ERUS 2018: Cystectomy in Muscle-Invasive Bladder Cancer of the Octogenarian. Benefit or Over Treatment?

Marseille, France (UroToday.com) The topic of radical cystectomy (RC) in octogenarians was discussed by Dr. Palou in this session.  The planet’s population in the 20th century has doubled twice, and the number of people over the age of 65 is set to double within 25 years. Dr. Palou then gave numbers regarding RC for bladder cancer:

  1. The cure rate varies between 25-80%
  2. Under-staging is seen in 40% of patients
  3. Occult metastases are evident in 50% of patients
  4. Operative mortality is approximately 2%
  5. The need for reoperation is around 10%
  6. Perioperative morbidity is between 34% and 70%.
The standard treatment for muscle-invasive bladder cancer is RC with pelvic lymph node dissection. Patients with an untreated disease die of the metastatic disease usually within two years. Therefore, common logic suggests, that surgery is justified in any patients with a life expectancy of more than 2-5 years.

Nowadays, the life expectancy of an average 80-year-old man is 88.25 years, for an 85-year-old man – 90.82 years, and for a 95-year-old man – 98 years!  It is, however, important to note that with increasing age, the risk in surgery rises as well.

So why not offer these patients a TURBT procedure only? It is considerably less aggressive, with less morbidity and mortality during hospitalization. Furthermore, lowering the tumor burden could facilitate chemotherapeutic drug action on the bladder. However, the results of TURBT only compared to RC are considerably worse.

Several series have been published analyzing octogenarians who underwent RC (Table 1). These studies demonstrate a mortality rate of a maximum of 5.3%. A  study analyzing the effect of age on survival after RC showed that elderly patients had a higher ASA score, received less adjuvant therapy, had a much higher rate of ileal conduit over the age of 80, but had a similar rate of disease-specific survival1.

Table 1:
UroToday ERUS2018 radical cystectomy in octogenarians
An analysis of the National Cancer Database (NCDB) of 9270 octogenarian patients with bladder cancer, and with a median follow-up of 12.8 months, demonstrated several interesting findings2. First, globally there were more patients treated with TURBT than with any other modality. Second, patients who underwent RC had a much better comorbidity score, and a significantly low percentage of patients received neoadjuvant chemotherapy (3.7%). Third, in academic centers, more RC was performed than in community centers2. The best overall survival was seen in patients treated with RC and chemotherapy.

Dr. Palou then discussed the topic of urinary diversion (UD) in this elderly population. Being older than 80 is not a contraindication to use bowel for UD. But, if the use of bowels is not possible, or there is a serious co-existing medical condition, one alternative is to perform cutaneous ureterostomy. This form of UD has been shown to be the least burdensome type of UD for a patient with compromised general health3.

Dr. Palou concluded his discussion and summarized that elderly patients have a higher ASA score, undergo less lymphadenectomy, and have a higher pathological T3 stage. Predictors of increased complication rate among this unique population include previous radiotherapy, higher comorbidity score, the performance of pelvic lymphadenectomy, and use of bowel for UD. The main predictors for increased cancer-specific mortality and overall mortality include higher clinical and pathological T stage, preoperative hematuria, and higher comorbidity score. Most importantly, age was never shown to be an independent predictor of both overall and cancer-specific mortality. Lastly, the life expectancy of an 80-year-old man today is between 7- and 9 years, and this must be taken into account when considering management strategy.

Presented by: Palou, Barcelona, Spain

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter:@GoldbergHanan at the EAU Robotic Urology Section (ERUS) Meeting - September 5 - 7, 2018 - Marseille, France

References:

  1. Horovitz D, Turker P, Bostrom PJ, et al. Does patient age affect survival after radical cystectomy? BJU international 2012; 110(11 Pt B): E486-93.
  2. Fischer-Valuck BW, Rao YJ, Rudra S, et al. Treatment Patterns and Overall Survival Outcomes of Octogenarians with Muscle Invasive Cancer of the Bladder: An Analysis of the National Cancer Database. The Journal of Urology 2018; 199(2): 416-23.
  3. Deliveliotis C, Papatsoris A, Chrisofos M, et al. Urinary diversion in high-risk elderly patients: modified cutaneous ureterostomy or ileal conduit? Urology 2005; 66(2): 299-304.
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