Management of patients with muscle-invasive bladder cancer with clinical evidence of pelvic lymph node metastases

Identification of clinically positive pelvic lymph node metastases (cN+) in patients with muscle-invasive bladder cancer is currently challenging, as the diagnostic accuracy of available imaging modalities is limited. Conventional CT is still considered the gold-standard approach to diagnose lymph node metastases in these patients. The development of innovative diagnostic methods including radiomics, artificial intelligence-based models and molecular biomarkers might offer new perspectives for the diagnosis of cN+ disease. With regard to the treatment of these patients, multimodal strategies are likely to provide the best oncological outcomes, especially using induction chemotherapy followed by radical cystectomy and pelvic lymph node dissection in responders to chemotherapy. Additionally, the use of adjuvant nivolumab has been shown to decrease the risk of recurrence in patients who still harbour ypT2-T4a and/or ypN+ disease after surgery. Alternatively, the use of avelumab maintenance therapy can be offered to patients with unresectable cN+ tumours who have at least stable disease after induction chemotherapy alone. Lastly, patients with cN+ tumours who are not responding to induction chemotherapy are potential candidates for receiving second-line treatment with pembrolizumab.

The evolving treatment landscape of metastatic urothelial cancer

Cisplatin-based chemotherapy is currently the first-line standard of care for patients with metastatic urothelial cancer (mUC); however, up to 50% of patients are ineligible for cisplatin, necessitating alternative treatment options. Immune checkpoint inhibitors have been shown to be effective in cisplatin-ineligible patients. However, despite advances in the first-line setting, the prognosis remains poor, and challenges persist in selecting optimal therapies, treatment sequences and combination regimens. Maintenance therapy with avelumab revealed improved overall (OS) and progression-free survival (PFS) compared with best supportive care alone in patients with platinum-responsive mUC. Antibody-drug conjugates and targeted therapy with fibroblast growth factor receptor (FGFR) inhibitors have shown promise in selected patients, particularly in patients with metastatic disease that has progressed despite platinum-based chemotherapy. At the European Society of Medical Oncology Congress in 2023, groundbreaking results were presented from two phase III trials, EV-302/KEYNOTE-A39 and CheckMate 901, focusing on previously untreated mUC. In the former, the combination of enfortumab vedotin and pembrolizumab showed significant improvements in OS, PFS and overall response rate compared with chemotherapy alone; the combination of nivolumab with gemcitabine-cisplatin chemotherapy demonstrated a significant extension in median OS, PFS and overall response rate compared with chemotherapy alone. In addition, erdafitinib therapy resulted in significantly longer OS than chemotherapy among patients with mUC and FGFR alterations after previous treatment with immune checkpoint inhibitors. This comprehensive summary of the current treatment landscape for mUC incorporates clinical trial evidence and discussion of agents that are currently under investigation to provide support for clinical decision making and understanding of future therapeutic approaches.

Efficacy of cytoreductive radical cystectomy in metastatic urothelial bladder cancer based on site and number of metastases

BACKGROUND

Recent studies have highlighted the overall survival (OS) benefit of cytoreductive radical cystectomy (CRC) in metastatic bladder cancer (mBCa). Cytoreductive surgery has been established in other urologic cancers. However, the efficacy of CRC and optimal criteria for patient selection in mBCa is unclear. This study investigated the oncologic efficacy of CRC, particularly emphasizing the location and number of metastasis sites as a predictor of survival and treatment response.

METHODS

A retrospective analysis of cT2-4N0-3M1 mBCa patients treated with multiagent chemotherapy between 2004 and 2019 was conducted using the National Cancer Database. Patients were classified by additional treatment with CRC or conservative local treatment (CLT), consisting of transurethral resection of bladder tumor, radiation, or no local treatment and propensity score (PS) matched. Kaplan-Meier analysis and multivariate Cox Proportional Hazards model assessed the effect of CRC or CLT on OS within the matched cohort and in four subgroups (1) patients with only distant lymph node (LN) metastasis vs. any organ metastasis, (2) patients with single metastasis vs. multiple metastases. Sensitivity analysis estimated the influence of unmeasured confounders on CRC OS benefit.

RESULTS

Propensity matching yielded 247 and 251 patients treated with CRC and CLT, respectively. Median OS in patients who received CRC was greater than that of patients treated with CLT (20.4 months vs. 12.0 months, P < 0.001). CRC was associated with reduced mortality risk in patients with only distant LN metastases (HR = 0.545, P = 0.039), any organ metastasis (HR = 0.421, P < 0.001), and single visceral metastasis (HR = 0.483, P = 0.002). However, CRC did not significantly improve OS in patients with multiple metastases (HR = 0.501, P = 0.064).

CONCLUSION

These findings demonstrate an OS benefit of CRC with multiagent chemotherapy and pinpoint multiple visceral metastases as a potential contraindication for CRC. Although limited by the influence of unmeasured confounders, these findings may inform future prospective investigations into CRC.

Definitions, outcomes and perspectives for oligometastatic bladder cancer: towards a standardized terminology

PURPOSE OF REVIEW

Oligometastatic (om) cancer is considered as a transitional state in between locally confined disease and widespread metastases, accessible to a multimodal treatment, combining systemic and local therapy. In urothelial bladder cancer (BCa), the definitions and the approaches to this condition are poorly standardised and mainly based on retrospective data. We aim to portray the framework for uro-oncologic terminology in omBCa and go through the latest evidence and the future perspectives.

RECENT FINDINGS

Retrospective and registry data support the potential benefits of multimodality treatment for carefully selected omBCa patients, especially following a good response to systemic treatment. In 2023, a Delphi consensus has defined omBCa, allowing maximum three metastatic lesions, theoretically amenable to radical local treatment. In de-novo omBCa, surgical treatment of primary tumour might improve overall survival (OS), according to a matched registry analysis; also, consolidative radiotherapy was associated with better OS in two recent cohorts. Furthermore, metastasis-directed therapy (MDT) has shown high local control rates and promising OS (14.9-51 months) in a meta-analysis; benefits might be more pronounced for single-site omBCa and nodal or lung lesions.

SUMMARY

From a clinical perspective, in de-novo omBCa, the local treatment of primary and metastatic sites might improve disease control and survival, in selected patients; in the oligorecurrent setting, MDT achieves good local symptom control with limited side effects; in selected cases, it could convey a survival benefit, too. From a research perspective, well designed prospective evidence is eagerly awaited, based on recently adopted shared definitions for omBCa.

