AUA 2017: Comparative Effectiveness of Trimodal Therapy Versus Radical Cystectomy for Localized Muscle-Invasive Urothelial Carcinoma of the Bladder

Boston, MA ( Dr. Seisen and colleagues presented their findings comparing effectiveness of trimodal therapy (TMT) versus radical cystectomy (RC) for localized muscle-invasive bladder cancer (MIBC) [1] at this afternoon’s 2017 AUA Annual meeting invasive bladder cancer podium session. Trimodal therapy includes complete transurethral resection of bladder tumor, followed by concomitant radiotherapy and chemotherapy. Clearly bladder preservation is desirable; a recent study found that on propensity score matching analysis, there was no difference in survival outcomes among patients undergoing either TMT or RC for MIBC [2], however this has not been assessed at the population level.

The authors used the National Cancer Database from 2004-2011 to identify 1,257 (9.8%) and 11,586 (90.2%) patients receiving TMT and RC, respectively. IPTW-adjusted Kaplan-Meier curves showed that median OS was similar between TMT (40 months, 95%CI 34-46) and RC groups (43 months, 95%CI 41-45, p=0.29). In IPTW-adjusted Cox regression analysis with time-varying covariate, TMT was associated with a significant adverse effect on OS after 25 months of follow-up (HR.1.37, 95%CI 1.16-1.59). On exploratory analysis, the adverse treatment effect of TMT decreased significantly with age (HR 0.99, 95%CI 0.98-0.99), suggesting that TMT may be best utilized in elderly patients. There was no difference between TMT and RC when considering sex, Charlson Comorbidity Index, or cT-stage. The strengths of the study include the rigorous methodology applied to this population level data and the long-term follow-up available. Limitations include the fact that strict TMT criteria are difficult to determine in population level data, and the actual indication for TMT is not specified and may be used in sick patients unsuitable for RC.

In conclusion, TMT was associated with worse long-term OS compared to RC for MIBC, however selected subgroups may be reasonable candidates for TMT. Ultimately, in the absence of randomized controlled trials, we will rely on methodologically advanced observational studies to help guide treatment decisions.

1) Seisen T, Sun M, Lipsitz SR, et al. Comparative effectiveness of trimodal therapy versus radical cystectomy for localized muscle-invasive urothelial carcinoma of the bladder. Eur Urol 2017 [Epub ahead of print].
2) Kulkarni GS, Hermanns T, Wei Y, et al. Propensity score analysis of radical cystectomy versus bladder-sparing trimodal therapy in the setting of a multidisciplinary bladder cancer clinic. J Clin Oncol 2017 [Epub ahead of print].

Speaker: Thomas Seisen, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, USA

Co-Authors: Maxine Sun, Stuart R. Lipsitz, Firas Abdollah, Jeffrey J. Leow, Mani Menon, Nicolas von Landenberg, Philipp Gild, Morgan Roupret, Mark Preston, Lauren C. Harshman, Adam S. Kibel, Paul L. Nguyen, Joaquim Bellmunt, Toni K. Choueiri, Quoc-Dien Trinh

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre
Twitter: @zklaassen_md

at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA