ASCO GU 2018: A Decision-Support Tool to Assist Muscle-Invasive Bladder Cancer Patients Choosing Between Radical Cystectomy and Chemoradiotherapy

San Francisco, CA ( Patients with high-risk muscle-invasive bladder cancer (MIBC) who are borderline medically operable for radical cystectomy (RC) face a difficult decision between RC which has higher short-term treatment-related morbidity/mortality & chemoradiotherapy (CRT) which is better tolerated in the short-term but may have worse long-term cancer control outcomes. To date, there are no existing decision support tools to assist patients & providers in understanding these trade-offs. Therefore, the authors developed a visualization tool to inform patients & providers how the relative risks & benefits of RC & CRT vary over time with respect to overall survival (OS).


The authors identified cT2-3 N0 M0 urothelial bladder cancer patients ≥65 y/o treated with RC +/- chemo (n = 5981) or definitive-dose CRT after TURBT (n = 793) in the National Cancer Database, 2003-2011. The database was split into a development & validation cohort. Multivariable Cox regression with time-varying covariates was performed to assess pre-treatment factors associated with overall survival (OS). The inverse probability of treatment weighting method using propensity score was employed to reduce selection bias. External validation was performed. Visualization tool showing adjusted survival curves based on pre-op patient features was generated with input from patients & a multidisciplinary expert panel. This tool calculates median OS & the “break-even point,” where the short-term OS disadvantage of RC equals the long-term advantage of RC (i.e. the point where the restricted mean survival for RC & CRT are equal).


On multivariable analysis, significant predictors of OS were age, Charlson comorbidity index, & cT stage (p < 0.001 for all). Using these results, the authors developed a web application that utilizes clinical inputs to generate patient-specific survival curves that display estimated OS differences over time. Median OS, the break-even point, & percent alive at the break-even point are provided.


The authors report on the first decision-support tool developed to assist high-risk borderline operable MIBC patients & their providers in understanding the short-term & long-term trade-offs between RC & CRT. 

Presented by: Brian Christopher Baumann, MD

Co Authors:  Wei-Ting Hwang, Sharadha Srinivasan, Xingmei Wang, Ronac Mamtani, David J. Vaughn, Leilei Xia, S. Bruce Malkowicz, Thomas J. Guzzo, John Paul Christodouleas; Washington University in St. Louis, St. Louis, MO; University of Pennsylvania, Philadelphia, PA

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 American Society of Clinical Oncology Genitourinary (ASCO GU) Cancers Symposium, February 8-10, 2018 - San Francisco, CA