Prognostic Impact of Histologic Subtype and Divergent Differentiation in Patients with Metastatic Urothelial Carcinoma Treated with Enfortumab Vedotin: A Multicenter Retrospective Study

Subtype of urothelial carcinoma (SUC), defined here as urothelial carcinoma with any histologic subtype or divergent differentiation, is a clinically aggressive disease. However, the efficacy of enfortumab vedotin (EV) against SUC remains unclear. Hence, this study aimed to assess the oncological outcomes of patients with SUC treated with EV for metastatic disease. We retrospectively evaluated consecutive patients with advanced lower and upper urinary tract cancer who received EV after platinum-based chemotherapy and immune checkpoint blockade therapy at six institutions. The objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) were compared between patients with pure urothelial carcinoma (PUC) and those with SUC. We identified 44 and 18 patients with PUC and SUC, respectively. Squamous differentiation was the most common subtype element, followed by glandular differentiation and sarcomatoid subtype. Although patients with SUC had a comparable ORR to those with PUC, the duration of response for SUC was short. Patients with SUC had poorer PFS than those with PUC; however, no significant difference was observed in OS. Multivariate analysis revealed that SUC was significantly associated with shorter PFS. Although the response of metastatic SUC to EV was similar to that of PUC, SUC showed faster progression than PUC.

The role of radiation therapy for de novo metastatic bladder and renal cancers

Metastatic bladder and renal cancers account respectively for 2.1% and 1.8% of cancer deaths worldwide. The advent of immune checkpoint inhibitors has revolutionized the management of metastatic disease, by demonstrating considerable improvements in overall survival. However, despite initial sensitivity to immune checkpoint inhibitors for most patients, both bladder and renal cancer are associated with short progression-free survival and overall survival, raising the need for further strategies to improve their efficacy. Combining systemic therapies with local approaches is a longstanding concept in urological oncology, in clinical settings including both oligometastatic and polymetastatic disease. Radiation therapy has been increasingly studied with either cytoreductive, consolidative, ablative or immune boosting purposes, but the long-term impact of this strategy remains unclear. This review intends to address the impact of radiation therapy with either curative or palliative intent, for synchronous de novo metastatic bladder and renal cancers.

Radiotherapy in metastatic bladder cancer

PURPOSE

To review available and emerging evidence of radiotherapy for symptom management and disease control in metastatic bladder cancer.

METHODS

A literature search and subsequent cross-referencing were carried out for articles in the PubMed and Scopus databases using terms 'radiotherapy' OR 'palliative radiation therapy' with 'metastatic bladder cancer' OR 'advanced bladder cancer' between 1990 and 2023, excluding articles with no English translation.

RESULTS

Palliative radiotherapy is an effective and accessible treatment for the alleviation of haematuria and pain due to the primary and metastatic disease. With growing recognition of oligometastatic disease state at diagnosis, response, or progression, radiotherapy can consolidate response by ablating residual or resistant lesions. Experience with other primary cancers supports positive impact of radiotherapy on disease control, quality of life, and survival in oligometastatic stage, without significant adverse effects. Alongside immune checkpoint inhibitors, fibroblast growth receptor inhibitors, and antibody-drug conjugates, the immunomodulatory potential of radiotherapy is being explored in combination with these systemic therapies for metastatic bladder cancer.

CONCLUSION

Radiotherapy is an effective, safe, and accessible treatment modality for palliation as well as disease control in various clinical settings of metastatic bladder cancer. Its role in oligometastatic stage in combination with systemic therapy is expected to expand with emerging evidence.

Bladder cancer

Bladder cancer is a global health issue with sex differences in incidence and prognosis. Bladder cancer has distinct molecular subtypes with multiple pathogenic pathways depending on whether the disease is non-muscle invasive or muscle invasive. The mutational burden is higher in muscle-invasive than in non-muscle-invasive disease. Commonly mutated genes include TERT, FGFR3, TP53, PIK3CA, STAG2 and genes involved in chromatin modification. Subtyping of both forms of bladder cancer is likely to change considerably with the advent of single-cell analysis methods. Early detection signifies a better disease prognosis; thus, minimally invasive diagnostic options are needed to improve patient outcomes. Urine-based tests are available for disease diagnosis and surveillance, and analysis of blood-based cell-free DNA is a promising tool for the detection of minimal residual disease and metastatic relapse. Transurethral resection is the cornerstone treatment for non-muscle-invasive bladder cancer and intravesical therapy can further improve oncological outcomes. For muscle-invasive bladder cancer, radical cystectomy with neoadjuvant chemotherapy is the standard of care with evidence supporting trimodality therapy. Immune-checkpoint inhibitors have demonstrated benefit in non-muscle-invasive, muscle-invasive and metastatic bladder cancer. Effective management requires a multidisciplinary approach that considers patient characteristics and molecular disease characteristics.

Selective multimodal bladder-sparing therapy for muscle-invasive bladder cancer: the present and the future

INTRODUCTION

Despite the lack of level 1 evidence, selective bladder-sparing therapy using trimodal therapy is currently recommended by guidelines as a standard of care in patients with non-metastatic, muscle-invasive bladder cancer who are eligible for the treatment.

AREAS COVERED

This article reviews major studies of selective, bladder-sparing therapy utilizing multiple modalities for muscle-invasive bladder cancer and those comparing the oncological outcomes between bladder-sparing therapy and radical cystectomy. Also discussed are predictive biomarkers potentially capable of guiding treatment decisions by patients with muscle-invasive bladder cancer and a novel strategy for boosting the antitumor immune response in bladder-sparing therapy. PubMed databases were searched for records of 30 June 2023 or earlier.

EXPERT OPINION

Selective, bladder-sparing therapy appears to be underutilized at present. To promote its use, measures should be taken to facilitate the referral of eligible patients to specialist centers and broaden the number of facilities providing the therapy. Recent studies have suggested a prognostic benefit of radiotherapy for the primary lesion in patients with metastatic bladder cancer. Given that irradiation can induce the abscopal effect, particularly in combination with immune checkpoint inhibitors, demand for bladder-sparing therapies may increase in the context of treatments for metastases.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis from Urothelial Origin: a Case Report and Literature Review

Introduction

Urothelial carcinomas (UC) are the fourth most common tumours. Approximately, 50% of patients with invasive bladder cancer relapse after radical cistectomy (RC). In this report, we present the case of peritoneal carcinomatosis from bladder UC treated with cytoreductive surgery plus the administration of hyperthermic intraperitoneal chemotherapy (CRS + HIPEC).

Case Presentation

A 34-year-old woman diagnosed with high-grade bladder cancer with peritoneal recurrence in 2017. She underwent cytoreductive surgery followed by HIPEC with mitomycin C. Histopathological results showed metastases from UC in the left ovary and right diaphragmatic peritoneum. In 2021, the patient underwent surgery after treatment with atezolizumab for abdominal wall recurrence. Today, the patient is alive and free of tumor recurrence 12 months after the last surgery.

Discussion

Despite advances in surgical technique and patient selection, the risk of relapse remains high among patients with muscle-invasive bladder cancer. We face the case of a young female patient with local, peritoneal, and lymphatic recurrence of bladder cancer after RC who had a partial response to chemotherapy. The possibility of CRS + HIPEC is offered by the surgical oncology unit, referent in the management of peritoneal carcinomatosis. Surgery is capable of resecting residual tumor in patients with a partial response or who have been erroneously underdiagnosed.

Conclusion

CRS + HIPEC might be a valid option to be considered in well-selected patients and to be performed in reference units. There is a need for more collaborative clinical trials and prospective studies addressing the role of surgery in patients with metastatic bladder cancer.

Retrospective Analysis of a Cohort of Patients with Metastatic Bladder Cancer with Metastatic Sites Limited to the Pelvis and Retroperitoneum Treated at a Single Institution between 2009 and 2020

Bladder cancer (BC) presenting with pelvic and retroperitoneal lymph nodes presents a therapeutic challenge. The impact of chemoradiotherapy on pelvic and retroperitoneal lymph node metastasis as a consolidation treatment has not been established. Between 2009 and 2020, 502 patients who were treated with first-line chemotherapy for BC in our center, were retrospectively identified. Patients who received chemoradiotherapy or radiotherapy with an equivalent radiation dose superior to 30 Gy were included in the RTCT group, and other patients were included in the control group (CT group). We performed an analysis of progression-free survival (PFS) and overall survival (OS) for these two cohorts using the Kaplan–Meier method. A total of 89 patients were included, 24 in the RTCT group and 65 in the CT group. Chemoradiotherapy improved both OS (p = 0.034) and PFS (p = 0.009) in comparison with chemotherapy alone: 26.3 months (95% IC 0.0–52.9) and 19.4 months (95% IC 5.0–33.7), respectively, in the RTCT group versus 17.2 months (95% IC 13.7–20.6) and 11.2 months (95% IC 8.6–13.8), respectively, in the CT group. Grade 3/4 toxicity was related to chemotherapy and to chemoradiotherapy at levels of 31% and 24%, respectively. For mBC with metastatic regional or retroperitoneal lymph nodes, chemoradiotherapy seems to confer benefits for both OS and PFS.

Consolidative Radiotherapy for Metastatic Urothelial Bladder Cancer Patients with No Progression and with No More than Five Residual Metastatic Lesions Following First-Line Systemic Therapy: A Retrospective Analysis

Local consolidative radiotherapy in the treatment of metastatic malignancies has shown promising results in several types of tumors. The objective of this study was to assess consolidative radiotherapy to the bladder and to residual metastases in metastatic urothelial bladder cancer with no progression following first-line systemic therapy.

MATERIALS/METHODS

Patients who received first-line therapy for the treatment of metastatic urothelial bladder cancer (mUBC) and who were progression-free following treatment with no more than five residual metastases were retrospectively identified through the database of four Comprehensive Cancer Centers, between January 2005 and December 2018. Among them, patients who received subsequent definitive radiotherapy (of EQD2Gy > 45Gy) to the bladder and residual metastases were included in the consolidative group (irradiated (IR) group), and the other patients were included in the observation group (NIR group). Progression-free survival (PFS) and overall survival (OS) were determined from the start of the first-line chemotherapy using the Kaplan-Meier method. To prevent immortal time bias, a Cox model with time-dependent covariates and 6-month landmark analyses were performed to examine OS and PFS.

RESULTS

A total of 91 patients with at least stable disease following first-line therapy and with no more than five residual metastases were analyzed: 51 in the IR group and 40 in the NIR group. Metachronous metastatic disease was more frequent in the NIR group (19% vs. 5%, p = 0.02); the median number of metastases in the IR group vs. in the NIR group was 2 (1-9) vs. 3 (1-5) (p = 0.04) at metastatic presentation, and 1 (0-5) vs. 2 (0-5) (p = 0.18) after completion of chemotherapy (residual lesions), respectively. Two grade 3 toxicities (3.9%) and no grade 4 toxicity were reported in the IR group related to radiotherapy. With a median follow up of 85.9 months (95% IC (36.7; 101.6)), median OS and PFS were 21.7 months (95% IC (17.1; 29.7)) and 11.1 months (95% IC (9.9; 14.1)) for the whole cohort, respectively. In multivariable analysis, consolidative radiotherapy conferred a benefit in both PFS (HR = 0.49, p = 0.007) and OS (HR = 0.47, p = 0.015) in the whole population; in the landmark analysis at 6 months, radiotherapy was associated with improved OS (HR = 0.48, p = 0.026), with a trend for PFS (HR = 0.57, p = 0.082).

CONCLUSION

Consolidative radiotherapy for mUBC patients who have not progressed after first-line therapy and with limited residual disease seems to confer both OS and PFS benefits. The role of consolidative radiotherapy in the context of avelumab maintenance should be addressed prospectively.

Cytoreductive Surgery in Patients with Urothelial Bladder Cancer

Cytoreductive cystectomy appears to have survival advantages as a part of multimodal approach for well-selected patients with bladder cancer. Patient with clinical lymph node metastases might benefit from surgical consolidation after achieving a measurable response to chemotherapy. The exact role of cytoreductive/consolidative cystectomy is yet to be determined in well-designed prospective trials.

Survival Impact of Nephroureterectomy for De Novo Stage IV Nonmetastatic and Metastatic Upper Tract Urothelial Carcinoma

Background

Whether nephroureterectomy (NU) provides survival benefits in patients with stage IV upper tract urothelial carcinoma (UTUC) remains unclear. We compared the effect of chemotherapy (CT) alone with that of CT combined with NU (CT + NU) on the overall survival (OS) of patients with stage IV nonmetastatic UTUC (nmUTUC) and metastatic UTUC (mUTUC).

Patients and Methods

This multicenter retrospective cohort study included the data of patients with UTUC undergoing CT alone or CT + NU from the Chang Gung Cancer Database (2002–2015) and followed them until August 2017. OS and hazard ratios (HRs) were assessed using the Kaplan–Meier method and Cox proportional hazards model, respectively.

Results

This study included 308 patients with stage IV UTUC, comprising 139 with nmUTUC and 169 with mUTUC. Moreover, 91 (74.6%) patients with nmUTUC and 31 (25.4%) patients with mUTUC received NU. The CT + NU group had a higher 3-year OS rate (41.0.% vs 16.7%, p < 0.001), longer median OS duration (20.7 vs 9.0 months, p < 0.001), and lower risk of death (HR, 0.48; 95% confidence interval, 0.36–0.66; p < 0.001) than did the CT-alone group. Similarly, patients with mUTUC who underwent CT + NU had a longer median OS duration (25.0 vs 7.8 months, p < 0.001) and lower risk of death (HR, 0.37; 95% confidence interval, 0.23–0.59; p < 0.001) than did those who received CT alone.

Conclusion

Compared with CT alone, NU + CT can provide survival benefits to patients with nonmetastatic and metastatic stage IV UTUC.

