The outcome of elderly patients with advanced urothelial carcinoma after platinum-based combination chemotherapy

Age related trends in the utilization of neoadjuvant chemotherapy for muscle invasive bladder cancer

PURPOSE

The current standard of care for muscle invasive bladder cancer (MIBC) is neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC). Previous research has shown under-utilization of NAC for treatment of MIBC, especially among the elderly. Our aim was to stratify NAC use by decade of life and analyze trends in use over time along with recording pathologic downstaging and perioperative outcomes.

MATERIALS AND METHODS

The National Cancer Database was queried for patients with cT2-4NanyM0 MIBC treated with RC from 2010 to 2016 with urothelial carcinoma. Nineteen thousand nine hundred fifty seven patients met criteria for analysis. We retrospectively analyzed trends in use of NAC, readmission rate, mortality rate, and pathologic downstaging with NAC all stratified by decade of life.

RESULTS

Of the 19,957 patients treated with RC for MIBC, only 30.9% underwent NAC. There was a statistically significant increase in NAC use across all age groups from 2010 to 2016. Receipt of NAC was associated with decreased age on univariate analysis (P < 0.001) and on logistic regression (OR: 0.617 for age 70-79, OR: 0.221 for age ≥80 vs. age <60; P < 0.001). Patients receiving NAC were more likely to exhibit pathologic downstaging at time of RC (OR: 3.907; P < 0.001), and this trend held for each age group examined. Among patients receiving NAC, the risk of 30 and 90-day mortality was associated with increasing age; however, age was not associated with 30-day readmission for those receiving NAC.

CONCLUSION

Rates of NAC use prior to RC have increased among all age groups with the lowest utilization rate among the elderly. NAC use was associated with greater pathologic downstaging in all age groups. These data show a promising trend in the uptake of the gold standard for treatment of MIBC; however, the underlying etiology of differing rates of NAC utilization remains to be determined.

Overall Survival of Patients Receiving Cisplatin or Carboplatin for Primary Metastatic Urothelial Carcinoma of the Bladder: A Contemporary Dutch Nationwide Cohort Study

BACKGROUND

Cisplatin is preferred to carboplatin when treating metastatic urothelial carcinoma of the bladder (mUCB), despite its greater toxicity. Randomised studies underpinning this have been performed in noncontemporary populations with limitations in sample sizes and analyses, affecting their validity in current clinical practice.

OBJECTIVE

To estimate overall survival (OS) and assess the benefit of cisplatin-based regimens over carboplatin-based regimens in a contemporary cohort of patients with mUCB.

DESIGN, SETTING, AND PARTICIPANTS

A nationwide retrospective cohort study was conducted in patients diagnosed with de novo mUCB in the Netherlands between 2016 and 2019, who underwent first-line treatment with cisplatin- or carboplatin-based chemotherapy, based on the data from the Netherlands Cancer Registry.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A propensity model for receiving cisplatin-based chemotherapy based on age, sex, age-adjusted Charlson Comorbidity Index, renal function, performance status, serum haemoglobin, and the presence of visceral and bone metastases was used to produce inverse probability weighting (IPW) per patient. Unadjusted and IPW-adjusted Kaplan-Meier OS curves of both chemotherapy groups were compared by restricted mean survival time (RMST).

RESULTS AND LIMITATIONS

Of the 1041 patients with mUCB, 359 received either cisplatin (n = 170; 47%) or carboplatin (n = 189; 53%) as first line. The cisplatin group was younger, had fewer comorbidities, and had better performance status and renal function. The median OS in the cisplatin and carboplatin groups was 13.1 and 11.5 mo, respectively. After IPW adjustment, prognostic factors were balanced between the two chemotherapy groups (standardised differences <0.1), and differences in RMST were <2.0 mo and not statistically significant up to 24 mo.

CONCLUSIONS

After accounting for all known prognostic factors, we found no significant survival benefit for cisplatin over carboplatin as first-line chemotherapy in mUCB.

PATIENT SUMMARY

In this study, we compared the survival benefits of cisplatin- and carboplatin-based chemotherapy for patients with metastatic bladder cancer.

Contemporary analysis of the effect of marital status on survival in upper tract urothelial carcinoma patients treated with radical nephroureterectomy: A population-based study

PURPOSE

Unmarried status is an established risk factor for worse cancer control outcomes in various malignancies. Moreover, several investigators observed worse outcomes in unmarried males, but not in females. This concept has not been tested in upper tract urothelial carcinoma and represents the topic of the study.

METHODS

Within Surveillance, Epidemiology and End Results database (2004-2016), we identified 8833 non-metastatic upper tract urothelial carcinoma patients treated with radical nephroureterectomy (5208 males vs. 3625 females). Kaplan Meier plots and multivariable Cox regression models predicting overall mortality, other-cause mortality and cancer-specific mortality were used.

RESULTS

Overall, 1323 males (25.4%) and 1986 females (54.8%) were unmarried. Except for lower rates of chemotherapy in unmarried males (15.6 vs. 19.6%, P = 0.001) and unmarried females (13.8 vs. 23.6%, P < 0.001), no clinically meaningful differences were recorded between males and females. In multivariable Cox regression models, unmarried status was an independent predictor of higher overall mortality in both males (Hazard ratio [HR]: 1.33, 95% confidence interval [CI]: 1.19-1.48, P < 0.001) and females (HR: 1.13, 95%CI: 1.00-1.27, P = 0.04), as well as of higher other-cause mortality in both males (HR: 1.53, 95%CI: 1.26-1.84,P < 0.001) and females (HR: 1.43, 95%CI: 1.15-1.78,P < 0.01). However, higher cancer-specific mortality was only recorded in unmarried males (HR: 1.24, 95%CI: 1.08-1.42, P < 0.01), but not in females (HR: 1.02, 95%CI: 0.89-1.17, P = 0.7).

CONCLUSION

Unmarried status is a marker of worse survival in both males and females and should be flagged as an important risk factor at diagnosis, in both sexes. In consequence, unmarried patients represent candidate for interventions aimed at decreasing the survival gap relative to married counterparts.

Benefit of Adjuvant Chemotherapy After Radical Cystectomy for Treatment of Urothelial Carcinoma of the Bladder in the Elderly -An International Multicenter Study

BACKGROUND

Radical cystectomy (RC) is the standard treatment for muscle invasive bladder cancer, but approximately half of all patients will ultimately succumb to disease progression despite apparent cure with extirpative surgery. Elderly patients are at especially high risk of advanced disease and may benefit from perioperative systemic therapy.

OBJECTIVE

To assess the real-world benefit of adjuvant chemotherapy (AC) in patients ≥75 years old.

