BERKELEY, CA (UroToday.com) - In our current study, we evaluated which of the well-established comorbidity and performance status indices — the American Society of Anesthesiologists (ASA) score, Adult Comorbidity Evaluation-27 (ACE27), Eastern Cooperative Oncology Group (ECOG) performance status, Charlson Comorbidity Index (CCI), and Age-Adjusted Charlson Comorbidity Index (ACCI) — best predicts the survival outcome of patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB).
A retrospective chart review of 555 consecutive patients diagnosed with UCB who underwent RC between January 2000 and April 2010 at the General Hospital of Bolzano in Italy and the University of Regensburg in Germany were included in the study.
Five indices were assessed: ASA, ACE27, CCI, ACCI, and ECOG. The ASA score was obtained prospectively. ACE27, CCI, ACCI, and ECOG were obtained retrospectively based on prospectively documented comorbidity information from patient records, anesthesia notes, and structured admission sheets. Based on the literature, all indices were dichotomized. The statistical end points were cancer-specific mortality (CSM) and cancer-independent mortality (CIM) to especially examine the role of comorbidity in disease-free patients.
The median age was 70.5 years (IQR: 63–76). The median follow-up for patients alive at follow-up was 28 months (IQR: 12–54). Nearly half the patients were deceased at the end of the follow-up (n = 249, 44.9%), roughly a quarter having died of the disease (n = 146, 26.3%). Overall mortality of the cohort was 26%, 46%, 54%, and 58% after 12, 36, 60, and 84 months, respectively.
All indices were independent predictors for CIM but not for CSM, but interestingly the ASA score was the only index that significantly increased the predictive accuracy of the predefined CIM model (+2.3%; p = 0.045). To create a clinically valuable tool, we devised a weighted prognostic model including age and the best prognosticators within the performance and comorbidity scores (ASA/ACE27 0–1/2–3). A 3-year CIM rate of 8%, 26%, and 47% was calculated for the low-, intermediate-, and high-risk groups, respectively. Patients >75 years of age with ASA 3/4 and ACE27 >1 exhibited a CIM risk seven times greater than patients 75 years of age with ASA 1/2 and ACE27 0/1. This study is limited by the short follow-up and its retrospective nature, however it must be noted that both the ASA score and comorbidities were obtained prospectively and that only the calculation of the indices was performed retrospectively. This characteristic renders our study ‘‘quasi-prospective,’’ as it is based on accurate, prospectively documented patient information.
Higher comorbidity status and decreased physical status were independently associated with CIM after RC. The prospectively obtained ASA score showed the best predictive capacity and, as such, is to be seen as the instrument of choice. External prospective validation of these results is required.
Roman Mayra and Hans-Martin Fritscheb 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.
a Department of Urology, Central Hospital of Bolzano, Bolzano, Italy
b Department of Urology, University of Regensburg, Caritas St. Josef Medical Centre, Regensburg, Germany