Efficacy of Surgery on the Primary Tumour in Patients with Metastatic Bladder Cancer: A Comprehensive Review

BACKGROUND: The benefit of surgery of the primary tumor in metastatic bladder cancer is unknown. OBJECTIVE: Perform a comprehensive contemporary literature review on the benefit of surgery of the primary tumor in metastatic bladder cancer. METHODS: Ovid MEDLINE, Ovid EMBASE, and Cochrane Library from January 1, 1990 to April 20, 2020 were queried for relevant articles published in English. Each article was evaluated by at least two content experts prior to inclusion which were blinded to the other’s evaluation. A third content expert was used when there was not a unanimous decision. Additional articles were added at the discretion of the authors. RESULTS: Long-term survival is possible in patients with initially unresectable and/or limited metastatic disease. Multi-modal therapy with chemotherapy and surgery have the most favorable outcomes when compared to single treatment modalities in selected populations. Patients who demonstrate a robust response to pre-surgical therapy are likely to benefit the most from consolidative surgery. Patients with distant metastatic disease may benefit from consolidative surgery; however, this benefit may only be seen in those with metastatic disease limited to one site. CONCLUSIONS: Surgery of the primary tumor in metastatic bladder cancer either in the setting of surgery alone, consolidative therapy or coupled with adjuvant therapy may be beneficial in well selected patients and should generally be limited to those who have a response to primary chemotherapy. Randomized clinical control trials are needed to further our understanding of the role of surgery in metastatic bladder cancer. Systematic Review Registration number: CRD42020182861

Plasmacytoid variant urothelial carcinoma of the bladder: effect of radical cystectomy and chemotherapy in non-metastatic and metastatic patients

PURPOSE

Data about optimal management of plasmacytoid (PCV) bladder cancer patients are extremely scarce and limited by sample size. We focused on PCV bladder cancer patients to explore the effect of radical cystectomy (RC) and chemotherapy in non-metastatic (T _2-4N_0-3M₀), as well as in metastatic (T_anyN_anyM₁) subgroups.

METHODS

Using the Surveillance, Epidemiology and End Results database (2000-2016), we identified 332 PCV patients with muscle-invasive disease or higher (≥ T₂N₀M₀). Kaplan-Meier plots and Cox regression models addressed cancer-specific mortality (CSM).

RESULTS

In 332 PCV patients, median age was 68 years (Interquartile range [IQR]:58-76). Of those, 252 were non-metastatic patients (76%) vs 80 were metastatic patients (24%), at presentation. Of non-metastatic patients, 142 (56%) underwent RC and 131 (52%) underwent chemotherapy. Chemotherapy did not improve CSM in non-metastatic PCV. Conversely, RC was associated with lower CSM (hazard ratio [HR]: 0.51, p = 0.002). Median CSM-free survival was 48 vs 38 months for RC treated vs RC not treated. Of metastatic patients, 22 (28%) underwent RC and 42 (52%) underwent chemotherapy. Both chemotherapy and RC improved CSM in metastatic PCV. Median CSM-free survival was 12 vs 7 months for RC treated vs RC not treated (HR: 0.27, p < 0.001). Median CSM-free survival was 11 vs 4 months for chemotherapy exposed vs chemotherapy naïve (HR: 0.32, p = 0.002).

CONCLUSIONS

Although RC resulted in lower CSM, chemotherapy failed to show that effect in non-metastatic PCV patients. Conversely, both chemotherapy and RC resulted in statistically significantly lower CSM in metastatic PCV patients.

[Locally advanced or oligometastatic bladder cancer-role of local treatment of the primary tumor and metastases]

Hintergrund

Das muskelinvasive Blasenkarzinom stellt in seiner Behandlung eine besondere Herausforderung dar, da die Therapie mit signifikanten Nebenwirkungen und Komplikationsraten einhergeht, insbesondere bei Patienten mit relevanten Begleiterkrankungen. Im metastasierten Stadium besteht der Therapiezweck in der Palliation, wobei das Vorliegen einer Oligometastasierung eine gesonderte Rolle einnimmt. In diesem Stadium kann auch die Therapie des Primärtumors relevant sein, wenn die Metastasen neben einer systemischen Therapie ebenso lokal behandelt werden können – insbesondere auch in Hinblick auf die über die letzten Jahre die Therapielandschaft erweiternden neuen medikamentösen Möglichkeiten.

Ziel der Arbeit

In diesem Reviewartikel sollen die Einflüsse einer definitiven Therapie des Primärtumors bei Patienten mit oligometastasiertem Urothelkarzinom der Harnblase dargelegt werden.

Material und Methoden

Basierend auf einer nicht-systemischen Literaturrecherche soll ein Überblick über bestehende Ergebnisse zur Therapie des oligometastasierten Blasenkarzinoms in Hinblick auf den Einfluss der Therapie des Primärtumors geben, wobei die Daten meist auf retrospektiven Studien und Metaanalysen bestehen.

Schlussfolgerung

Eine Lokaltherapie des Primärtumors im Rahmen eines multimodalen Therapiekonzepts kann bei selektionierten Patienten mit lymphogen metastasiertem und oligometastasiertem Blasenkarzinom einen positiven Einfluss auf Überleben, Lebensqualität und Vermeidung von Lokalkomplikationen nehmen, wobei für die Wahl der lokalen Therapie dieselben Kriterien angewendet werden sollten wie im nicht-metastasierten Stadium.

Comparative effectiveness analysis of first-line immunotherapy versus chemotherapy in metastatic urothelial carcinoma of the bladder

BACKGROUND

Clinical trials have not shown a significant overall survival (OS) difference between chemotherapy and immunotherapy as first-line agents in metastatic urothelial carcinoma (UC). However, the generalizability of these findings in a real-world setting has not yet been evaluated in comparative effectiveness studies.

OBJECTIVE

To assess the effectiveness of first-line immunotherapy compared with chemotherapy regimens on OS in patients with metastatic UC of the bladder.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective propensity-matched study identified metastatic bladder UC patients in the National Cancer Database from 2014 to 2017 who received either first-line immunotherapy-monotherapy or multi-agent chemotherapy, and who were not treated on a clinical trial protocol.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was OS from the date of diagnosis to date of death or censoring at last follow-up. Patients were stratified into first-line immunotherapy and chemotherapy treatment groups. After 1:1 nearest-neighbor caliper-matching of propensity scores, the survival analysis was conducted using Cox regression modeling and Kaplan-Meier estimates.

RESULTS AND LIMITATIONS

A total of 2,796 patients were included in the final study population, and 960 in the matched cohort (480 per treatment group). Utilization of immunotherapy increased over the time period studied as chemotherapy decreased (Immunotherapy: 3%-37%; Chemotherapy: 97%-63%; P < 0.001). In the overall cohort, patients who received first-line immunotherapy were older and more comorbid than those who received first-line chemotherapy (Age: 73 v. 67, respectively, P < 0.001; Charlson-Deyo score ≥2: 17% v. 11.5%, respectively, P < 0.001). In the matched cohort, patients who were treated with first-line immunotherapy had similar OS to those who were treated with first-line chemotherapy (HR: 0.91, 95CI 0.72-1.15). Due to the retrospective nature of the study, interpretation is limited by potential selection bias from unmeasured confounding.

