystectomy (RC) is the current mainstay for muscle-invasive bladder cancer (MIBC). Concerns regarding morbidity, mortality and quality of life have favored the introduction of bladder sparing strategies. Trimodal therapy, combining transurethral resection, chemotherapy and radiotherapy is the current standard of care for bladder preservation strategies in selected patients with MIBC. EVIDENCE ACQUISITION A comprehensive search of the Medline and Embase databases was performed. A total of 19 studies were included in a systematic review of bladder sparing strategies in MIBC management was carried out following the preferred reporting items for systematic reviews and meta-analysis (PRISMA). EVIDENCE SYNTHESIS The overall median complete response rate after trimodal therapy (TMT) was 77% (55-93). Salvage cystectomy rate with TMT was 17% on average (8-30). For TMT, the 5-year cancer-specific survival and overall survival rates range from 42-82% and 32-74%, respectively. Currently data supporting neoadjuvant or adjuvant chemotherapy in bladder sparing approaches are emerging, but robust definitive conclusions are still lacking. Gastrointestinal toxicity rates are low around 4% (0.5-16), whereas genitourinary toxicity rates reached 8% (1-24). Quality of life outcomes are still underreported. CONCLUSIONS Published data and clinical experience strongly support trimodal therapy as an acceptable bladder sparing strategy in terms of oncological outcomes and quality of life in selected patients with MIBC. A strong need exists for specialized centers, to increase awareness among urologists, to discuss these options with patients and to stress the increased participation of patients and their families in treatment path decision-making.
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Affiliation(s)
- Elvira Polo-Alonso
- Department of Urology, Instituto Valenciano de Oncologia (IVO), Valencia, Spain
| | - Cynthia Kuk
- Division of Urology, Departments of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada.,Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Georgi Guruli
- Division of Urology, Virginia Commonwealth University, Richmond, VA, USA
| | - Asit K Paul
- Division of Hematology, Oncology and Palliative Care Unit, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - George Thalmann
- Division of Hematology, Oncology and Palliative Care Unit, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ashish Kamat
- Department of Urology, Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Solsona
- Department of Urology, Instituto Valenciano de Oncologia (IVO), Valencia, Spain
| | - George Thalmann
- Department of Urology, University Hospital of Bern, Bern, Switzerland
| | - Alfredo I Urdaneta
- Division of Hematology, Oncology and Palliative Care Unit, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Alexandre R Zlotta
- Division of Urology, Departments of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada.,Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Maria C Mir
- Department of Urology, Instituto Valenciano de Oncologia (IVO), Valencia, Spain -
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Rahouma M, Kamel M, Nasar A, Harrison S, Lee B, Port J, Altorki N, Stiles BM. Treatment of cT3N1M0/IIIA non-small cell lung cancer and the risk of underuse of surgery. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)30503-1. [PMID: 32279970 DOI: 10.1016/j.jtcvs.2020.01.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 01/19/2020] [Accepted: 01/31/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Surgery may be underused for stage IIIA non-small cell lung cancer. Although an argument can be made for definitive chemoradiation for N2/3 mediastinal nodal disease, the role of a nonsurgical strategy is less clear in patients with cT3N1M0 stage IIIA given a lack of randomized data. We sought to determine the outcomes of patients with cT3N1M0 by treatment type from the National Cancer Database. METHODS The National Cancer Database (2004-2014) was queried for patients with cT3N1M0 non-small cell lung cancer, known treatment modalities, and sequence. Comparisons between groups were performed using Mann-Whitney and chi-square tests. Cox regression was performed to identify predictors of overall survival. Propensity score matching analysis was performed to compare overall survival in surgery versus definitive chemoradiation. RESULTS We identified 1937 patients undergoing surgery (1518 up-front and 419 after neoadjuvant treatment) and 1844 patients undergoing definitive chemoradiation. Among patients undergoing surgery without prior treatment, 19% were overstaged and were found to have pN0, whereas 9.6% had pN2/3. Median overall survival was 33.1 months in the surgery group (± adjuvant/neoadjuvant) versus 18 months in definitive chemoradiation. To compare outcomes in balanced groups, we propensity matched 1081 pairs of patients. Median overall survival was 31.1 months in the surgery group compared with 19.1 months in the definitive chemoradiation group (P < .001). By multivariable analysis, surgery (hazard ratio, 0.65; confidence interval, 0.59-0.73), female sex (hazard ratio, 0.88; confidence interval, 0.79-0.98), age (hazard ratio, 1.02; confidence interval, 1.01-1.03), squamous histology (hazard ratio, 1.22; confidence interval, 1.07-1.38), and Charlson score of 2 (hazard ratio, 1.31; confidence interval, 1.11-1.54) were predictors of survival. CONCLUSIONS In the National Cancer Database, approximately half of patients with clinical T3N1M0 were treated with definitive chemoradiation rather than surgery. This practice should be avoided in operable patients, because surgical resection is associated with better survival.
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Affiliation(s)
- Mohamed Rahouma
- Cardiothoracic Department, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY; Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohamed Kamel
- Cardiothoracic Department, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY; Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Abu Nasar
- Cardiothoracic Department, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Sebron Harrison
- Cardiothoracic Department, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Benjamin Lee
- Cardiothoracic Department, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Jeffrey Port
- Cardiothoracic Department, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Nasser Altorki
- Cardiothoracic Department, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Brendon M Stiles
- Cardiothoracic Department, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY.
