(UroToday.com) The 2022 EAU annual meeting featured a session on new insights in the management of upper tract urothelial cancer, including a presentation by Dr. Shravan Morisetty discussing the impact of adjuvant chemotherapy on overall survival in patients with node-positive upper tract urothelial carcinoma. Previous studies reported a possible beneficial impact of adjuvant chemotherapy on overall survival in patients with node-positive upper tract urothelial carcinoma. Dr. Morisetty and colleagues hypothesized that in these individuals the impact of adjuvant chemotherapy on overall survival can vary based on patient demographics, and tumor characteristics.
This study focused on 420 patients with non-metastatic pN+ upper tract urothelial carcinoma, treated with radical nephroureterectomy, between 2004 and 2016, within the national cancer database. All patients had complete data. Adjuvant chemotherapy was defined as receiving chemotherapy within 90 days from surgery. Regression tree analysis considered all available covariates and stratified patients into groups based on their overall survival rate, with the aim of identifying the groups that differ the most in their prognosis. Subsequently, Kaplan-Meier and Cox regression analysis tested the impact of adjuvant chemotherapy on overall survival in each group.
The median patient age was 71 years (IQR 63-77), with most patients having pT3 disease (66.3%), and negative surgical margins (74.8%). The median number of removed and positive nodes was 3 (IQR 1-8), and 1 (IQR 1-3) nodes, respectively. Regression tree stratified patients into the following three groups:
- High-risk — patients with positive margins (24%)
- Intermediate-risk: patients with negative margins, and ≥3 positive nodes (20%)
- Low-risk: patients with negative margins, and <3 positive nodes (56%)
These groups represented respectively 24%, 20%, and 56% of the entire cohort, and had a 3-year overall survival rate of respectively 24%, 30%, and 49% (log-rank p<0.001).
In the low-risk group, patients treated with adjuvant chemotherapy had a more favorable 3-year overall survival rate than their counterparts who didn’t (55% vs 40%, p=0.004). On multivariable analysis, adjuvant chemotherapy had an impact on overall survival in all patients (HR 0.70, 95% CI 0.60-0.86), as well as low risk (HR 0.46, 95% CI 0.35-0.60), and intermediate risk (HR 0.49, 95% CI 0.26-0.93) patients. However, adjuvant chemotherapy did not have a significant impact on high-risk patients (HR 1.17, 95% CI 0.74-1.74).
Dr. Morisetty concluded his presentation by discussing the impact of adjuvant chemotherapy on overall survival in patients with node-positive upper tract urothelial carcinoma with the following take-home messages:
- Among node-positive upper tract urothelial carcinoma patients treated surgically, those with negative margins, and positive nodes count <3 have the best prognosis, and can benefit from adjuvant chemotherapy
- Conversely, patients with positive margin or extensive nodal disease perform poorly even when treated with adjuvant chemotherapy, and can be spared the morbidity of such a treatment
- This study may be the first risk stratified approached delineating selection criteria for adjuvant chemotherapy treatment of upper tract urothelial carcinoma
Presented by: Shravan Morisetty, MD Candidate, Wayne State University, School of Medicine, Detroit, United States of America
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 2022 European Association of Urology (EAU) Annual Hybrid Meeting, Amsterdam, NL, Fri, July 1 – Mon, July 4, 2022.