CONCLUSIONS AND RELEVANCE

Metastatic bladder UC patients who received first-line immunotherapy had similar OS to those who received first-line chemotherapy.

High-intensity local treatment of clinical node-positive urothelial carcinoma of the bladder alongside systemic chemotherapy improves overall survival

PURPOSE

Clinical node-positive urothelial carcinoma of the bladder (cN+UCaB) is a rapidly fatal disease with limited information on comparative-effectiveness of available treatment options. We sought to examine the impact of high-intensity vs. conservative local treatment (LT) regimens in management of these patients alongside systemic chemotherapy.

MATERIALS AND METHODS

We identified 3,227 patients within the National Cancer Data Base who underwent multiagent systemic chemotherapy along with either high-intensity or conservative LT for primary cN+UCaB between 2004-2016. Patients who received no LT, TURBT alone, or <50 Gy radiation therapy to the bladder were included in the conservative group, while patients that received radical cystectomy with pelvic lymphadenectomy or ≥50 Gy radiation therapy with TURBT were included in the high-intensity group. Inverse probability of treatment weighting (IPTW) adjusted Kaplan-Meier and Cox regression analyses were used to assess overall survival (OS). Additionally, to assess whether the benefit of high-intensity LT differs by baseline mortality risk, we tested an interaction between 5-year predicted life-expectancy and the LT type.

RESULTS

Overall, 784 (24.3%) and 2,443 (75.7%) cN+UCaB patients underwent high-intensity and conservative LT, respectively. IPTW-adjusted Kaplan-Meier analysis demonstrated OS to be significantly higher in the high-intensity group compared to the conservative group: 5-year OS 28.4% vs. 18.3%, respectively (Log-rank P<0.001). IPTW-adjusted multivariable Cox regression analysis confirmed the benefit of high-intensity LT in prolonging OS (HR 0.63, P<0.001). Interaction analysis showed that high-intensity LT approach was associated with longer OS in all patients regardless of their baseline 5-year life-expectancy (P_interaction=0.79).

CONCLUSION

Eligible patients with cN+UCaB should be considered for aggressive local treatment alongside multiagent systemic chemotherapy. Prospective trials are needed to validate these preliminary findings.

Utilization and outcomes of metastasectomy for patients with metastatic urothelial cancer: An analysis of the national cancer database

BACKGROUND

Surgical resection of oligometastatic disease has been shown to be associated with an improved survival in other malignancies, though its role is not established in metastatic urothelial carcinoma (mUC). We sought to examine utilization trends of metastasectomy in mUC and associated outcomes using the NCDB database.

METHODS

We queried the NCDB from 2004 to 2016 for patients with metastatic urothelial carcinoma who had undergone metastasectomy. The annual utilization trend of metastasectomy was evaluated by linear regression. We compared overall survival (OS) between propensity score matched patients who had undergone metastasectomy and those who had not using two-sided log-rank and Cox regression models. We also performed sensitivity analyses on subcohorts of mUC.

RESULTS

The utilization rate of metastasectomy in mUC was 7% and did not change significantly over time. Patients who received metastasectomy on average were younger, had >cT3 disease, had radical surgery to the primary tumor, and received systemic therapy. After propensity score matching, metastasectomy was not associated with an OS benefit for mUC patients (HR, 0.94; 95% CI, 0.83 to 1.07; P=0.38). Stratified subgroup analysis based on systemic therapy, radical surgery to primary tumor, clinical N stage, and primary location of disease did not show an OS benefit of metastasectomy.

CONCLUSION

Metastasectomy is uncommonly used, though utilization has persisted over more than a decade. Despite selection biases and residual confounding favoring patients undergoing metastasectomy, we found similar OS among these individuals and those who did not undergo metastasectomy.

Postoperative and Survival Outcomes After Cytoreductive Surgery in the Treatment of Metastatic Upper Tract Urothelial Carcinoma

OBJECTIVE

To analyze utilization and outcomes of cytoreductive surgery (CRS) after systemic chemotherapy in select patients with metastatic upper tract urothelial carcinoma (UTUC).

MATERIAL AND METHODS

We identified 1,73 patients with cM1 UTUC from the National Cancer Database who were treated with first-line multiagent chemotherapy from 2004 to 2015. Patients considered surgical candidates based on Charlon-Deyo performance score were stratified into nonsurgical versus surgical arms based on receipt of CRS after systemic therapy. Those receiving radiation, immunotherapy, or other types of treatment were excluded. Cox proportional hazard models were used to analyze prognostic factors for overall survival (OS). Propensity-score matching and inverse probability of treatment weighting-adjusted regression models were used to compare OS.

RESULTS

A total of 1182 patients were included of which 349 (29.5%) were treated with definitive surgery. Median follow-up was 64 months (95% confidence interval:49.8-79.4) for chemotherapy+surgery versus 61.2 (52.2-78.7) for the chemotherapy-alone arms (P = .09). Patients treated with surgery were younger and more commonly treated at academic facilities. Patients who received CRS had improved median-OS versus those treated with chemotherapy alone (13.7 vs 10.8 months, log-rank P-value <.001). Predictors of OS were performance score, treatment at academic facility, and performance of CRS. Furthermore, in propensity-score and inverse probability of treatment weighting-adjusted Cox regression analyses, CRS was associated with significant OS benefit (hazard ratios = 0.61, 95% confidence interval:0.49-0.77, and 0.63;0.55-0.72; respectively).

CONCLUSION

We provide a contemporary report on the survival benefit of CRS after treatment with systemic therapy for M1 UTUC patients. Longitudinal studies are needed to evaluate the role of surgery, when feasible, within multidisciplinary approaches for this relatively, rare disease.

Impact of high-intensity local treatment on overall survival in stage IV upper tract urothelial carcinoma

OBJECTIVES

To investigate the impact of high-intensity local treatment (LT) on overall survival (OS) in patients with stage IV upper tract urothelial carcinoma (UTUC).

PATIENTS AND METHODS

Within the National Cancer Database, we identified 7,357 patients diagnosed with stage IV UTUC from 2004 to 2015. Patients who underwent high-intensity LT, defined as radical surgery of the primary tumor, were compared with those who did not. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Weighted survival analyses were used to test the association between high-intensity LT and OS. Multivariable Cox model was used to assess for independent predictors of OS. Sensitivity analysis was used to account for possible biases.

