EAU 2018: Curative Treatment for Muscle-Invasive Bladder Cancer in Elderly Patients: A Systematic Review
Historical series have demonstrated less aggressive treatment is offered for elderly patients. Specifically, partial or radical cystectomy rates among patients ≥80 years of age were 11.5% compared to 24.8% for patients 70-79 years of age, and 32.2% for those <70 years of age [2]. Comparatively, patients undergoing only TURBT included 59.5% of patients <70 years of age, 66.5% for those 70-79 years of age, and 79% for those ≥80 years of age.
When assessing timing of mortality among elderly patients undergoing radical cystectomy, younger vs elderly patients have comparable peri-operative mortality, elderly have slightly worse 30-day mortality and drastically worse 90-day mortality rates [1]. With regards to morbidity, elderly patients have more minor complications, essentially equivalent late complications and comparable early complications.
A previous phase II trial assessed the outcomes of concurrent weekly gemcitabine with 4 weeks of radiotherapy [3]. Among 50 patients, 47 completed treatment and had a post-treatment cystoscopy of which 88% achieved a complete endoscopic response. At a median follow-up of 36 months (range, 15-62 months), 36 patients were alive, and 32 had a functional and intact bladder. Fourteen patients died, seven as a result of metastatic MIBC, five died as a result of intercurrent disease, and two died as a result of treatment-associated deaths. Four patients underwent cystectomy; three because of recurrent disease and one because of toxicity. The 3-year cancer-specific survival was 82%, and overall survival was 75%. This study demonstrated that concurrent gemcitabine-based chemoradiotherapy produces a high response rate in MIBC and has durable local control and acceptable toxicity.
Dr. Fonteyne concluded with several take-home messages, including (i) biologic age, not years alone should guide treatment in the elderly, (ii) a proportion of elderly patients do benefit from a standardized aggressive treatment regimen, (iii) if a patient is not suited for aggressive treatment, the clinician should seek alternative options.
Presented by: Valerie Fonteyne, Ghent University Hospital, De Pintelaan, Ghent, Belgium
References:
1. Fonteyne V, Ost P, Bellmunt J, et al. Curative treatment for muscle invasive bladder cancer in elderly patients: A systematic review. Eur Urol 2018;73(1):40-50.
2. Hollenbeck BK, Miller DC, Taub D, et al. Aggressive treatment for bladder cancer is associated with improved overall survival among patients 80 years old or older. Urology 2004;64(2):292-297.
3. Choudhury A, Swindell R, Logue JP, et al. Phase II study of conformal hypofractionated radiotherapy with concurrent gemcitabine in muscle-invasive bladder cancer. J Clin Oncol 2011;29(6):733-738.
Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, twitter: @zklaassen_md at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark