Dr. Brausi framed his discussion by highlighting the facts that the population of patients > 80 years of age is rapidly growing, and by 2050 the number of octogenarians will more than double from present population numbers. Bladder cancer is the 5th leading cause of cancer death in this patient population as well, indicating that rates of bladder cancer incidence and deaths are expected to rise as the population of octogenarians grows rapidly. This will subsequently require more frequent and difficult decisions to be made about the ideal way to treat these elderly patients with muscle-invasive bladder cancer (MIBC), because it has been well established that the majority of patients with untreated MIBC will die from their malignancy within 2 years.
As there have been improvements in anesthesia and peri-operative care in the last several decades, urologists have been more inclined to offer patients radical cystectomy, particularly if a patient’s additional life expectancy is projected to be >2 years. He acknowledges, however, that surgery certainly is riskier in this patient population due to increased medical comorbidities. The rates of ileus, pneumonia, and delirium are independently predicted by increased age in several studies.
Brausi feels, though, that surgery can be safely carried out in these patients with several necessary principles, including careful pre-operative evaluation and optimization of any active medical issues, minimization of the time spent intraoperatively, minimization of the invasiveness of surgery, and meticulous post-operative care and follow-up evaluations.
He then reviewed frailty scores, and their utility in patient selection for radical cystectomy in the octogenarian population. He showed that increased frailty scores predict both post-operative complications as well as 30 and 90-day post-operative mortality rates. He strongly believes that an adequate pre-operative evaluation and calculation of these scores, ideally by a dedicated geriatric or perioperative medical team is important to ensure that only appropriate patients are selected to undergo cystectomy.
Dr. Brausi continued his discussion by reviewing the multidisciplinary approach to geriatric patients that is undertaken at his center in Modena, Italy. Since February 2002, they have a multidisciplinary team including cardiology, anesthesia, urology, geriatrics, medical oncology, and radiation oncology. He again stressed the absolute necessity of a thorough preoperative evaluation and patient optimization. His group retrospectively reviewed their data from March 2000 to December 2012 and identified 170 octogenarians that underwent radical cystectomy at their institution with a mean age 83.2 years. The overall survival for this cohort of patients was 60% at 1 year, 43.6% at 2 years, and 40% at 3 years. The 90-day mortality rate was 9.8%, and mean hospital stay was 14.5 days.
He concluded that radical cystectomy is an accepted treatment modality in the octogenarian population, with acceptable perioperative complication rates and 30-day mortality rates. He again stressed the multidisciplinary approach that is necessary for the optimal care of these patients. As the population continues to age, we as a urologic community will be faced with these difficult treatment decisions more often and implementation of ideal care pathways may be helpful in minimizing complications and optimizing oncologic outcomes.
Presented By: Maurizio Brausi, MD, ASL Modena, Italy
Written by: Brian Kadow, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA, at the 19th Annual Meeting of the Society of Urologic Oncology (SUO), November 28-30, 2018 – Phoenix, Arizona