Predicting survival after radical cystectomy for bladder cancer

Accurate prediction is essential for patient counselling, appropriate selection of treatments and determination of eligibility for clinical trials. In this review we assess the available determinants of oncological outcome after radical cystectomy (RC) for transitional cell carcinoma of the urinary bladder. We reviewed previous publications to provide guidelines in terms of criteria, limitations and clinical value of available tools for predicting patient outcome after RC. Our findings suggest that while individual surgical, patient and pathological features provide useful estimates of survival outcome, the inherent heterogeneity of tumour biology and patient characteristics leads to significant variation in outcome. By incorporating all relevant continuous predictive factors for individual patients, integrative predictive models, such as nomograms or artificial neural networks, provide more accurate predictions and generally surpass clinical experts at predicting outcomes. Nonetheless, there is a clear need for the development and validation of molecular biomarkers and their incorporation into multivariable predictive tools. Significant progress has been made in identifying important molecular markers of disease and the development of multifactorial tools for predicting the outcome after RC.     

Stage-specific impact of pelvic lymph node dissection on survival in patients with non-metastatic bladder cancer treated with radical cystectomy

Study Type – Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? In patients treated with radical cystectomy, pelvic lymph node dissection may have a beneficial effect on cancer control outcomes. We examined the effect of pelvic lymph node dissection on stage‐specific cancer control outcomes.

OBJECTIVE

• ? To examine the effect of stage‐specific pelvic lymph node dissection (PLND) on cancer‐specific (CSM) and overall mortality (OM) rates at radical cystectomy (RC) for bladder cancer.

METHODS

• ? Overall, 11 183 patients were treated with RC within the Surveillance, Epidemiology, and End Results database.
• ? Univariable and multivariable Cox regression analyses tested the effect of PLND on CSM and OM rates, after stratifying according to pathological tumour stage.

RESULTS

• ? Overall, PLND was omitted in 25% of patients, and in 50, 35, 27, 16 and 23% of patients with respectively pTa/is, pT1, pT2, pT3 and pT4 disease (P < 0.001).
• ? For the same stages, the 10‐year CSM‐free rates for patients undergoing PLND compared with those with no PLND were, respectively, 80 vs 71.9% (P = 0.02), 81.7 vs 70.0% (P < 0.001), 71.5 vs 56.1% (P = 0.001), 43.7 vs 38.8% (P = 0.006), and 35.1 vs 32.0% (P = 0.1).
• ? In multivariable analyses, PLND omission was associated with a higher CSM in patients with pTa/is, pT1 and pT2 disease (all P ≤ 0.01), but failed to achieve independent predictor status in patients with pT3 and pT4 disease (both P ≥ 0.05).
• ? Omitting PLND predisposed to a higher OM across all tumour stages (all P ≤ 0.03).

CONCLUSIONS

• ? Our results indicate that PLND was more frequently omitted in patients with organ‐confined disease.
• ? The beneficial effect of PLND on cancer control outcomes was more evident in these patients than in those with pT3 or pT4 disease.
• ? PLND at RC should always be considered, regardless of tumour stage.

     

Palliative care use among bladder cancer patients treated with radical cystectomy

IntroductionPractice guidelines recommend early consideration for palliative care for patients with advanced malignancies, and there has been limited research regarding the use of palliative care for patients with advanced bladder cancer. Our aim is to describe the rate and determinants of the use of palliative care consultation for patients treated with radical cystectomy at our institution.MethodsA retrospective review was performed to identify patients who underwent cystectomy for bladder cancer between September 2014 and June 2019 at our institution. Our primary outcome was receipt of palliative care, defined as receiving a palliative care consult. We tested for associations between factors and our outcome of interest, and then estimated the impact on various determinants of palliative care use by fitting a multivariable logistic regression model.ResultsOver the study period, 294 patients underwent radical cystectomy. Of those patients, 29 (9.9%) received palliative care. Mean time from surgery to palliative care consult was 11.4 months. Palliative care consults were initiated by urologists in 32.1% of cases. On multivariable analysis, patients were more likely to receive palliative care if they had pT3+ disease (P < 0.001), were readmitted after surgery (P = 0.028), or had any major complication after surgery (P = 0.025).ConclusionRates of palliative care consults in patients with advanced bladder cancer at our institution are higher than other population-based estimates nationally. The majority of palliative care consults were requested by medical oncologists, highlighting an opportunity for educational initiatives for urologic oncologists to promote earlier consideration of palliative care referrals.     

Racial disparity in quality of care and overall survival among black vs. white patients with muscle-invasive bladder cancer treated with radical cystectomy: A national cancer database analysis

Objectives

To examine the impact of race on quality of care and overall survival (OS) among patients with muscle invasive bladder cancer (MIBC) treated with radical cystectomy (RC) in the U.S.

miR-527在膀胱癌中的表达及对膀胱根治性切除术后生存状况的预测

目的:分析miR-527在膀胱癌中的表达及对膀胱根治性切除术后生存状况的预测。方法:收集2017年3月至2018年4月在上海中医药大学附属上海市中西医结合医院接受手术治疗的75例膀胱癌患者的膀胱癌组织和相应的癌旁正常膀胱组织,采用qRT-PCR法检测癌旁组织及癌组织中miR-527的表达水平,分析miR-527表达情况...     