METHODS

We retrospectively reviewed patients who underwent RC for non-metastatic urothelial carcinoma of the bladder (UCB) from 12 participating international medical institutions. Kaplan-Meier survival curves and Cox regression models were used to assess the association between age groups, administration of AC and oncological outcome parameters such as recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS).

RESULTS

4,335 patients were included in the analyses, of which 820 (18.9%) were ≥75 years old. These elderly patients had a higher rate of adverse pathologic features. In an univariable subgroup analysis in patients ≥75 years with lymph node metastasis, 5-year OS was significantly higher in patients who had received AC (41% vs. 30.9%, p = 0.02). In a multivariable Cox model that was adjusted for several established outcome predictors, there was a significant favorable association between the administration of AC in elderly patients and OS, but no RFS or CSS.

CONCLUSIONS

In this large observational study, the administration of AC was associated with improved OS, but not RFS or CSS, in elderly patients treated with RC for UCB. This is of clinical importance, as elderly patients are more likely to have adverse pathologic features and experience worse survival outcomes. Treatment of UCB should include both a multidisciplinary approach and a geriatric evaluation to identify patients who are most likely to tolerate and benefit from AC.

Incidence and Survival Rates of Contemporary Patients with Invasive Upper Tract Urothelial Carcinoma

BACKGROUND

Contemporary incidence and mortality rates of upper tract urothelial carcinoma (UTUC) are unavailable.

OBJECTIVE

To describe contemporary UTUC incidence and mortality rates in the USA.

DESIGN, SETTING, AND PARTICIPANTS

Within the Surveillance, Epidemiology and End Results (SEER) database (2004-2016), we identified 13 075 UTUC patients. Of all, 9208 (70.4%) harbored nonmetastatic UTUC and were treated with radical nephroureterectomy versus 1174 (9.0%) who harbored metastatic UTUC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Age-standardized incidence rates per 100 000 person years were calculated. Kaplan-Meier curves and multivariable Cox regression models addressed cancer-specific and overall mortality.

RESULTS AND LIMITATIONS

Overall UTUC age-standardized incidence rates decreased from 1.3 to 1.1 cases per 100 000 person years (average annual percentage change: -1.32%, p = 0.002). Moreover, age-standardized incidence rates decreased for T_1-2N₀M₀ (average annual percentage change: -2.77%, p < 0.001) but increased for T_1-4N_0-2M₁ stage (average annual percentage change: +2.87%, p < 0.01). In nonmetastatic UTUC treated with radical nephroureterectomy, stage, grade, age, and sex (p < 0.001) were independent predictors in multivariable Cox regression models focusing on cancer-specific mortality. In metastatic UTUC, chemotherapy administration, radical nephroureterectomy treatment, and ureteral primary were independent predictors of lower overall mortality in multivariable Cox regression models.

CONCLUSIONS

Although overall incidence of UTUC decreased, the incidence of metastatic UTUC increased over the study period. The majority of nonmetastatic UTUC harbored T₁N₀M₀ stage. However, T₃N₀M₀, T₄N₀M₀, and T_1-4N_1-2M₀ stages, respectively, affected 28.9%, 4.6%, and 10.0% of all incident cases. In metastatic UTUC, both chemotherapy and radical nephroureterectomy use exerted an important protective effect on overall mortality, and ureteral primaries exhibited more favorable survival.

PATIENT SUMMARY

From 2004 to 2016, the incidence of upper tract urothelial carcinoma decreased in the USA. However, more advanced stages are on the rise.

Trends in utilization of neoadjuvant and adjuvant chemotherapy for muscle invasive bladder cancer

Purpose

Previous studies have noted increased utilization of perioperative chemotherapy over time. The goal of this study was to determine trends in perioperative chemotherapy use within a contemporary population.

Materials and Methods

The National Cancer Database was queried for patients diagnosed with cT2-4N0M0 urothelial muscle invasive bladder cancer from 2011 to 2015 and underwent subsequent radical cystectomy. We retrospectively analyzed factors associated with perioperative chemotherapy and evaluated overall treatment trends in the use of neoadjuvant and adjuvant chemotherapy. Linear regression, logistic regression, Cox regression, and Kaplan–Meier analysis were performed.

Results

In total, 7,101 patients met inclusion criteria for analysis. The use of perioperative chemotherapy increased from 46.4% in 2011 to 57.2% in 2015 (p=0.003). Neoadjuvant chemotherapy use increased from 22.9% to 32.3% (p=0.007) over the time period analyzed, while adjuvant chemotherapy use experienced no significant change (23.5% to 24.9%, p=0.182). Logistic regression demonstrated that increased age and Charlson Comorbidity Index were predictors of not receiving chemotherapy (p<0.05), while those with increasing T stage, income above $48,000, and insurance other than Medicaid or Medicare were more likely to receive perioperative chemotherapy (p<0.05). Kaplan–Meier analysis revealed patients receiving neoadjuvant chemotherapy had the best 5-year overall survival at 48.3% compared to adjuvant chemotherapy (42.6%) or no chemotherapy (37.8%) (p<0.001).

Conclusions

The increasing use of perioperative chemotherapy noted in prior studies has continued through 2015. Neoadjuvant chemotherapy appears to drive this increase while adjuvant chemotherapy utilization remains unchanged. Clinical and socioeconomic factors affect utilization of perioperative chemotherapy.

The utilization status of neoadjuvant chemotherapy in muscle-invasive bladder cancer: a systematic review and meta-analysis

INTRODUCTION

To give a comprehensive depiction of the utilization status of neoadjuvant chemotherapy (NAC) in muscle invasive bladder cancer (MIBC) worldwide.

EVIDENCE ACQUISITION

Potential relevant research papers of Pubmed, Embase, Web of Science, and the Cochrane Library were reviewed to identify eligible studies. Primary outcomes of this meta-analysis were utilization rate of NAC and its utility distribution in different genders, races, ages, countries and temporal trends. The utilization rates of NAC were calculated as 'Proportion (s)' with 95% confidence intervals (CIs) and pooled estimates were calculated by using a random-effect model.

EVIDENCE SYNTHESIS

A total of thirteen studies and 35,738 patients were included. The total proportion of NAC applied in MIBC populations prior to radical cystectomy (RC) was 17.2% (95% CI: 12.5-21.9%, I²=99.7%). The comparative analyses showed there were no significant differences existing in different genders or races on NAC utilization rates. In terms of age distribution, <60 age group conferred higher utilization rate of NAC than the older (OR=1.919, 95% CI: 1.671-2.202, P=0.0001). As for regional distribution, our meta-analysis showed that Japan (Proportion: 44.0%, 95% CI: 6.5-81.5%, I²=99.6%) and Sweden (37.9%, 95% CI: 34.9-40.8%) were the top two leading countries which contributed to the most frequent application of NAC. In respect of pathologic responses after NAC, complete, partial and down-staged pathologic responses were achieved in 16.6% (95% CI: 7.4-25.9%, I²=89.7%), 14.6% (95% CI: 0.8-28.5%, I²=89.7%) and 45.0% (95% CI: 17.8-72.2%, I²=98.8%) patients, respectively.

CONCLUSIONS

The present study shows the low utilization rate of NAC in MIBC patients. Standardization of the treatment modality of MIBC and promotion of guidelines might be necessary to expedite the adoption of NAC in near future.

Comparative Study of the Safety and Efficacy of First-Line Cisplatin and Carboplatin Chemotherapy in Elderly Patients with Metastatic Urothelial Carcinoma

OBJECTIVES

Platinum-based chemotherapy is the standard treatment for metastatic urothelial carcinoma (mUC). However, considering elderly patients often experience comorbidities and frailty, the utility of cisplatin-based chemotherapy for elderly patients is still debatable. We conducted this study to compare the safety and efficacy of carboplatin and cisplatin in elderly patients with mUC.

METHODS

This retrospective study enrolled elderly patients with mUC (defined as aged ≥70 years) who underwent first-line platinum-based chemotherapy between September 2001 and October 2018. The primary endpoints were chemotherapy-related adverse events (AEs), including treatment-related hospitalization or death. The secondary outcomes were overall survival (OS) and progression-free survival calculated by Kaplan-Meier analysis.

RESULTS

In total, 108 elderly patients with mUC were enrolled and allocated into the cisplatin or carboplatin group. Patients treated with carboplatin-based chemotherapy had a significantly higher incidence of all grade ≥3 AEs (78.8 vs. 50.0%, p = 0.008) than those on cisplatin. AE-related hospitalization (47.5 vs. 19.1%, p = 0.002) and treatment-related death (17.5 vs. 4.4%, p = 0.02) were significantly increased in the carboplatin group. In the univariate analysis, the median OS in the cisplatin group was significantly increased compared with the carboplatin group (13.6 vs. 7.2 months, p = 0.045). The Cox multivariate regression model indicated that leukocytosis (HR 3.17, 95% CI 1.84-5.46, p < 0.001) and anemia (HR 2.02, 95% CI 1.11-3.65, p = 0.02) were independent prognostic factors.

CONCLUSION

Elderly patients with mUC treated with cisplatin-based chemotherapy had better survival and safety profiles than those treated with carboplatin. Age itself was not a crucial factor in determining cisplatin eligibility.

Real-World Effectiveness of Chemotherapy in Elderly Patients With Metastatic Bladder Cancer in the United States

Background

Outcomes for patients with metastatic bladder cancer (mBC) are generally poor and progressively worse following first-line (1L) chemotherapy.

Objective

To evaluate treatment patterns, survival outcomes, and characteristics of a large, real-world US population of elderly patients with advanced mBC receiving 1L and second-line (2L) treatment retrospectively.

Methods

We identified patients with advanced mBC (aged ≥66 years)-newly diagnosed between January 1, 2004, and December 31, 2011-in the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program-Medicare linked database and assessed their palliative systemic chemotherapy treatments and survival outcomes.

Results

Of 1703 eligible patients, 42% received 1L chemotherapy; 1L-treated patients tended to be younger and healthier than nontreated patients. Only 27% of 1L-treated patients received cisplatin-based chemotherapy, most commonly cisplatin-gemcitabine. Cisplatin-treated patients were younger and had fewer comorbidities than non-cisplatin-treated patients. Thirty-five percent of 1L-treated patients subsequently received 2L chemotherapy. Patients received a variety of 2L agents as combination chemotherapy (52%) or single-agent chemotherapy (39%). Median overall survival durations in 1L-treated and 2L-treated patients were 8.5 and 7.9 months, respectively.

Conclusions

Results from this retrospective SEER-Medicare database analysis underscore the historical inadequacies of 1L and 2L treatments in elderly patients with advanced mBC. Few patients were treated with 1L chemotherapy, a minority of whom received 1L cisplatin-based chemotherapy, and even fewer received 2L chemotherapy. These findings highlight the disconnect between 1L treatment in clinical trials and treatment in the real-world setting and the lack of standard approaches to 2L treatment in the United States.

Early chemotherapy discontinuation and mortality in older patients with metastatic bladder cancer: The AGEVIM multicenter cohort study

PURPOSE

Median age for the diagnosis of metastatic bladder cancer (MBC) is 73 years. The feasibility of chemotherapy in older patients is controversial. Our objectives were to assess associations linking age to first line chemotherapy regimen selection, early chemotherapy discontinuation, and 1-year mortality in everyday practice.

MATERIALS AND METHODS

Between 1999 and 2011, 197 consecutive patients aged≥70 years with MBC referred to 4 hospitals were included in the AGEVIM multicenter cohort. At baseline, we recorded performance status (PS); tumor characteristics; the Charlson Comorbidity Index; and plasma creatinine, hemoglobin, and albumin. Early discontinuation data were available for 193 patients, and overall 1-year mortality for 180 patients. We assessed the probabilities of initial cisplatin-based combination chemotherapy (CCC), early discontinuation (≤2 cycles), and 1-year mortality, using multivariate logistic regression and Cox proportional hazards modeling.

RESULTS

Among the 193 patients (mean age: 76±4.3y), with 2 metastatic site in median 43.5% received CCC, 36.3% gemcitabine and carboplatin, and 20.2% gemcitabine alone. The probability of CCC decreased with age independently from sex, PS, creatinine clearance, and Charlson Comorbidity Index (P<0.0001), early discontinuation occurred in 24.9% of patients. Factors independently associated with global chemotherapy early discontinuation were age (adjusted odds ratio_{per additional year} = 1.11; 95% CI: 1.02-1.20; P = 0.01) and higher metastatic-site number (adjusted odds ratio_{per additional site} = 1.45; 95% CI: 1.08-1.95; P = 0.01). The number of patients was too small for a robust analysis of factors associated with early chemotherapy discontinuation in each chemotherapy regiment subgroup. Independent predictors of 1-year mortality (median = 9.6 mo) were early discontinuation (adjusted hazard ratio [aHR] = 4.77 [2.85-7.96] when PS<2 and 20.6 [9.43-44.82] when PS≥2; P<0.0001), albumin<35g/l (aHR = 3.06 [1.81-5.17], P = 0.0001), creatinine clearance<30ml/min (aHR = 2.96 [1.45-6.06], P = 0.009), and higher metastatic-site number (aHR = 1.34 [1.14-1.56], P<0.0001).

CONCLUSION

Less than half of older patients with MBC received initial CCC and 25% had≤2 cycles of chemotherapy. Older age was associated with decreased CCC prescription, independently from known contraindications, and with global chemotherapy early discontinuation, but not with 1-year mortality.

Preoperative Anemia and Low Hemoglobin Level Are Associated With Worse Clinical Outcomes in Patients With Bladder Cancer Undergoing Radical Cystectomy: A Meta-Analysis

PURPOSE

The aim of this study was to determine the effect of preoperative anemia status and hemoglobin level on clinical outcomes in patients with bladder cancer undergoing radical cystectomy.

MATERIALS AND METHODS

A systematic review of literature with meta-analyses of predefined outcomes based on a search of PubMed and EMBASE was performed. Hazard ratios (HRs) measuring the association between preoperative anemia/hemoglobin and all-cause mortality, cancer-specific mortality, and disease recurrence were calculated with random effects model. Study heterogeneities were quantified by I² tests. Publication bias was assessed with funnel plots.

RESULTS

A total of 17 studies evaluating the impact of preoperative anemia status (categorical, 11 studies) and hemoglobin level (continuous, 7 studies) on clinical outcomes were included. The cutoff value of anemia varied among studies (10.5-13.5 g/dL for male, 10.5-13.4 g/dL for female). Meta-analyses showed that compared with non-anemia, anemia was associated with increased all-cause mortality (HR, 1.75; 95% confidence interval [CI], 1.48-2.05; P < .00001; I² = 30%), cancer-specific mortality (HR, 1.80; 95% CI, 1.45-2.25; P < .00001; I² = 26%), and disease recurrence (HR, 1.37; 95% CI, 1.16-1.62; P = .0002; I² = 9%). Meta-analyses showed that higher level of hemoglobin was associated with decreased all-cause mortality (HR, 0.90; 95% CI, 0.87-0.92; P < .00001; I² = 13%), cancer-specific mortality (HR, 0.90; 95% CI, 0.85-0.95; P = .0003; I² = 61%), and disease recurrence (HR, 0.95; 95% CI, 0.91-0.99; P = .01; I² = 53%). No obvious publication bias was observed.

CONCLUSIONS

Preoperative anemia and low hemoglobin level are associated with earlier recurrence and shorter survival of patients with bladder cancer undergoing radical cystectomy. However, well-designed prospective studies with large sample size and limited confounding factors are needed to confirm and update our findings.

Suboptimal use of neoadjuvant chemotherapy in radical cystectomy patients: A population-based study

INTRODUCTION

We aimed to assess contemporary rates of neoadjuvant chemotherapy (NC) use.

METHODS

We relied on the Surveillance, Epidemiology and End Results (SEER)-Medicare database for non-metastatic, muscle-invasive (T2-T4a) urothelial carcinoma of the urinary bladder (UCUB) patients who underwent radical cystectomy (RC) between 1991 and 2009. Multivariable logistic regression analyses tested predictors of NC use, such as: T-stage, N-stage, year of diagnosis, age at diagnosis, gender, race, use of radiotherapy (RT), marital status, urban status, socioeconomic status, tumour grade, and Charlson comorbidity index (CCI).

RESULTS

Overall, 5207 patients treated with RC were identified. Of those, 332 (6.4%) received NC. The rate of NC increased over time from 6.1% (1991) to 15.0% (2009) (p<0.001). In multivariable analyses, year of diagnosis (odds ratio [OR]: 4.7; p<0.001), lower T-stage (T3 vs. T2: OR: 0.7; p=0.003), married status (OR: 1.5; p=0.006), and younger age at diagnosis (≥80 vs. 66-69: OR: 0.6; p=0.006) were associated with a higher odds of NC; all represented independent predictors of NC use. Neither race nor CCI demonstrated statistical significance.

CONCLUSIONS

We reported lower than anticipated overall (6.4%) use of NC. Nonetheless, the rate increased from 6.1% (1991) to 15.0% (2009). Older and unmarried individuals were less likely to receive NC. NC rates were higher in T2 UCUB patients. Some of the observed discrepancies, such as lower use in unmarried individuals, may require correction. Better adherence to guidelines should be encouraged and implemented, especially based on the confirmed benefits of NC according to randomized, controlled trials. The study is limited by a retrospective design and limited variables.

Outcome of patients with nonmetastatic muscle-invasive bladder cancer not undergoing cystectomy after treatment with noncisplatin-based chemotherapy and/or radiotherapy: a retrospective analysis

Transurethral resection of bladder tumor (TURBT), radiotherapy, chemotherapy, or combinations can be used in patients with muscle-invasive bladder cancer (MIBC) not undergoing cystectomy. Nevertheless, unfitness for cystectomy is frequently associated with unfitness for other therapeutic modalities. We report the outcome of patients with MIBC who did not undergo cystectomy and did not receive cisplatin-based chemotherapy. Selection criteria for the study were nonmetastatic MIBC, no cystectomy, no cisplatin-based chemotherapy. Chemotherapy and/or radiotherapy should have been used aside from TURBT. Forty-nine patients (median age 79), managed between April 2001 and January 2012, were included in this analysis. Median Charlson Comorbidity Index was 5, while 76% were unfit for cisplatin. Treatment included radiotherapy (n = 7), carboplatin-based chemotherapy (n = 25), carboplatin-based chemotherapy followed by radiotherapy (n = 10), and radiochemotherapy (n = 7). Five-year event-free rate was 26% (standard error [SE] = 7) for overall survival, 23% (SE = 7) for progression-free survival, and 30 (SE = 8) for cancer-specific survival (CSS). Patients who were treated with combination of radiotherapy and chemotherapy had significantly longer CSS compared to those treated with radiotherapy or chemotherapy only (5-year CSS rate: 16% [SE 8] vs. 63% [SE 15], P = 0.053). Unfit-for-cystectomy patients frequently receive suboptimal nonsurgical treatment. Their outcome was poor. Combining chemotherapy with radiotherapy produced better outcomes and should be prospectively evaluated.

Management of muscle-invasive bladder cancer in the elderly

PURPOSE OF REVIEW

The number of cases of muscle-invasive bladder cancer is increasing along with the age of the population. Management of muscle-invasive bladder cancer in the elderly is complex, requiring a multidisciplinary team approach and a comprehensive assessment of each individual patient.

RECENT FINDINGS

A geriatric assessment should be used to inform treatment decisions in elderly patients with bladder cancer. There is increasing evidence to support aggressive therapy in appropriate elderly patients, including radical cystectomy and neoadjuvant chemotherapy. Adjuvant chemotherapy also has a role in patients with high-risk disease after cystectomy. A bladder preservation approach with trimodality therapy is a well tolerated and effective alternative to cystectomy in appropriately selected patients.

