Oncologic Impact of Preoperative Hypoalbuminemia in Elderly Patients Treated with Radical Cystectomy for Urothelial Bladder Cancer
This was a single center retrospective study taking place between 2007 and 2015 in Italy, with 450 patients referred for a radical cystectomy. Of these, 109 patients (24.2%) older than 80 were selected. Preoperative hypoalbuminemia was defined as serum albumin < 3.5 g/dL.
The median age was 84 (IQR 81-86, range: 80-92) years, and the Charlson comorbidity index (CCI) was 3 (IQR 2-4). The preoperative data demonstrate that patients had median preoperative serum albumin of 4.0 (IQR 3.8-4.3) g/dL and hypoalbuminemia was seen in 16 (14.7%) patients. Clinical T3-4 and N+ were recorded in 11 (10.1%) and 9 (8.3%) of patients, respectively. Preoperative hydronephrosis was registered in 28.4% of patients.
Postoperative data revealed that pT3-4 and pN1-2 were recorded in 69 (63.4%) and 16 (14.7%) of patients, respectively. Median follow-up was 24.6 (IQR 14.5-35.1) months. The actuarial 3-year and 5-year overall survival was 40.9% (SE 5.4%) and 16.8% (SE 5.5%), respectively. The actuarial 3-year and 5-year CSS was 62.2% (SE 5.7%) and 45.7% (SE 10.2%), respectively. Patients with a rising preoperative albumin level had a significantly higher overall survival (p=0.01) and a higher cancer-specific survival (p<0.0001) (Figure 1). On multivariable analysis, preoperative hypoalbuminemia was independently associated with worse overall survival at both preoperative (HR: 2.22, CI95% 1.16-4.23, p=0.01) and postoperative (HR:2.06, CI 95% 1.13-3.78, p=0.02) models, after adjusting for established clinicopathological features.
In conclusion, patients older than 80 with preoperative hypoalbuminemia seem to have a worse oncologic outcome after radical cystectomy. The authors recommend measuring the preoperative serum albumin before radical cystectomy, as this could assist us in improving postoperative clinical outcomes and predict the prognosis of elderly patients. The limitations of this study included its retrospective nature, single institution data, and short-term follow-up. Also, it would be interesting to do a comparison with younger patients undergoing radical cystectomy and see whether hypoalbuminemia is also a risk factor in the younger population. In any case, according to the Enhanced Recovery After Surgery (ERAS) principles, patients (at any age), should be optimized before radical cystectomy. Therefore, a low albumin level should be treated and raised preoperatively to enhance patient outcomes.
Figure 1 – Cancer-specific and overall survival stratified by albumin level:
Figure 2 – Preoperative and postoperative multivariable Cox regression analyses models for overall survival in patients older than 80 undergoing radical cystectomy:
Presented by: Mary Andrea, Firenze, Italy
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the Global Conference on Bladder Cancer 2018 - September 20-21, 2018 Madrid, Spain