Factors influencing post-recurrence survival in bladder cancer following radical cystectomy

Study Type – Prognosis (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Tumour recurrence following radical cystectomy for bladder cancer generally heralds a grave prognosis. Post‐cystectomy recurrences usually occur within the first 2–3 years, and most patients die within 15 months of recurrence. However, few patients have a more prolonged survival following recurrence. Several studies have identified factors prognostic for bladder cancer recurrence and survival following cystectomy. However, the role of clinicopathological variables in determining patient outcome following bladder cancer recurrence is hitherto undocumented. This is the first retrospective single‐institution study to analyze factors that influence prognosis following bladder cancer soft‐tissue recurrence after radical cystectomy. The investigation identified pathologic stage, lymph node density, type of urinary diversion, time to recurrence after surgery, site of recurrence, and administration of post‐recurrence chemotherapy as independent predictors of post‐recurrence survival. The findings call attention to the importance of pathological assessment at cystectomy, diligent surveillance and post‐recurrence management in ensuring optimal patient outcome following recurrence. It also emphasizes the aggressive nature of invasive bladder cancer when traditional treatment strategies fail.

OBJECTIVE

• ? To identify prognostic indicators that influence post‐recurrence survival following radical cystectomy for bladder cancer.

PATIENTS AND METHODS

• ? In all, 2029 patients with bladder cancer underwent radical cystectomy with intent to cure between 1971 and 2005 at our institution. Of these, 447 patients (22%) developed non‐urinary tract recurrence and were chosen for further analysis.
• ? Clinicopathological characteristics were analysed by univariate and multivariate analysis to identify factors prognostic for post‐recurrence survival.

RESULTS

• ? Median time to recurrence was 13.21 months and median post‐recurrence overall survival was 5.59 months.
• ? Pathological stage (P < 0.001), intravesical therapy (P= 0.035), tumour upstaging (P < 0.001), lymph node density (P < 0.001) and recurrence site (P= 0.017) were associated with time to recurrence.
• ? Age (P= 0.042), type of urinary diversion (P < 0.014), surgical margin status (P= 0.049), pathological stage (P < 0.001), lymph node density (P < 0.001), time to recurrence (P < 0.001), recurrence site (P < 0.001) and post‐recurrence chemotherapy administration (P < 0.001) were univariately prognostic for post‐recurrence overall survival.
• ? Multivariate analysis confirmed the associations of pathological stage, type of urinary diversion, lymph node density, time to recurrence after cystectomy, site of recurrence and post‐recurrence chemotherapy administration with outcome following bladder cancer recurrence.
• ? Median post‐recurrence survival with either local or distant recurrence was 7.95 months and 5.95 months, respectively, whereas patients with both local and distant recurrences had median post‐recurrence survival of 3.98 months.

CONCLUSIONS

• ? Bladder cancer recurrence forebodes poor prognosis, with 6 months' median survival following recurrence. Advanced pathological stage, positive surgical margins, high lymph node density and early recurrence portends poorer outcome.
• ? Although patients with local recurrence have a slightly better prognosis, those with disease recurrence at local and distant sites perform very poorly; nearly 97% of all patients with recurrence eventually succumb to the disease.
• ? Chemotherapy administration following recurrence may improve survival, although further studies are needed to exclude selection bias.

     

Risk groups in bladder cancer patients treated with radical cystectomy

Objective

To stratify patients with bladder cancer into homogeneous risk groups according to statistically significant differences found in PFS (progression-free survival). To identify those patients at increased risk of progression and to provide oncological follow-up according to patient risk group.

Materials and Methods

A retrospective study of 563 patients treated with radical cystectomy (RC). In order to determine which factors might predict bladder tumour progression and death, uni- and multivariate analyses were performed. The risk groups were identified according to “inter-category” differences found in PFS and lack of differences, thus revealing intra-category homogeneity.

Results

Median follow up time was 37.8 months. Recurrence occurred in a total of 219 patients (38, 9%). In 63% of cases this was distant recurrence. Only two variables retained independent prognostic value in the multivariate analysis for PFS: pathological organ confinement and lymph node involvement. By combining these two variables, we created a new “risk group” variable. In this second model it was found that the new variable behaved as an independent predictor associated with PFS.Four risk groups were identified: very low, low, intermediate and high risk:• Very low risk: pT0 N0• Low risk: pTa, pTis, pT1, pT2 and pN0• Intermediate risk: pT3 and pN0• High risk: pT4 N0 or pN1-3.

Conclusions

We retrospectively identified 4 risk groups with an independent prognostic value for progression-free survival following RC. Differences in recurrence patterns after RC between risk groups have led us to set different intervals in monitoring for cancer.     

