Re: An Interval Longer than 12 Weeks Between the Diagnosis of Muscle Invasion and Cystectomy is Associated with Worse Outcome in Bladder Carcinoma

Comparison of Outcomes Between Radical Radiotherapy and Radical Cystectomy in Muscle Invasive Bladder Cancer in a Cancer Specialized Unit of a Developing Country

Introduction Radical cystectomy (RC) is the current standard of care for treating muscle-invasive bladder cancer (MIBC), however bladder preservation by offering radical radiotherapy (RT) is gaining interest for improving the quality of life while maintaining a reasonable oncological outcome. In this study, we have compared outcomes of the two treatment options. Materials and methods This is a 10-year retrospective cohort study that included all patients who were treated for histologically proven muscle-invasive bladder cancer in the department of uro-oncology at Shaukat Khanum Memorial Cancer Hospital and Research Centre from January 2005 to January 2015. Data was analysed using Statistical Product and Service Solutions (SPSS), version 21 (IBM Corp., Armonk, NY). The primary end point of our study was to calculate the three- and five-year disease-free survival (DFS) and overall survival (OS). Results A total of 230 patients were included in the study with male gender predominating (88%). The mean and standard deviation for age was 58.32+11.128. Radical cystectomy was performed in 119 patients while 111 received RT. Clinically, 34% had stage 2 disease, while 66 % had stage 3 cancer. The median follow-up duration was 41 months (range: 2-155). During follow-up 57.4% of patients showed no recurrence. Local recurrence was found in 9.6% patients and distant metastasis in 32.2%. The three-year DFS of RC was 63% and that of RT was 57% while the five-year DFS for RC and RT were 60% and 49%, respectively (p=0.196). The three-year OS of RC was 64% and that for RT was 58%. On further analysis the five-year OS of RC was 53% and that for RT was 50% (p=0.98). Upon stage-based comparisons, we found no statistically significant difference between the three- and five-year DFS and OS of stage 2 and stage 3 when treated with either modality. Conclusion Most studies favor RC and consider it as the gold standard treatment for muscle-invasive bladder tumor treatment. The current study reveals that bladder preservation approach by chemo radiotherapy is a viable treatment option, having comparable oncological outcomes with patients receiving radical cystectomy, and can be offered to patients having muscle-invasive urothelial bladder cancer.

Delay in the surgical treatment of bladder cancer and survival: systematic review of the literature

OBJECTIVES

Eighty per cent of the newly diagnosed invasive bladder tumours are invasive from the outset. Half of these patients already have occult distant metastases reflecting the rapid nature of progression. The aim of the current study was to review the literature to determine if delay in cystectomy leads to worse prognosis and to determine if a possible cutoff point for delay exists, after which a worse outcome would be expected.

METHODS

We performed a systematic review of publications indexed in Medline and other scientific databases by analyzing types and causes of delay in performing radical cystectomy. Information on the impact of such delays on tumour recurrence and survival was collected and summarized. Papers that described only delay without any outcome correlation were excluded from the study.

RESULTS

A total of 13 papers published from 1965 to 2006 were included in this study. Three (23%) papers did not find any correlation between pretreatment delays and survival. Two (15%) papers reported a trend towards worse survival with delay. Eight (62%) papers documented significant association between delay and worse prognosis. Delay influenced survival as an independent variable in two (25%) of these eight papers. In the remaining six (75%) manuscripts, delay was significantly associated with a higher pathologic stage.

CONCLUSIONS

Although studies on bladder cancer failed to show a linear relationship between delay and prognosis, the majority confirmed that delays are associated with worse outcome. Studies suggested a window of opportunity of less than 12 weeks from diagnosis of invasive disease to radical cystectomy.

Effect of Preoperative Delay on Survival in Patients With Bladder Cancer Undergoing Cystectomy in Quebec: A Population Based Study

PURPOSE

In Canada there is growing concern that waiting time for cancer surgery has been increasing. We used population based data to estimate the average PD for RC in Quebec and assess whether delayed surgery has a negative impact on long-term survival.

MATERIALS AND METHODS

We used the provincial billing database of the maladie du Quebec to identify all patients with bladder cancer 18 years or older who underwent RAMQ from 1990 to 2002. PD was calculated as the time elapsed between the most recent transurethral resection and the date of RC. Patients were categorized according to PD tertiles into 3 groups, namely 1) 20 or less, 2) 21 to 47 and (C) 48 days or greater. Cox proportional hazards models were used to assess the effect of PD on overall survival, while adjusting for patient and provider factors.

RESULTS

During the study period 1,592 radical cystectomies were performed. Overall median PD was 33 days (95% CI 30 to 35). Median PD increased from 23 days in 1990 to 50 in 2002. After adjusting for calendar year, and patient and provider variables there were no significant differences in survival among the 3 delay categories. However, patients subject to greater than 12 weeks of delay were at 20% greater risk for dying (95% CI 1.0 to 1.5, p = 0.051).

CONCLUSIONS

In line with previous reports PD greater than 12 weeks seems to be associated with a worse long-term prognosis.

TREATMENT DELAY AND PROGNOSIS IN INVASIVE BLADDER CANCER

PURPOSE

We studied treatment delay, and the impact on disease specific survival and stage progression in a series of patients who had undergone cystectomy.

MATERIALS AND METHODS

All 141 patients underwent radical cystectomy between 1990 and 1997 due to locally advanced bladder cancer. Treatment delay was defined as time from pathological confirmation of invasive disease to performance of cystectomy, and was registered retrospectively from the patient charts. Two patients received neoadjuvant chemotherapy and were excluded from further analyses. Followup continued until April 2003 with death due to bladder cancer as the end point. Causes of death were retrieved from the Swedish Cause of Death Registry.

RESULTS

The median treatment delay was 49 days, but was significantly longer for the 71 cases who were referred from other hospitals (63 vs 41 days, p < 0.001). Treatment delay did not influence cumulative incidence of death from bladder cancer. Considering all cases, there was no significant correlation between treatment delay and stage progression. For clinical stage T2 tumors, median treatment delay was 76 days among patients with stage progression compared to 41 and 48 days for those with stage regression and stage equivalence, respectively (p = 0.20).

CONCLUSIONS

Treatment delay was not found to influence disease specific survival in the present study. Furthermore, treatment delay was not significantly longer in cases that progressed compared to those with equal or lower pathological stage in the cystectomy specimen.