Refining patient selection for neoadjuvant chemotherapy prior to radical cystectomy - Abstract

PURPOSE: We evaluated survival of patients with muscle-invasive bladder cancer undergoing radical cystectomy without neoadjuvant chemotherapy to confirm the utility of existing clinical tools to identify low risk patients who could be treated with radical cystectomy alone and a high risk group most likely to benefit from neoadjuvant chemotherapy.

MATERIALS AND METHODS: We identified patients with muscle-invasive bladder cancer undergoing radical cystectomy without neoadjuvant chemotherapy at our institution between 2000 and 2010. Patients were deemed high risk based on the clinical presence of hydroureteronephrosis, cT3b-T4a disease, and/or histologic evidence of lymphovascular invasion, micropapillary or neuroendocrine features on transurethral resection. We evaluated survival (disease-specific, progression-free, and overall) and rate of pathological upstaging. An independent cohort of patients from a separate institution was used to confirm our findings.

RESULTS: We identified 98 high risk and 199 low risk patients eligible for analysis. High risk patients exhibited decreased five-year overall survival (47.0 vs. 64.8%) and decreased disease-specific (64.3 vs. 83.5%) and progression-free (62.0 vs. 84.1%) survival probabilities compared to low risk patients (p< 0.001). Survival outcomes were confirmed in the validation subset. On final pathology, 49.2% of low risk patients were upstaged.

CONCLUSIONS: Five-year disease-specific survival of low risk patients was above 80%, supporting the distinction of high and low risk muscle-invasive bladder cancer. The presence of high risk features identifies patients with a poor prognosis who are most likely to benefit from neoadjuvant chemotherapy, while many of those who are low risk can undergo upfront surgery with good expectations and avoid chemotherapy-associated toxicity.

Written by:
Culp SH, Dickstein RJ, Grossman HB, Pretzsch SM, Porten S, Daneshmand S, Cai J, Groshen S, Siefker-Radtke A, Millikan RE, Czerniak B, Navai N, Wszolek MF, Kamat AM, Dinney CP.   Are you the author?
Department of Urology, University of Virginia, University to Texas M.D. Anderson Cancer Center.

Reference: J Urol. 2013 Jul 30. pii: S0022-5347(13)05010-6.
doi: 10.1016/j.juro.2013.07.061

PubMed Abstract
PMID: 23911605 Bladder Cancer Section