Effect of preoperative delay on survival in patients with bladder cancer undergoing cystectomy in Quebec: a population based study

PURPOSE: In Canada there is growing concern that waiting time for cancer surgery has been increasing. We used population based data to estimate the average PD for RC in Quebec and assess whether delayed surgery has a negative impact on long-term survival. MATERIALS AND METHODS: We used the provincial billing database of the maladie du Quebec to identify all patients with bladder cancer 18 years or older who underwent RAMQ from 1990 to 2002. PD was calculated as the time elapsed between the most recent transurethral resection and the date of RC. Patients were categorized according to PD tertiles into 3 groups, namely 1) 20 or less, 2) 21 to 47 and (C) 48 days or greater. Cox proportional hazards models were used to assess the effect of PD on overall survival, while adjusting for patient and provider factors. RESULTS: During the study period 1,592 radical cystectomies were performed. Overall median PD was 33 days (95% CI 30 to 35). Median PD increased from 23 days in 1990 to 50 in 2002. After adjusting for calendar year, and patient and provider variables there were no significant differences in survival among the 3 delay categories. However, patients subject to greater than 12 weeks of delay were at 20% greater risk for dying (95% CI 1.0 to 1.5, p = 0.051). CONCLUSIONS: In line with previous reports PD greater than 12 weeks seems to be associated with a worse long-term prognosis.     

Late oncological occurrences following radical cystectomy in patients with bladder cancer

PURPOSE: To evaluate the prognoses and predictive factors of late oncological occurrences and its impact on follow-up strategy in patients with bladder tumours treated with radical cystectomy. MATERIALS AND METHODS: Late oncological occurrences were considered when they took place after three years from cystectomy or when early recurrence was controlled with therapy and patients developed recurrence again after a three-year disease-free interval. Univariate and multivariate analysis of predictive factors for late oncological occurrences were carried out on 215 patients at risk of late oncological recurrences. RESULTS: Among 357 patients treated with cystectomy, 163 (45.6%) relapsed, 149 (41.7%) of them as early recurrence and 17 (4.7%) were considered as late oncological events. This incidence increased up to 8% when patients at risk were considered. Three patients with early recurrence reached a complete response after treatment and relapsed again as late recurrences. Distant metastases and local recurrence represented 78.5% of early recurrence as opposed to 11.7% in late oncological occurrences, whereas, extravesical urothelium recurrences represented 8.6% and 70% respectively (p<0.01). Among patients with late oncological occurrences, nine (53%) were disease-free, seven with urothelial recurrence and two of three with lymph-node recurrence whereas only eight (5.6%) patients with early recurrence were free of tumour (p<0.0001). Multiple tumours, prostate involvement and organ-confined tumours in cystectomy specimen were the independent variables for predicting late oncological occurrences in multivariate analysis. CONCLUSIONS: Recurrences in the remaining urothelium prevail as the pattern of late oncological occurrences. The prognosis of these events is significantly better than an early recurrence. Patients at risk of late oncological occurrences are those with multiple tumours, prostate involvement and with organ-confined tumours in cystectomy specimen. After three years from cystectomy, the follow-up schedule of these patients be limited to performing an annual CT-scan and urinary cytology to detect essentially upper urinary tract recurrence and extrapelvic lymph-nodal recurrence. Afterwards an annual intravenous urography might replace to CT-scan since lymph-nodal involvement was not detected.     

The relationship between perioperative blood transfusion and overall mortality in patients undergoing radical cystectomy for bladder cancer

ObjectivesThe relationship between perioperative blood transfusion (PBT) and oncologic outcomes is controversial. In patients undergoing surgery for colon cancer and several other solid malignancies, PBT has been associated with an increased risk of mortality. Yet, the urologic literature has a paucity of data addressing this topic. We sought to evaluate whether PBT affects overall survival following radical cystectomy (RC) for patients with bladder cancer.MethodsThe medical records of 777 consecutive patients undergoing RC for urothelial carcinoma of the bladder were reviewed. PBT was defined as transfusion of red blood cells during RC or within the postoperative hospitalization. The primary outcome was overall survival. Clinical and pathologic variables were compared using χ² tests, and Cox multivariate survival analyses were performed.ResultsA total of 323 patients (41.6%) underwent PBT. In the univariate analysis, PBT was associated with increased overall mortality (HR 1.40, 95% CI 1.11–1.78). Additionally, an independent association was demonstrated in a non-transformed Cox regression model (HR, 95% CI 1.01–1.36) but not in a model utilizing restricted cubic splines (HR 1.03, 95% CI 0.77–1.38). The c-index was 0.78 for the first model and 0.79 for the second.ConclusionsIn a traditional multivariate model, mirroring those that have been applied to this question in the general surgery literature, we demonstrated an association between PBT and overall mortality after RC. However, this relationship is not observed in a second statistical model. Given the complex nature of adequately controlling for confounding factors in studies of PBT, a prospective study will be necessary to fully elucidate the independent risks associated with PBT.