RESULTS

Among stage IV patients, 10.6% (n = 779) had locally advanced disease (T4), 32.6% (n = 2,399) had node-positive disease (N+) and 56.8% (N = 4,179) had distant metastases (M+). Fewer than half of the patients underwent high-intensity LT (n = 2,908, 39.5%) while the remainder did not. On IPTW-adjusted survival analysis, high-intensity LT was associated with a prolonged OS (11.17 months [IQR, 5.19 to 24.28] months vs. 6.18 months [IQR, 2.27 to 14.49], P ≤ 0.001). A similar benefit was seen on adjusted survival analyses for each stage IV subgroup, defined according to TNM characteristics. The survival benefit was confirmed at sensitivity analysis.

CONCLUSION

High-intensity LT in balanced cohorts of patients with stage IV UTUC is associated with prolonged OS including those with locally advanced (T4), node-positive (N+) or distant metastases (M+).

Definitive Local Therapy Is Associated with Improved Survival in Metastatic Soft Tissue Sarcomas

Background: Definitive local therapy is often utilized in patients with metastatic soft tissue sarcomas (STS) to reduce morbidity associated with local tumor progression. We hypothesize that it is associated with improved overall survival (OS). Methods: Patients with newly diagnosed metastatic STS treated with chemotherapy were identified from the National Cancer Database and dichotomized into cohorts: 1. definitive local therapy (defined as either definitive dose radiotherapy, definitive surgery, or surgery with perioperative radiotherapy) or 2. conservative therapy (defined as systemic therapy with or without palliative therapy). The association between definitive local therapy and OS, and factors associated with the receipt of definitive local therapy were assessed. Results: Total of 4180 patients were identified. Compared with the conservative therapy, receipt of any definitive local therapy was associated with improved OS (median 17.9 vs. 10.1 months). The survival benefit remained on multivariate analyses and propensity-score matched analyses, with a stepwise improvement with surgery and combined modality local therapy, specifically radiotherapy (HR: 0.77; p < 0.001), surgery (HR: 0.67; p < 0.001), and combined surgery and radiotherapy (HR: 0.42; p < 0.001). Conclusions: Analysis of a large national cancer registry of patients with metastatic STS suggests that chemotherapy plus definitive local therapy is associated with a significant survival benefit compared to the standard chemotherapy alone.

Efficacy and Safety of Locoregional Radiotherapy With Chemotherapy vs Chemotherapy Alone in De Novo Metastatic Nasopharyngeal Carcinoma: A Multicenter Phase 3 Randomized Clinical Trial

Importance

The role of locoregional radiotherapy in patients with de novo metastatic nasopharyngeal carcinoma (mNPC) is unclear.

Objective

To investigate the efficacy and safety of locoregional radiotherapy in de novo mNPC.

Design, Setting, and Participants

Patients with biopsy-proven mNPC, who demonstrated complete or partial response (RECIST v1.1) following 3 cycles of cisplatin and fluorouracil chemotherapy, were enrolled. Eligible patients were randomly assigned (1:1) to receive either chemotherapy plus radiotherapy or chemotherapy alone. Overall, 126 of 173 patients screened were eligible to the study, and randomized to chemotherapy plus radiotherapy (n = 63) or chemotherapy alone (n = 63). Median (IQR) follow-up duration was 26.7 (17.2-33.5) months.

Interventions

The chemotherapy regimens were fluorouracil continuous intravenous infusion at 5 g/m2 over 120 hours and 100 mg/m2 intravenous cisplatin on day 1, administered every 3 weeks for 6 cycles. Patients assigned to the chemotherapy plus radiotherapy group received intensity-modulated radiotherapy (IMRT) after chemotherapy.

Main Outcomes and Measures

The primary end point of the study was overall survival (OS). The secondary end point was progression-free survival (PFS) and safety.

Results

Overall, 126 patients were enrolled (105 men [83.3%] and 21 women [16.7%]; median [IQR] age, 46 [39-52] years). The 24-month OS was 76.4% (95% CI, 64.4%-88.4%) in the chemotherapy plus radiotherapy group, compared with 54.5% (95% CI, 41.0%-68.0%) in the chemotherapy-alone group. The study met its primary end point of improved OS (stratified hazard ratio [HR], 0.42; 95% CI, 0.23-0.77; P = .004) in favor of chemotherapy plus radiotherapy. Progression-free survival was also improved in the chemotherapy plus radiotherapy group compared with the chemotherapy-alone group (stratified HR, 0.36; 95% CI, 0.23-0.57). No significant differences in acute hematological or gastrointestinal toxic effects were observed between the treatment arms. The frequency of acute grade 3 or higher dermatitis, mucositis, and xerostomia was 8.1%, 33.9%, and 6.5%, respectively, in the chemotherapy plus radiotherapy group. The frequency of late severe grade 3 or higher hearing loss and trismus was 5.2% and 3.4%, respectively, in the chemotherapy plus radiotherapy group.

Conclusions and Relevance

In this randomized clinical trial, radiotherapy added to chemotherapy significantly improved OS in chemotherapy-sensitive patients with mNPC.

Trial Registration

ClinicalTrials.gov Identifier: NCT02111460.

Brachytherapy-based radiotherapy is associated with improved survival for newly diagnosed metastatic cervical cancer

PURPOSE

The purpose of this study was to explore the value of brachytherapy (BT) in metastatic cervical cancer, as it has not been well evaluated before.

METHODS AND MATERIALS

We analyzed 2391 patients with Stage IVB cervical cancer from 2004 to 2015 by using data from the Surveillance, Epidemiology, and End Results registry. The parameters were analyzed by Kaplan-Meier and Cox proportional hazards regression models to evaluate cancer-specific survival (CSS) and overall survival.

RESULTS

In general, both univariate and multivariate analysis showed that age, histologic type, tumor size, and chemotherapy were associated with CSS and overall survival (p < 0.05). Further subgroup analysis showed BT alone or BT combined with external beam radiotherapy improved CSS despite the tumor size. In addition, chemotherapy and chemoradiotherapy prolonged CSS compared with external beam radiotherapy alone or no chemotherapy or radiotherapy independently of tumor size (p < 0.05).

CONCLUSIONS

For newly diagnosed metastatic cervical cancers, BT with or without external beam radiotherapy is associated with improved survival. As an aggressive option, chemoradiotherapy is also a potential treatment strategy.

Is it Time to Consider Eliminating Surgery from the Treatment of Locally Advanced Bladder Cancer?

The similar clinical behavior, overlapping therapeutic patterns, and several clinical trials addressing the neoadjuvant and first-line therapy settings for bladder cancer support the call for a more uniform definition of "locally advanced" disease. We highlight the diverse therapeutic opportunities that patients with locally advanced bladder cancer may receive at present. Multimodal management, and post-therapy surgery in particular, may still have a role in selected patients.

Deferred Cytoreductive Nephrectomy in Patients with Newly Diagnosed Metastatic Renal Cell Carcinoma

BACKGROUND

The use of cytoreductive nephrectomy (CN) selectively for patients who show a favorable response to upfront systemic therapy may be an approach to select optimal candidates with metastatic renal cell carcinoma (mRCC) who are most likely to benefit.

