AUA 2018: Oophorectomy at Time of Radical Cystectomy: Re-evaluating the Definition of Radical Cystectomy in Women

San Francisco, CA (UroToday.com) The classical teaching of performing a radical cystectomy for female patients is removal of the ovaries, uterus and anterior vaginal wall. This is also supported by the current American Urologic Association guidelines for muscle invasive bladder cancer (MIBC), presumably to mitigate the risk of concurrent or future ovarian cancer [1]. Recent data on oophorectomy has suggested an increased risk of all-cause mortality, cardiovascular disease, and osteoporosis in both premenopausal and postmenopausal women, in addition to the increased risk of cognitive impairment and diminished sexual function in premenopausal women. A recently published survey of Society of Urologic Oncology members found that 75% had performed an ovarian-sparing radical cystectomy, and that 14% were aware that salpingectomy alone reduces the risk of ovarian cancer [2].



Furthermore, 95% of respondents were aware that bilateral salpingo-oophorectomy (BSO) increases the risk of osteoporosis, 66% were aware that it leads to cardiovascular disease, and only 26% were aware that BSO increases all-cause mortality. At the invasive bladder cancer session at AUA 2018, Marc Abboud and colleagues from the University of Oklahoma presented results of their population-level analysis assessing the impact of oophorectomy at the time of radical cystectomy. Their hypothesis was that the risk of concurrent or subsequent ovarian cancer in women undergoing radical cystectomy for bladder cancer is low, and therefore oophorectomy at the time of radical cystectomy can be avoided. 

For this study, the authors queried the Surveillance, Epidemiology and End Results (SEER) database for all women with a diagnosis of primary bladder cancer who underwent radical cystectomy between 1998 and 2010 (n=1,851). Patients with concurrent or a subsequent diagnosis of ovarian cancer were then identified using the SEER multiple primaries dataset. The authors then used a multiple primary standardized incidence ratio (MP-SIR) was calculated as an estimate of the relative risk of a concurrent or subsequent ovarian malignancy using SEER*Stat software.

Among the 1,851 women meeting inclusion criteria, the median age at diagnosis was 69 (range: 24-99) years, and the majority (83.1%) of patients were Caucasian. The most common SEER stage was regional disease (80.4%). Furthermore, 221 (11.9%) women developed a subsequent non-bladder malignancy, of which only 2 (0.11%) women developed subsequent ovarian cancer during the observation period (at 5 and 24 months after RC). The MP-SIR for development of an ovarian malignancy was found to be 0.50. 
The strengths of the current study is the population-level analysis necessary to perform a study requiring a large enough sample size to make meaningful conclusions. The limitations of this study, inherent to SEER database studies, include the inability to assess chemotherapy received or comorbidities among included patients. Furthermore, SEER is not able to track the physical presence of ovaries at the time of radical cystectomy.  Dr. Abboud concluded with several take-home messages from their study: 

  • The risk of concurrent or subsequent ovarian malignancy in women undergoing radical cystectomy for bladder cancer is very low (0.11%) 
  • Oophorectomy at the time of radical cystectomy is unnecessary (emphasize salpingectomy) and may place women at undue risk of cardiovascular disease, osteoporosis, cognitive impairment, and diminished sexual function 
Presented By: Marc A. Abboud, University of Oklahoma, Oklahoma City, OK, 
Co-Authors: Allan K. Topham, Philadelphia, PA, Daniel C. Parker, Heather R. Burks, Michael S. Cookson, Sanjay G. Patel, Oklahoma City, OK

References: 
1. American Urological Association. Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline. Available at: http://www.auanet.org/guidelines/muscle-invasive-bladder-cancer-new-(2017)  
2. Sussman RD, Han CJ, Marchalik D, et al. To oophorectomy or not to oophorectomy: Practice patterns among urologists treating bladder cancer. Urol Oncol 2018;36(3):90.e1-90.e7. 

Written by:  Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre Twitter: @zklaassen_md at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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