SUMMARY

Treatment decisions should not be based on chronologic age alone and advanced age should not preclude aggressive or curative therapy. The recent molecular characterization of bladder cancer and several recent immunotherapy trials provide hope of a more targeted approach to treatment of bladder, potentially improving both effectiveness and tolerability of treatment regimens in the elderly.

Young Cervical Cancer Patients May Be More Responsive than Older Patients to Neoadjuvant Chemotherapy Followed by Radical Surgery

Objective

To evaluate the effects of age and the clinical response to neoadjuvant chemotherapy (NACT) in patients with cervical cancer who received neoadjuvant chemotherapy followed by radical surgery.

Methods

A total of 1,014 patients with advanced cervical cancer who received NACT followed by radical surgery were retrospectively selected. Patients were divided into young (aged ≤35 years, n = 177) and older (aged >35 years, n = 837) groups. We compared the short-term responses and survival rates between the groups. The five-year disease-free survival (DFS) and overall survival (OS) rates were stratified by age, NACT response, and FIGO stage.

Results

The overall response rate was 86.8% in the young group and 80.9% in the older group. The young patients had an earlier FIGO stage (P<0.001), a higher rate of adenocarcinoma (P = 0.022), and more lymph node metastasis (P = 0.033) than the older patients. The presence of adenocarcinoma as the histological type (P = 0.024) and positive lymph node metastasis (P<0.001) were identified as independent risk factors for survival. When stratified by age and clinical response, young patients with no response to NACT had a worse clinicopathological condition compared with the other subgroups. Compared with non-responders, responders to NACT had a higher five-year DFS rate (80.1% versus 71.8%; P = 0.019) and OS rate (82.6% versus 71.8%; P = 0.003) among the young patients but not among the older patients.

Conclusions

Responders to NACT aged 35 years or younger benefitted the most from NACT, while the young non-responders benefitted the least. Age might represent an important factor to consider when performing NACT in patients with cervical cancer.

Muscle-invasive urothelial bladder cancer: an update on systemic therapy

Urothelial carcinoma is a common malignancy that carries a poor prognosis when the disease includes muscle invasion. Metastatic urothelial carcinoma is almost uniformly fatal. The evidence behind treatment options in the neoadjuvant, adjuvant and metastatic settings are discussed in this manuscript, with a focused review of standard and investigational cytotoxic, targeted, and immunotherapy approaches. We have focused especially on neoadjuvant cisplatin-based therapy (supported by level one evidence) and on novel immunotherapy agents such as checkpoint inhibitors, which have shown great promise in early clinical studies.

Treatment of muscle invasive bladder cancer in the elderly: navigating the trade-offs of risk and benefit

PURPOSE

Despite the fact that bladder cancer patients have the highest median age of any type of cancer, older patients with muscle invasion are often under-treated.

METHODS

In this review, we report the most up to date literature on the patterns of care and treatment of older patients with muscle invasive bladder cancer. Data on under-treatment, geriatric principles, cystectomy, perioperative chemotherapy, and bladder preservation for older patients are presented and analyzed.

CONCLUSION

Chronologic age should not exclude patients from curative-intent therapy. Functional age as determined by geriatric assessments and multidisciplinary evaluation can help clinicians decide on the best course of treatment for individual patients. Cystectomy, perioperative chemotherapy, and curative-intent bladder preservation are reasonable options in healthy older adults. Observation should be limited to patients with extremely poor performance status and very limited life expectancy.

Contemporary Systemic Therapy for Urologic Malignancies in Geriatric Patients

Current data on systemic therapy in geriatric populations with genitourinary malignancies are largely derived from retrospective analyses of prospectively conducted trials or retrospective reviews. Although extrapolation of these data to real-world patients should be cautious, patients aged 65 years or older with good functional status and minimal comorbidities seem to enjoy similar survival benefit from therapy as their younger counterparts. Chronologic age alone should generally not be used to guide management decisions. Comprehensive geriatric assessment tools and prospective studies in older adults integrating comprehensive geriatric assessment can shed light on the optimal management of urologic malignancies in this population.

Utilization of Systemic Chemotherapy in Advanced Urothelial Cancer: A Retrospective Collaborative Study by the Hellenic Genitourinary Cancer Group (HGUCG)

BACKGROUND

Advanced urothelial cancer (AUCa) is associated with poor long-term survival. Two major concerns are related to nonexposure to cisplatin-based chemotherapy and poor outcome after relapse. Our purpose was to record patterns of practice in AUCa in Greece, focusing on first-line treatment and management of relapsed disease.

METHODS

Patients with AUCa treated from 2011 to 2013 were included in the analysis. Fitness for cisplatin was assessed by recently established criteria.

RESULTS

Of 327 patients treated with first-line chemotherapy, 179 (55%) did not receive cisplatin. Criteria for unfitness for cisplatin were: Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥ 2, 21%; creatinine clearance ≤ 60 mL/min, 55%; hearing impairment, 8%; neuropathy, 1%; and cardiac failure, 5%. Forty-six patients (27%) did not fulfill any criterion for unfitness for cisplatin. The main reasons for these deviations were comorbidities (28%) and advanced age (32%). Seventy-four (68%) of 109 patients who experienced a relapse received second-line chemotherapy. The most frequent reason for not offering second-line chemotherapy was poor PS or limited life expectancy (66%).

CONCLUSION

In line with international data, approximately 50% of Greek patients with AUCa do not receive cisplatin-based chemotherapy, although 27% of them were suitable for such treatment. In addition, about one third of patients with relapse did not receive second-line chemotherapy because of poor PS or short life expectancy. Enforcing criteria for fitness for cisplatin and earlier diagnosis of relapse represent 2 targets for improvement in current treatment practice for AUCa.

Prognostic and predictive factors in patients treated with chemotherapy for advanced urothelial cancer: where do we stand?

The standard of care for patients with local advanced or metastatic urothelial carcinoma is chemotherapy. However, results with this are rather disappointing, and validated prognostic factors and biomarkers of tumor response, which are useful in the decision-making process, are still lacking. PubMed databases were searched for articles published until November 2013. Several promising clinical and biological candidate prognostic factors or markers of tumor response to first- or second-line therapy, such as hemoglobin, performance status, visceral metastasis and ERCC1, hENT1 and EMT markers, have been identified and described in this article. In summary, clinical parameters and molecular profiling could revolutionize the management of local advanced or metastatic urothelial cancer, but an improvement in individualized therapeutic approaches still seems distant.

Predictors of referral for neoadjuvant chemotherapy prior to radical cystectomy for muscle-invasive bladder cancer and changes in practice over time

INTRODUCTION

In patients with non-metastatic muscle-invasive bladder cancer (MIBC) fit for curative therapy, a multidisciplinary approach consisting is recommended. This approach includes local treatment (usually radical cystectomy), ideally combined with neoadjuvant chemotherapy (NACT). Despite a survival benefit with NACT, uptake remains low. We assessed NACT consultation in Alberta and examined associative factors, as well as the relationship to survival.

METHODS

Patients with MIBC were identified through the Alberta Cancer Registry. Demographic and clinicopathologic information was collected from electronic medical records between 2007 and 2011. In addition to descriptive statistics, logistic regression was used to determine factors associated with receiving NACT consultation. Overall survival was described using a Kaplan-Meier estimate.

RESULTS

Of the 315 radical cystectomy patients, 140 (45.1%, 95% confidence interval [CI] 39.5, 50.8) received NACT consultation. Patients ≥80 years (odds ratio [OR] 0.21, 95% CI 0.08, 0.57, p = 0.002) and those treated in Calgary (OR 0.11, 95% CI 0.05, 0.25, p < 0.001) were less likely to receive NACT consultation. The rate of NACT consultation increased steadily from 2007 to 2011 (OR 1.23, 95% CI 1.04, 1.45 per year of diagnosis, p = 0.018). After a median follow-up of 28.1 months (range: 14.6-50.3), median survival was 54.7 months for patients who received NACT consultation versus 31.2 months for those who did not (p = 0.030).

CONCLUSIONS

NACT consultation in patients with MIBC undergoing radical cystectomy has improved over time; however, regional differences underscore the need for a standardized approach to NACT consultation, including common referral mechanisms.

Trends in the use of perioperative chemotherapy for localized and locally advanced muscle-invasive bladder cancer: a sign of changing tides

BACKGROUND

Despite the documented survival benefit conferred by neoadjuvant (NAC) and adjuvant chemotherapy (AC), there has been a slow adoption of guideline recommendations for the use of perioperative chemotherapy (POC) in patients with muscle-invasive bladder cancer (MIBC).

OBJECTIVE

To evaluate temporal trends in POC utilization and identify factors influencing POC delivery in a representative cohort of patients with MIBC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study identifying factors associated with receipt of POC and evaluating temporal changes in NAC and AC utilization. We included patients from the National Cancer Data Base (NCDB) with no prior malignancy who ultimately underwent radical cystectomy for ≥ cT2/cN0/cM0 MIBC between 2006 and 2010.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relationships between demographic and hospital factors and the likelihood of receiving POC were evaluated using Pearson chi-square and Wilcoxon rank-sum tests, and multivariable logistic regression. Temporal changes in NAC and AC use were detected using a linear test of trend.

RESULTS AND LIMITATIONS

A total of 5692 patients met our inclusion criteria. POC use increased from 29.5% in 2006 to 39.8% in 2010 (p < 0.001). NAC use increased from 10.1% in 2006 to 20.8% in 2010 (p = 0.005); AC remained stable between 18.1% and 21.3% (p = 0.68). Multivariable modeling revealed advanced age, increasing comorbidity, lack of insurance, increased travel distance, geographic location outside the northeastern United States, and lower income as negatively associated with POC receipt (all p < 0.05). Limitations include retrospective design and potential sampling bias, excluding patients treated at non-NCDB facilities.

CONCLUSIONS

POC use for MIBC increased from 2006 to 2010, with this increase disproportionately due to rising NAC utilization. Nonetheless, there is persistent variation in the likelihood of receiving POC secondary to nonclinical factors.

PATIENT SUMMARY

When retrospectively analyzing a representative cohort of patients undergoing radical cystectomy for muscle-invasive bladder cancer between 2006 and 2010, we noted that preoperative chemotherapy rates increased steadily while use of chemotherapy after surgery remained stable. Factors related to access to care significantly influenced receipt of chemotherapy.

EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines

CONTEXT

The European Association of Urology (EAU) guidelines panel on Muscle-invasive and Metastatic bladder cancer (BCa) updates its guidelines yearly. This updated summary provides a synthesis of the 2013 guidelines document, with emphasis on the latest developments.

OBJECTIVE

To provide graded recommendations on the diagnosis and treatment of patients with muscle-invasive BCa (MIBC), linked to a level of evidence.

EVIDENCE ACQUISITION

For each section of the guidelines, comprehensive literature searches covering the past 10 yr in several databases were conducted, scanned, reviewed, and discussed both within the panel and with external experts. The final results are reflected in the recommendations provided.

EVIDENCE SYNTHESIS

Smoking and work-related carcinogens remain the most important risk factors for BCa. Computed tomography (CT) and magnetic resonance imaging can be used for staging, although CT is preferred for pulmonary evaluation. Open radical cystectomy with an extended lymph node dissection (LND) remains the treatment of choice for treatment failures in non-MIBC and T2-T4aN0M0 BCa. For well-informed, well-selected, and compliant patients, however, multimodality treatment could be offered as an alternative, especially if cystectomy is not an option. Comorbidity, not age, should be used when deciding on radical cystectomy. Patients should be encouraged to actively participate in the decision-making process, and a continent urinary diversion should be offered to all patients unless there are specific contraindications. For fit patients, cisplatinum-based neoadjuvant chemotherapy should always be discussed, since it improves overall survival. For patients with metastatic disease, cisplatin-containing combination chemotherapy is recommended. For unfit patients, carboplatin combination chemotherapy or single agents can be used.

CONCLUSIONS

This 2013 EAU Muscle-invasive and Metastatic BCa guidelines updated summary aims to increase the quality of care and outcome for patients with muscle-invasive or metastatic BCa.

PATIENT SUMMARY

In this paper we update the EAU guidelines on Muscle-invasive and Metastatic bladder cancer. We recommend that chemotherapy be administered before radical treatment and that bladder removal be the standard of care for disease confined to the bladder.

Calcaneal acrometastasis from urothelial carcinoma of the ureter: a case report and literature review

Purpose

Ureteral cancer is a rare entity. Typical symptoms are painless hematuria as well as flank pain. Bone metastasis of ureteral cancer can occur in nearby bone structures, such as the spine, pelvis, and hip bone. Distal bone metastasis, such as that in the calcaneus bone, however, is rare.

Case report

An 82-year-old woman presented to the orthopedic clinic at the university hospital with a 3-month history of left heel pain. A magnetic resonance imaging (MRI) of her foot demonstrated a calcaneal lytic lesion. A biopsy of the lytic lesion showed urothelial carcinoma with squamous differentiation. A computed tomography (CT) scan of the abdomen and pelvis showed left hydronephrosis and an obstructive mass in the left ureter, at the iliac crossing. The patient received combined therapy that included local radiation, bisphosphonate, and chemotherapy, with complete resolution of her cancer-related symptoms. However, she eventually died from the progressive disease, 20 months after the initial diagnosis.