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10
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Jiang DM, Chung P, Kulkarni GS, Sridhar SS. Trimodality Therapy for Muscle-Invasive Bladder Cancer: Recent Advances and Unanswered Questions. Curr Oncol Rep 2020; 22:14. [PMID: 32008105 DOI: 10.1007/s11912-020-0880-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW Bladder-sparing trimodality therapy (TMT) has become an accepted alternative to cystectomy for selected muscle invasive bladder cancer (MIBC) patients unfit for cystectomy or opting for bladder preservation. This review will summarize recent advances in TMT for MIBC. RECENT FINDINGS A growing body of literature has emerged which supports the use of TMT. However, its delivery is yet to be standardized. The role of chemotherapy and predictive biomarkers remain to be elucidated. Novel bladder-sparing approaches, drug combinations including immunotherapy and targeted therapies are under investigation in clinical trials, with the goal of ultimately enhancing survival and quality of life outcomes. Recent advances in TMT have made bladder preservation possible for MIBC patients seeking an alternative local therapy to cystectomy. With careful patient selection, TMT offers comparable survival outcomes to cystectomy, and improved quality of life as patients are able to successfully retain their bladder.
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Affiliation(s)
- Di Maria Jiang
- Department of Medicine, Division of Medical Oncology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Canada, 700 University Avenue, Toronto, ON, Canada
| | - Peter Chung
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, University of Toronto, Canada, 700 University Ave, Toronto, ON, Canada
| | - Girish S Kulkarni
- Departments of Surgery and Surgical Oncology, Division of Urology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Canada, 6-824, 700 University Avenue, Toronto, ON, Canada
| | - Srikala S Sridhar
- Department of Medicine, Division of Medical Oncology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Canada, 700 University Avenue, Toronto, ON, Canada.
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11
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Solanki AA, Liauw SL. The perils of using registry data to compare the survival and cost of radical cystectomy and trimodality therapy in bladder cancer. Transl Androl Urol 2019; 8:S533-S537. [PMID: 32042640 DOI: 10.21037/tau.2019.12.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
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12
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Xu X, Zhang G, He L, Zhu Y. Clinicopathological impacts of c-Met overexpression in bladder cancer: evidence from 1,336 cases. Onco Targets Ther 2019; 12:2695-2702. [PMID: 31114223 PMCID: PMC6497828 DOI: 10.2147/ott.s197540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 02/19/2019] [Indexed: 12/13/2022] Open
Abstract
Background: The clinicopathological impacts of c-Met overexpression in bladder cancer have been investigated in several studies with conflicting results. We performed this systematic review and meta-analysis to assess the pathologic and prognostic roles of c-Met status in bladder cancer patients. Methods: Eligible studies were searched and identified from the PubMed and China National Knowledge Infrastructure (CNKI) databases (up until October 4, 2018). The DerSimonian-Laird random-effects model was used to calculate the pooled risk estimates. Results: Eight studies including 1,336 bladder cancer cases were eventually included in this meta-analysis. We detected a significantly increased risk of poor overall survival (OS) associated with the high expression of c-Met (HR=2.42, 95% CI 1.36-4.32). There was no association between c-Met status and nuclear grade (OR=0.82, 95% CI 0.29-2.31) or tumor stage (OR=1.42, 95% CI 0.41-4.89). Conclusion: This study shows that the overexpression of c-Met in primary cancer tissues is associated with a worse OS in human bladder cancer. However, larger studies using standardized methods and criteria are warranted to verify these findings.
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Affiliation(s)
- Xin Xu
- Department of Urology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang, People's Republic of China
| | - Guanjun Zhang
- Department of Urology, Hospital of Traditional Chinese Medicine of Shangyu, Shangyu 312300, Zhejiang, People's Republic of China
| | - Liujia He
- Department of Urology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang, People's Republic of China
| | - Yi Zhu
- Department of Urology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang, People's Republic of China
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13
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Abstract
PURPOSE OF REVIEW This review examines both trimodality therapy (TMT) in the definitive management of bladder cancer as well as the use of adjuvant radiotherapy for bladder cancer with a specific focus on publications from the last 2 years. RECENT FINDINGS TMT is an effective management strategy for muscle invasive bladder cancer with outcomes similar to radical cystectomy. Effectiveness of this strategy exists in variant histologies and can be personalized with use of biomarkers. There is a role for adjuvant radiotherapy in locally advanced bladder cancer, especially in the age of improved imaging and modern radiotherapy techniques. SUMMARY This review should provide the reader data necessary to support use of TMT and adjuvant radiation therapy in their clinic.
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Affiliation(s)
- Anthony Pham
- Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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14
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Lin HY, Ye H, Kernen KM, Hafron JM, Krauss DJ. National Cancer Database Comparison of Radical Cystectomy vs Chemoradiotherapy for Muscle-Invasive Bladder Cancer: Implications of Using Clinical vs Pathologic Staging. Cancer Med 2018; 7:5370-5381. [PMID: 30306728 PMCID: PMC6247074 DOI: 10.1002/cam4.1684] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 06/25/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To 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/METHODS A 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. RESULTS Patients 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). CONCLUSIONS Patients 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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Affiliation(s)
- Hong-Yiou Lin
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Hong Ye
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Kenneth M Kernen
- Michigan Institute of Urology and Beaumont Health, Troy, Michigan
| | - Jason M Hafron
- Michigan Institute of Urology and Beaumont Health, Troy, Michigan
| | - Daniel J Krauss
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
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