BERKELEY, CA (UroToday.com) - Age is a risk factor for the occurrence of bladder cancer and bladder cancer is a disease of the elderly.
The elderly and in particular the octogenarians have a worse tolerance for aggressive therapies due to the higher incidence of side effects and complications in patients that are usually affected by many other age-related comorbidities. When the urologist faces the treatment of an octogenarian affected by bladder cancer, he should answer many questions.
In the case of non-invasive bladder cancer, is it possible to use the same drugs that we use for younger patients (BCG vs. chemotherapeutic agents)? Should the timing and the schedule of follow-up be the same?
Very few studies evaluated the use of intravesical prophylaxis in the elderly. The only data available shows that the overall response to BCG is decreased in patients aged 80 years or over compared with younger patients. Age is a significant variable for decreased response to therapy. If data about intravesical therapies in octogenarians are poor, no evidence has been reported concerning follow-up schedules. Nevertheless, we can argue that if bladder cancer in the elderly is not surely less aggressive than in younger patients, and if the response to intravesical is worse, the follow-up scheme with cystoscopy and urine cytology should be as intense as in younger patients. A less accurate follow-up scheme should be provided only in case of a poor life expectancy due to severe comorbidities.
Should the octogenarian affected by muscle-invasive bladder cancer undergo radical cystectomy or a less invasive treatment? What is the preferred type of diversion? Is it possible to propose an orthotopic neobladder to an octogenarian patient?
Fortunately, literature offers a greater amount of evidence about the treatment of muscle-invasive bladder cancer in elderly. The analysis of data provided by Surveillance, Epidemiology and End Results (SEER) data found that individuals aged 75 years or over with muscle-invasive bladder cancer had a higher prevalence of cardiac disease, prior cancer diagnosis, chronic anemia, and poorer American Society of Anesthesiologists (ASA) Physical Status Classification than patients aged under 75 years. Thus, only a minority of those patients are ususally candidates for radical cystectomy. Even if a good number of studies reported the outcomes of radical cystectomy in elderly, data about octogenarians are still unsatisfying. There is evidence that survival advantages in patients aged over 80 years are more significant only if radical cystectomy is accompanied by pelvic lymphadenectomy. As far as complications are concerned, they are three times more frequent in octogenarians and mortality remains high (11%) in the period from surgery to 90 days post-surgery. In our experience, considering the last 100 patients (meant age 68,2 years, range 37-85) who underwent radical cystectomy at our institution (Ospedale Molinette), 11% of them were aged over 80 years. No differences were recorded both in mean hospital stay and intraoperative and post-operative complications. No cases of death were recorded in the group of the octogenarians. The outcomes recorded, better than those reported in literature series, could be explained by a stringent and careful selection of patients.
As far as the last question, about urinary diversion in octogenarians, again literature provides very little insight. No absolute contraindications are defined for bladder reconstruction through orthotopic neobladder in octogenarians, even if a worse continence is described. Only one single study evaluated the outcomes in patients with orthotopic neobladder with a survival of more than 5 years after the procedure: night-time continence was better in patients under 80 years (60% vs 38%, but not significant), max flow rate was slightly lower (not significant) and octogenarians changed their posture when voiding (sitting).
In conclusion, no real differences in the treatment and in the follow-up of octogenarians affected by bladder cancer are highlighted by the analysis of the existing literature. Nevertheless the urologist should be aware that octogenarians can have worse outcomes, more complications and higher mortality. The choice of the treatment should always be made on the basis of a careful evaluation of the patient, considering not only patient age but also comorbidities and life expectancy.
References
Taylor JA 3rd, Kuchel GA. Bladder cancer in the elderly: clinical outcomes, basic mechanisms, and future research direction. Nat Clin Pract Urol. 2009 Mar;6(3):135-44.
Prout GR Jr et al. (2005) Age and comorbidity impact surgical therapy in older bladder carcinoma patients: a population-based study. Cancer 104: 1638–1647
Joudi FN et al. (2006) The impact of age on the response of patients with superficial bladder cancer to intravesical immunotherapy. J Urol 175: 1634–1639
Chamie K et al. (2008) Cystectomy in the elderly: does the survival benefit in younger patients translate to the octogenarians? BJU Int 102: 284–290
Froehner M, Brausi MA, Herr HW, Muto G, Studer UE. Complications following radical cystectomy for bladder cancer in the elderly. Eur Urol. 2009 Sep;56(3):443-54. Epub 2009 May 18.
Takenaka A, Soga H, Terakawa T, Kumano M, Furukawa J, Muramaki M, Kurahashi T, Miyake H, Tanaka K, Yamanaka N, Fujisawa M. Assessment of voiding function of orthotopic neobladders in elderly patients with long-term survival. BJU Int. 2009 Apr;103(7):927-30
Written by:
Paolo Destefanis and Dario Fontana* as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
*Divisione Universitaria di Urologia 2 - Ospedale San Giovanni Battista “Molinette” - Torino
Corresponding author:
Dott. Paolo Destefanis
Divisione Universitaria di Urologia 2
Ospedale “San Giovanni Battista – Molinette”
Corso Bramante 88 – 10126 Torino- Italy
Tel +390116335521 – +393498412150
Fax +390116335707
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