Conclusion

This case highlights the rare presentation of ureter cancer with an initial presentation of foot pain, secondary to calcaneal metastasis. Multimodality therapy provides effective palliation of symptoms and improved quality of life. We also reviewed the literature and discuss the clinical benefits of multidisciplinary cancer care in elderly patients.

Cisplatin-based combination chemotherapy in septuagenarians with metastatic urothelial cancer

PURPOSE

Cisplatin-based chemotherapy is standard first-line treatment for metastatic urothelial carcinoma. However, cisplatin is frequently avoided in elderly patients due to concerns regarding toxicities. We analyzed the efficacy, and tolerability, of cisplatin-based chemotherapy in elderly patients.

METHODS

Individual patient data were pooled from 8 phase II and III trials evaluating cisplatin-based first-line chemotherapy in patients with metastatic urothelial carcinoma. Adverse events, treatment delivery, response proportions, and survival outcomes were compared between patients aged<70 vs. ≥ 70 years.

RESULTS

Of the 543 patients included, 162 patients (30%) were ≥ 70 years old. The majority (93%) of elderly patients were aged 70 to 79 years. There was no significant difference in the proportions of patients experiencing Grade 3 to 4 renal failure, febrile neutropenia, or treatment-related death between younger and older patient cohorts. The median survival of the patients ≥ 70 years was 12.1 months compared to 12.8 months for patients<70 years (P = 0.91). There was no significant difference in survival between age groups when controlling for baseline performance status or the presence of visceral metastases or both.

CONCLUSIONS

Fit septuagenarians, with adequate renal function, tolerate cisplatin-based chemotherapy similarly to their younger counterparts and achieve comparable clinical outcomes.

Patterns of use of systemic chemotherapy for Medicare beneficiaries with urothelial bladder cancer

OBJECTIVES

Examine the association between clinical, demographic, and socioeconomic factors and the receipt of systemic chemotherapy for bladder cancer. Examine factors influencing the use of combination chemotherapy plus cystectomy and use of specific chemotherapy drugs over time for bladder cancer.

MATERIALS AND METHODS

Data from the SEER-Medicare database were analyzed for patients diagnosed with urothelial carcinoma of the bladder between 1992 and 2002. Cox proportional hazards regression analyses were used to assess differences in use of systemic chemotherapy based on demographic and clinical factors, site of care, and year of diagnosis. We assessed the proportion of patients who received chemotherapy in the adjuvant and neoadjuvant settings as well as use of chemotherapy in the monotherapy setting. We estimated the proportion of claims made for several commonly used chemotherapy agents in the outpatient setting by year.

RESULTS

During follow-up, 13%, 28%, 37%, and 57% of patients with stages 1 through 4, respectively, received systemic chemotherapy for bladder cancer. Chemotherapy use in the neoadjuvant or adjuvant settings within 6 months of diagnosis was not commonly found. Neoadjuvant chemotherapy was delivered to 1.4% of stage 2 patients and 11% of stage 4 patients. In 2003, the most frequent claims for intravenous chemotherapy were for gemcitabine, carboplatin, and placlitaxel.

CONCLUSIONS

Chemotherapy was not generally used as recommended for persons with invasive bladder cancer in this patient population. Studies to clarify potential underutilization and variation in patterns of administration are warranted.

Biweekly carboplatin/gemcitabine in patients with advanced urothelial cancer who are unfit for cisplatin-based chemotherapy: report of efficacy, quality of life and geriatric assessment

OBJECTIVE

We evaluated safety and efficacy of first-line gemcitabine/carboplatin in unfit-for-cisplatin patients with advanced urothelial carcinoma and the effect on the quality of life and functional status of elderly patients (aged >70).

METHODS

Unfit patients had ECOG performance status (PS) > or =2, creatinine clearance <50 ml/min or comorbidities precluding cisplatin administration. Carboplatin at area under the curve of 2.5 and gemcitabine 1,250 mg/m(2) were administered biweekly. Elderly patients were stratified into group 1 (no activities of daily living (ADL) or instrumental ADL dependency and no comorbidities), group 2 (instrumental ADL dependency or 1-2 comorbidities) and group 3 (ADL dependency or > or =2 comorbidities).

RESULTS

Thirty-four patients were enrolled: 68% had PS 2-3, 69% a creatinine clearance <50 ml/min and 65% had 1 or more comorbidities. There were 3 cases of grade 3 toxicity (9%). Response rate was 24% [95% confidence interval (CI) 11-41]. Median follow-up was 8 months, median progression-free survival 4.4 months (95% CI 1.03-7.75) and median overall survival 9.8 months (95% CI 4.7-14.9). Patients in geriatric assessment groups 1 and 2 had a significantly longer median progression-free survival compared to group 3 [6.9 months (95% CI 1.3-12.4) vs. 1.9 months (95% CI 0.5-3.2); p = 0.005].

CONCLUSION

First-line gemcitabine/carboplatin combination is active in unfit-for-cisplatin patients with advanced urothelial carcinoma. Pretreatment quality of life and geriatric assessment may be useful in selecting patients likely to benefit from this treatment.

New developments in first- and second-line chemotherapy for transitional cell, squamous cell and adenocarcinoma of the bladder

PURPOSE OF REVIEW

To review the systemic treatment, patient selection and treatment outcome of transitional cell carcinoma of the urinary bladder, squamous cell carcinoma and adenocarcinoma, focusing on advances and findings within the last year.

RECENT FINDINGS

Cisplatin-based chemotherapy is considered to be the standard treatment for transitional cell carcinoma. In recent updates of randomized trials, patients with favorable prognostic factors were shown to have a chance of long-term disease-free survival even after chemotherapy for metastatic disease. Patient selection for cisplatin, newer drugs or alternative combinations is crucial. New genetic markers like excision repair cross-complementing 1 expression were developed and tested for this purpose. Adequate evaluation of renal function plays an important role for treatment selection, especially in the elderly population. Newer chemotherapeutics like oxaliplatin, vinflunine and pemetrexed have been studied in the first- or second-line settings. Their efficacy is promising, but there is still a need for further testing. Only few data are available on the systemic treatment of squamous cell carcinoma and adenocarcinoma. Complete resection seems to be more important than chemotherapy in the rare cases of adenocarcinoma of the urinary tract.

SUMMARY

In locally advanced and metastatic disease patient- and tumor-related prognostic factors and predictive factors for response to treatment will guide treatment decisions in the future.

[Systemic oncological treatment of bladder cancer]

M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) and Cisplatin/Gemzar are potent therapies in the treatment of advanced bladder cancer. C/G provides similar efficacy in terms of overall survival compared with M-VAC, but does so with a superior safety profile. Therefore C/G is widely accepted as standard of care in locally advanced and metastatic bladder cancer. Despite potentially curative surgery almost half of the patients with muscle-invasive bladder cancer will have recurrence of disease. Based on a recent meta-analysis with data from 3005 patients, and 2 randomised studies, neoadjuvant cisplatin-containing therapy has shown to improve overall survival. Thus, the use of neoadjuvant systemic treatment should be considered state-of-the-art. The question whether adjuvant treatment will improve the outcome is still not sufficiently answered.