OBJECTIVE

We sought to characterize outcomes of deferred CN (dCN) after upfront sunitinib, outcomes relative to sunitinib alone, and outcomes of CN followed by sunitinib.

DESIGN, SETTING, AND PARTICIPANTS

We used the prospectively maintained International mRCC Database Consortium (IMDC) database to identify patients with newly diagnosed mRCC (2006-2018).

INTERVENTION

Sunitinib alone, upfront CN followed by sunitinib, sunitinib followed by dCN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Outcomes were overall survival (OS) and time to sunitinib treatment failure (TTF). Kaplan-Meier and multivariable Cox regression analyses were performed; dCN was analyzed as a time-varying covariate to account for immortal time bias.

RESULTS AND LIMITATIONS

We evaluated 1541 patients, of whom 651 (42%) received sunitinib alone, 805 (52%) underwent CN followed by sunitinib, and 85 (5.5%) received sunitinib followed by dCN, at a median of 7.8 mo from diagnosis. Median OS periods for patients treated with sunitinib alone, CN followed by sunitinib, and sunitinib followed by dCN were 10, 19, and 46 mo, respectively, while the median TTF values were 4, 8, and 13 mo, respectively. In multivariable regression analyses, sunitinib followed by dCN was significantly associated with improved OS (hazard ratio [HR] = 0.45, 95% confidence interval [CI] 0.33-0.60, p < 0.001) and TTF (HR = 0.62, 95% CI 0.46-0.85, p = 0.003) versus sunitinib alone. Among CN-treated patients, sunitinib followed by dCN was associated with improved OS (HR = 0.52, 95% CI 0.39-0.70, p < 0.001) and TTF (HR = 0.71, 95% CI 0.56-0.90, p = 0.005) compared with upfront CN followed by sunitinib. In various sensitivity analyses, dCN remained significantly associated with improved OS and TTF.

CONCLUSIONS

Patients who received dCN were carefully selected and achieved long OS. With these benchmark outcomes, optimal selection criteria need to be identified and confirmation of the role of dCN in a clinical trial is warranted.

PATIENT SUMMARY

We characterized benchmark survival outcomes for patients with metastatic kidney cancer treated with sunitinib alone, nephrectomy (kidney removal) followed by sunitinib, and sunitinib followed by nephrectomy. Patients who had their nephrectomy after an initial course of sunitinib had prolonged survival.

The impact of gender on oncologic outcomes of bladder cancer

PURPOSE OF REVIEW

The purpose of this article is to review the current literature on the impact of gender on oncologic outcomes of bladder cancer (BCa).

RECENT FINDINGS

Women are more likely to experience disease recurrence, progression, and/or death across all disease states. Furthermore, women are less likely to respond to intravesical therapy for nonmuscle invasive BCa. These disparities are explained by several hypotheses such as differential exposure to environmental carcinogens, hormonal factors, and/or disease management. Additionally, it has been shown that women suffer from delays in diagnosis because of inefficiencies in healthcare delivery. On genomic analyses, women were found to be more likely to harbor basal subtypes of BCa compared with men.

SUMMARY

A steadily growing body of evidence reveals that women present with more advanced BCa and have stage-for-stage worse outcome compared with men. The underlying mechanisms for this gender difference are multifactorial. Further studies are needed to elucidate the molecular underpinning of this gender-gap and subsequently explore potential novel gender-specific management strategies.

Efficacy of Surgery in the Primary Tumor Site for Metastatic Urothelial Cancer: Analysis of an International, Multicenter, Multidisciplinary Database

BACKGROUND

The effect of local treatment on survival in advanced-stage patients has gained interest in several malignancies; however, limited data exist regarding urothelial carcinoma (UC).

OBJECTIVE

To test the impact of surgery of the primary tumor site on cancer-specific mortality (CSM) and overall mortality (OM) in patients affected by metastatic UC.

DESIGN, SETTING, AND PARTICIPANTS

Individual patient-level data from a multicenter collaboration, including metastatic UC patients treated with first-line cisplatin- or carboplatin-based chemotherapy administered between January 2006 and January 2011 from hospitals in the USA, Europe, Israel, and Canada.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Univariable and multivariable Cox regression analyses were used to assess the effect of surgery on CSM and OM in patients affected by metastatic UC using 3-mo landmark analyses. Subgroup analyses were performed on the basis of the number of metastasis sites involved and including only patients treated with surgery before the start of chemotherapy.

RESULTS AND LIMITATIONS

Of the 326 patients included in the study, 47 (14%) were treated with surgery of the primary tumor site. Median (interquartile range) follow-up was 43 (33-45)mo. Of the patients treated with surgery, 28 (60%) were affected by a primary bladder cancer and 19 (40%) by a primary upper urinary tract tumor. On multivariable analyses, surgery was associated with a protective effect on CSM (hazard ratio [HR]: 0.59, confidence interval [CI]: 0.35-0.98, p=0.04) and OM (HR: 0.45, CI: 0.37-0.99, p=0.04) compared with patients treated with chemotherapy only. Similar results were found considering patients only surgically treated before the start of chemotherapy. After stratifying according to the number of metastatic sites, surgery has an effect on survival in patients with only one metastatic site, while no survival benefit was observed in patients with two or more metastatic sites. The study is limited by its retrospective nature.

CONCLUSIONS

We found that surgery of the primary tumor site is associated with improved survival in patients with metastatic UC who received standard chemotherapy. This effect disappears in patients affected by two or more metastatic sites. Our results need to be validated in a high-quality prospective trial.

PATIENT SUMMARY

In our multicenter, retrospective series, surgery in metastatic urothelial cancer patients improve survival compared with patients treated with chemotherapy only. This effect was evident in patients with limited disease extent, identified as one metastatic site.

Real-world data: towards achieving the achievable in cancer care

The use of data from the real world to address clinical and policy-relevant questions that cannot be answered using data from clinical trials is garnering increased interest. Indeed, data from cancer registries and linked treatment records can provide unique insights into patients, treatments and outcomes in routine oncology practice. In this Review, we explore the quality of real-world data (RWD), provide a framework for the use of RWD and draw attention to the methodological pitfalls inherent to using RWD in studies of comparative effectiveness. Randomized controlled trials and RWD remain complementary forms of medical evidence; studies using RWD should not be used as substitutes for clinical trials. The comparison of outcomes between nonrandomized groups of patients who have received different treatments in routine practice remains problematic. Accordingly, comparative effectiveness studies need to be designed and interpreted very carefully. With due diligence, RWD can be used to identify and close gaps in health care, offering the potential for short-term improvement in health-care systems by enabling them to achieve the achievable.

Is the extirpative surgery for primary tumor helpful for the patients with metastatic urothelial cancer at the time of diagnosis?

