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.