The impact of age in the outcome of patients with advanced or recurrent cervical cancer after platinum-based chemotherapy

OBJECTIVES

Cervical cancer is a disease of middle-aged and elderly but still there are young women diagnosed with advanced disease that is incurable with local treatment and is treated with platinum-based combination chemotherapy. It is unknown whether these young patients have a poorer outcome compared to older patients or whether elderly patients have inferior outcome than younger patients when treated with combination chemotherapy.

METHODS

We compared the outcome between young (<35), elderly (>70) and middle-aged (35-70) women who were treated with platinum-based combination chemotherapy for advanced, recurrent or persistent disease.

RESULTS

Two hundred and eighteen patients were included in our database. The baseline clinical and disease characteristics were not different between age groups but anemia and thrombocytosis were more frequent in younger patients. Median survival for all patients was 13.4 (95%CI 11-15.8) months while survival of patients<35 years of age was 9 months (95% CI 5.8-12), of patients older than 70 was 10 months (95% CI 6.9-13) of patients 35 to 70 years of age was 14.5 months (95% CI 11-18) (p=0.004). Multiple factors were significant for survival in univariate analysis but only weight loss, pain score and relapse inside an irradiated filed were significant predictors of outcome in multivariate analysis.

CONCLUSIONS

Very young (<35) and elderly (>70) patients have a worse prognosis after treatment with combination chemotherapy for advanced or recurrent cervical cancer. Nevertheless, this difference is not significant when adjusted for other prognostic factors.

Defining Optimal Therapy for Muscle Invasive Bladder Cancer

PURPOSE

We defined an optimal curative strategy for muscle invasive bladder cancer and to determine how best to deliver curative therapy.

MATERIALS AND METHODS

We reviewed published reports from 1985 to 2006 dealing with the treatment of muscle invasive (stage T2-T4a) bladder cancer. We analyzed all cohort, phase II and randomized phase III studies providing level 1 to 3 evidence impacting survival.

RESULTS

Cisplatin based chemotherapy combined with high quality radical cystectomy and complete pelvic lymph node dissection improves survival over that of cystectomy alone. Surgery quality is an important predictor of survival even in patients receiving chemotherapy. Neoadjuvant chemotherapy is favored over adjuvant chemotherapy because it is better tolerated and more patients are able to receive effective therapy before rather than after surgery.

CONCLUSIONS

Neoadjuvant chemotherapy followed by radical cystectomy and complete pelvic lymph node dissection is the optimal curative strategy in most patients presenting with muscle invasive bladder cancer.

Chemotherapy practices and perspectives in invasive bladder cancer

Bladder cancer is the fifth most common cancer in adult patients. Two-thirds of patients have superficial tumors and their treatment is conservative. Nevertheless, 30% of superficial tumors become infiltrative and represent a third of tumors at initial diagnosis. Overall mortality from bladder cancer is 30%. Important molecular events may explain the carcinogenesis and evolution of these tumors. Infiltrating bladder cancers are currently treated by radical cystectomy. Neoadjuvant chemotherapy has demonstrated a positive impact on patients' outcomes before cystectomy. Adjuvant chemotherapy after cystectomy is currently being studied in an international randomized trial. Patients with advanced disease are treated by chemotherapy with palliative intentions. Two regimens are standard: the combination of methotrexate, vinblastine, adriamycin and cisplatin, and the combination of gemcitabine and cisplatin. The addition of paclitaxel to the latter regimen is the subject of ongoing study. Only a few patients have long-term nonevolutive disease. Research must be focused on the combination of chemotherapy and targeted drugs directed through gene methylation, cytokine-receptor activation and signaling pathways.

Systemic chemotherapy in locally advanced and/or metastatic bladder cancer

Transitional cell carcinoma of the bladder is a common malignancy. Advanced urothelial cancer is a chemosenstive neoplasm. Whereas the MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) regimen was long-considered the standard of care for patients with advanced disease, the evaluation of newer agents with retained activity and improved tolerability has been the focus of much investigation over the past decade. Combinations such as cisplatin-gemcitabine (GC) and intensified, G-CSF supported MVAC have shown more favourable toxicity profile and equal or even improved efficacy. Specific groups of patients (elderly, patients with renal dysfunction or poor performance status or co-morbidities) who cannot tolerate cisplatin-based therapy, should receive carboplatin, gemcitabine or taxane-based treatment. Continuing improvements in our understanding of the molecular phenotype of individual patient tumors may lead to the appropriate therapies that target molecular aberrations unique to this malignancy. This review will summarize recent developments in the management of locally advanced (T4b, N 2-3) and/or metastatic (M1) bladder cancer.

Formulas calculating creatinine clearance are inadequate for determining eligibility for Cisplatin-based chemotherapy in bladder cancer

PURPOSE

Efficacy of formulas calculating creatinine clearance (CrCl) to determine renal function eligibility (CrCl > 60 mL/min) for cisplatin-based chemotherapy has not been examined adequately in the bladder cancer population. We hypothesize these formulas may underestimate measured CrCl, and therefore the eligibility for cisplatin-based chemotherapy.

PATIENTS AND METHODS

A database of 208 patients with unresectable or metastatic bladder cancer treated on protocol at Memorial Sloan-Kettering Cancer Center (New York, NY) with cisplatin-based chemotherapy between 1983 and 1994 was examined retrospectively. The association between measured and calculated CrCl and the ability to complete three cycles (minimum therapeutic) of chemotherapy was examined.

RESULTS

Baseline measured CrCl was less than 60 mL/min in 16% compared with 12% to 44% using various formulas. Concordance between calculated and measured CrCl less than 60 mL/min was poor (range of kappa, 0.14 to 0.38). In patients older than age 65, 22% had a measured CrCl less than 60 mL/min, compared with 10% to 63% calculated using various formulas. Overall, 80% completed at least three cycles of cisplatin-based chemotherapy. The ability to complete at least three cycles was statistically significantly related with a measured CrCl more than 60 mL/min (P = .02), but not with calculated CrCl more than 60 mL/min.

CONCLUSION

Current formulas estimating CrCl tend to underestimate measured CrCl, especially in those older than 65 years. Depending on the formula used, up to 44% who actually received cisplatin-based chemotherapy based on measured CrCl would be deemed ineligible at present, potentially affecting survival outcomes. Methodology for determining CrCl and/or renal eligibility for cisplatin-based chemotherapy in patients with bladder cancer should be re-examined.