AUA 2021: Quality of Life After Cystectomy and Urinary Diversions 

(UroToday.com) The bladder cancer session at the Society of Urologic Oncology’s (SUO) program at the AUA 2021 virtual annual meeting included a presentation by Dr. Scott Gilbert who discussed the quality of life after cystectomy and urinary diversions. Dr. Gilbert started by defining health-related quality of life:

  • Quality of life and health-related quality of life are used interchangeably but are not the same
  • Health-related quality of life can be thought of as the impact of health, illness, and medical care on an individual’s overall quality of life
  • HealthyPeople.gov defines health-related quality of life as a multi-dimensional concept that includes domains related to physical, mental, emotional, and social functioning that goes beyond measures of population health, life expectancy, and cause of death, and focuses on the impact of health status on quality of life

 

Common health-related quality of life domains includes physical health, social functioning, mental health, environment, and general health perception and life satisfaction:

 

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Dr. Gilbert noted several characteristics and psychometrics, many of which are general tools, but also several that are condition/disease-specific, including MOS SF-36/12, WHOQOL-100, SIP, EQ-5D, PROMIS-29, FACT-G, EORTC QLQ-C30, PROMIS-Ca, FACT-Bl, FACT-Bl-Cys/VCI, BCI, EORTC-BLM30, and BUSS. These metrics have reliability (scores are consistent), validity (the instrument measures the intended construct), responsiveness (a change in scores corresponds to a change in health status), and interpretability (scores, and changes in score, have meaning to a consumer).

According to Dr. Gilbert, health-related quality of life is important for several reasons, such as (i) providing a global assessment of the impact of health and illness, (ii) uncovering undiagnosed or undetected health problems, (iii) significantly correlating with other clinical outcomes, such as survival, and (iv) being used to support innovation in clinical trials.  Importantly, over the last ~5 years, there has been an increase in the number and quality of health-related quality of life publications. The impact of cancer on health-related quality of life suggests that bladder cancer quality of life is significantly worse than patients without cancer, as highlighted in the following figure:

 

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An initial systematic review of the literature for health-related quality of life and bladder cancer studies was performed in 2009 (searching studies from 1996-2008) by Somani et al.,1 identifying 40 studies and reporting on 3,645 patients. Among these studies, only two reported a better health-related quality of life in favor of a neobladder, whereas two studies suggested a better body image perception in patients with a neobladder. Somani and colleagues provided an updated review of health-related quality of life studies among cystectomy patients in 2016,2 identifying 22 studies of 2,450 patients. Whereas none of the prospective studies showed any quality of life advantage with ileal conduit diversion, 3 of the 5 prospective studies and 4 of the 6 studies published after 2011 show better quality of life outcomes with neobladder than other urinary diversion types. All prospective studies published after 2011 have shown neobladder to have superior quality of life outcomes compared to other modalities of urinary diversion.

A prospective study by Singh and colleagues assessed quality-of-life outcomes in patients who underwent ileal conduit urinary diversion with those who underwent orthotopic neobladder reconstruction after radical cystectomy. Among 80 patients in the ileal conduit and 84 in the orthotopic neobladder group. None of the baseline characteristics were significantly different between the groups, except for age. In the preoperative phase, there were no significant differences in any of the quality-of-life domains between the ileal conduit or the orthotopic neobladder groups. At 6, 12, and 18 months in the postoperative period, physical functioning, role functioning, social functioning, and global health status/quality-of-life were better in patients in the orthotopic neobladder group than in those in the ileal conduit group.

 

Several assessments and conclusions of health-related quality of life from randomized clinical trials have been made, including:

  • No difference in FACT-VCI scores in the UT-San Antonio pilot trial (n=40)
  • No difference in EORTC-QLQ-C30 scores in the MSKCC trial (n=118)
  • No difference in FACT-Bl scores in the CORAL trial (n=59)
  • No difference in FAC-VCI/SF-8 scores in the RAZOR trial (n=302)
  • No difference in EORTC-QLQ-C30/EQ-5D scores in the BRAVO trial (n=50)

 

Dr. Gilbert concluded his presentation with the following take-home comments from his presentation of a quality life after cystectomy and urinary diversion:

  • The quality of health-related quality of life studies among cystectomy cohorts has improved over the last 5 years, but there is still much to learn and to do
  • In general, health-related quality of life outcomes is similar between patients who receive open cystectomy or robotic-assisted cystectomy, or an ileal conduit or neobladder
  • On average, the higher general quality of life scores is observed among neobladder patients and likely reflects a higher baseline health and function to a degree
  • Health-related quality of life measures and outcomes should be leveraged in a more proactive and productive way, including being compulsory about inclusion in randomized clinical trial design, and integrated into yet-to-be-developed educational resources that support surgeon counseling and patient decision-making

 

Presented by: Scott M. Gilbert, MD, Department of Urology, Moffitt Cancer Center, Tampa, FL

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2021 American Urological Association, (AUA) Annual Meeting, Fri, Sep 10, 2021 – Mon, Sep 13, 2021.


References:

  1. Somani BK, Gimlin D, Fayers P, et al. Quality of life and body image for bladder cancer patients undergoing radical cystectomy and urinary diversion – a prospective cohort study with a systematic review of the literature. Urology. 2009 Nov;74(5):1138-1143.
  2. Ghosh A, Somani BK. Recent trends in postcystectomy health-related quality of life (QoL) favors neobladder diversion: Systematic review of the literature. Urology. 2016 Jul;93:22-26.
  3. Singh V, Yadav R, Sinha RJ, et al. Prospective comparison of quality-of-life outcomes between ileal conduit urinary diversion and orthotopic neobladder reconstruction after radical cystectomy: A statistical model. BJU Int. 2014 May;113(5):726-732.

 

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