Bladder Cancer Therapy: Organ-Sparing or Primary Cystectomy?

Kate Johnson

April 15, 2014

STOCKHOLM — Patients with muscle invasive bladder cancer (MIBC) have better survival outcomes if they are treated with immediate primary cystectomy rather than receiving an initial bladder- sparing approach followed by a subsequent salvage cystectomy if necessary, according to research from the Royal College of Surgeons in London, United Kingdom.

"What we've shown is that, in accordance with the literature, salvage cystectomy patients do worse in overall survival compared to those who get primary immediate cystectomy, with a hazard ratio of nearly 1.5 ― that's 50% worse," researcher Arunan Sujenthiran, MD, told Medscape Medical News.

"With improved imaging, if we could identify the cohort of patients that will do badly with bladder-sparing approach ― and they probably have more aggressive disease in the first place ― then they should be offered cystectomy straight up with neoadjuvant chemotherapy," he said.

Dr. Sujenthiran presented the results here at the at the European Association of Urology (EAU) 29th Annual Congress.

However, the study has been sharply criticized for not being a true comparison.

Merging of UK and US Data

The study merged data from English cancer records and the US Surveillance, Epidemiology and End Results (SEER) database to include a total of 22,943 patients with MIBC.

The majority of patients (56%) underwent immediate primary cystectomy (IPC), with 40% receiving primary radiation therapy alone, and 4% undergoing bladder-sparing radical therapy and salvage cystectomy (BRT/SC) for residual disease or recurrence. Patients in all groups were well matched according to demographics as well as disease characteristics, said Dr. Sujenthiran.

The analysis showed that 8-year overall mortality (OM) and bladder cancer mortality (BCM) were significantly higher for patients receiving BRT/SC compared with those who had IPC (hazard ratio [HR], 1.47, P < .001, and 1.43, P < .001), with perioperative mortality rates not differing between the 2 groups.

But the analysis includes an "extremely flawed" comparison, said William Shipley, MD, professor of radiation oncology at Harvard Medical School, Boston, Massachusetts, when asked by Medscape Medical News for comment.

"Since the authors did not include in their retrospective analysis the majority of the patients treated with bladder-preserving CMT [combined modality techniques, meaning concurrent use of chemoradiation and bladder-sparing surgery], ie, those who did not recur and did not require a salvage cystectomy, it is not surprising nor unexpected that the results with initial primary cystectomy would be better," he wrote in an email.

"From our experience treating muscle-invading bladder cancer with modern bladder-preserving CMT, and with a long median follow-up of over 7 years ( Eur Urol. 2012;61:705-11), over 70% of patients did not require a salvage cystectomy for tumor persistence or recurrence. The disease-specific survival of this group is over 75%," he said.

"However, for those minority of poorly responding patients requiring a salvage cystectomy for persistent or recurrent invasive tumor in their bladder, the disease-specific survival is 45%," he said.

Urs Studer, MD, professor of urology at the University of Bern in Switzerland, voiced similar objections at the EAU meeting.

"They did not include all the patients in whom a radical transurethral resection was already enough," he told Medscape Medical News, after explaining this to the researchers. "These patients ― the successes with organ preservation treatment ― must also be included in the survival analysis."

Dr. Sujenthiran, Dr. Shipley, and Dr. Studer did not disclose any relevant financial relationships.

European Association of Urology (EAU) 29th Annual Congress: Abstract 123. Presented April 12, 2014.

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