The stagnant mortality rates for metastatic urothelial cancer (UC) have provoked efforts to find novel treatments. To test the utility of the extirpative surgery for primary tumor as an option for these patients, we investigated the perioperative and oncologic outcomes of surgery for primary tumors in metastatic UC patients.We reviewed the medical records of 130 metastatic UC patients (bladder: 88, upper tract UC: 42) at diagnosis from November 2005 to November 2016. A total of 56 patients (surgery group) underwent chemotherapy with extirpative surgery for the primary tumor, and 74 patients (non-surgery group) received chemotherapy. We evaluated perioperative outcomes, cancer-specific survival (CSS), and overall survival (OS) using Kaplan-Meier methods and factors related to OS and CSS using Cox regression models.Surgery group showed similar perioperative outcome and postoperative complications to those previously reported in UC patients without metastasis, and fewer urinary complications than non-surgery group. Surgery group showed better oncological outcomes than non-surgery group for median CSS (16.0 vs 10.0 months, P = 0.014) and median OS (14.0 vs 9.0 months, P = 0.043). Multivariate analysis showed Eastern Cooperative Oncology Group performance status and metastasis to liver as significant predictors of CSS and OS. Surgery was not related with OS, but a significant predictor of CSS.Extirpative surgery for primary tumor in metastatic UC can be feasible and it might have survival benefits, especially those patients with a tolerable general condition and no liver metastasis. In addition, LT reduces the possibility of a surgical procedure towing to urinary complications.

The role of metastatic burden in cytoreductive/consolidative radical cystectomy

PURPOSE

To describe our institutional experience with cytoreductive/consolidative radical cystectomy (CCRC) for metastatic urothelial carcinoma (UC) and to investigate clinicopathologic features predicting prolonged cancer specific survival (CSS) following CCRC.

METHODS

We performed IRB-approved review of our cystectomy database, and identified 43 patients with metastatic UC who underwent CCRC. Baseline demographics, chemotherapy regimen, clinicopathologic features, and perioperative complications were collected. Progression-free survival (PFS) and CSS were estimated from the time of CCRC. Univariate and multivariate Cox regression models were used to identify predictors of improved CSS after CCRC.

RESULTS

Of the 43 patients, 32 (74.4%) had clinical evidence of distant metastases, while 11 harbored occult metastases on the surgical specimen. The most common site of metastasis was the retroperitoneal lymph nodes, found in 30 patients. Solitary metastases were found in 22 patients (51.1%). Forty-one (95%) patients received chemotherapy prior to CCRC. Disease progression was detected in 35 patients after CCRC (median PFS 5.9 months), and 34 died of metastatic cancer (median CSS 12.3 months). On multivariate analysis, patients with solitary metastases were found to have improved CSS compared to those with multiple metastases (HR 2.62, 95% CI 1.16-5.90, p = 0.02), with median CSS of 26.0 months vs. 7.9 months (p < 0.001). Median postoperative length of stay was 10 days. Overall, 56% suffered postoperative complications, including one perioperative mortality.

CONCLUSIONS

CCRC is feasible in the setting of metastatic UC. Patients with solitary metastasis demonstrated longer CSS than those with multiple metastases, and should be considered candidates for future trials evaluating the role of CCRC for metastatic UC.

Contemporary Survival Rates for Muscle-Invasive Bladder Cancer Treated With Definitive or Non-Definitive Therapy

INTRODUCTION

Definitive, curatively intended therapy for muscle-invasive bladder cancer can be associated with significant morbidity and adverse effects on quality of life, leaving patients reluctant to opt for these interventions. We sought to provide perspective to patients and clinicians exploring therapy options.

MATERIALS AND METHODS

We examined stage-by-stage overall survival of definitive therapy (DT) (either radical cystectomy in conjunction with neoadjuvant chemotherapy or trimodal therapy) versus non-DT (including palliative transurethral resection, chemotherapy and radiation treatment) among 42,144 patients within the National Cancer Database (2004-2012).

RESULTS

The median overall survival stratified by receipt of DT versus non-DT was 45.3 versus 16.4 months, 26.7 versus 9.6 months, and 21.2 versus 7.5 months in American Joint Committee on Cancer stages II, III, and IV, respectively. In multivariable Cox regression analysis, DT conferred a significant survival benefit in all stages, most pronounced in American Joint Committee on Cancer stage IV (hazard ratio, 0.46; 95% confidence interval, 0.43-0.49; P < .001).

CONCLUSION

Despite potentially significant morbidity and adverse effects on quality of life, DT is associated with a sizable survival benefit.

Impact of tumor, treatment, and access on outcomes in bladder cancer: Can equal access overcome race-based differences in survival?

BACKGROUND

There are race-based differences in bladder cancer survival. To better understand this phenomenon, this study was designed to assess the statistical contributions of tumor, treatment, and access variables to race-based differences in survival.

METHODS

Data were extracted from the National Cancer Data Base on black and white adults with muscle-invasive bladder cancer from 2004 to 2015. The impact of tumor, access, and treatment variables on differences in survival was inferred by the performance of sequential propensity score-weighted analyses in which black and white patients were balanced with respect to demographics and health status (comorbidities) tumor characteristics, treatment, and access-related variables. The propensity score-weighted hazard of death (black vs white) was calculated after each iteration.

RESULTS

This study identified 44,577 patients with a median follow-up of 77 months. After demographics and health status were balanced, black race was associated with 18% worse mortality (hazard ratio, 1.18; 95% confidence interval [CI], 1.12-1.25; P < .001). Balancing by tumor characteristics reduced this to 16%, balancing by treatment reduced this to 10%, and balancing by access-related variables resulted in no difference. Access-related variables explained 40% (95% CI, 22.9%-57.0%) of the excess risk of death in blacks, whereas treatment factors explained 35% (95% CI, 22.2%-46.9%). The contribution of tumor characteristics was not significant.

CONCLUSIONS

In the models, differences in survival for black and white patients with bladder cancer are best explained by disparities in access and treatment, not tumor characteristics. Access to care is likely a key factor in racial disparities in cancer.

More Extensive Lymph Node Dissection Improves Survival Benefit of Radical Cystectomy in Metastatic Urothelial Carcinoma of the Bladder

BACKGROUND

Radical cystectomy (RC) may occasionally be performed in individuals with metastatic urothelial carcinoma of the bladder (mUCB). However, the role of lymph node dissection (LND) for such cases is unknown. Thus, we tested the effect of RC on cancer-specific mortality (CSM) and overall mortality in mUCB patients and the effect of LND and its extent on CSM.

PATIENTS AND METHODS

Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2013), we identified patients with mUCB who underwent RC with or without LND or non-RC management. Kaplan-Meier analyses and multivariable Cox regression models (CRMs) were used, after propensity score matching. The number of removed nodes best predicting CSM was identified using cubic splines and then was tested in multivariable CRMs.

RESULTS

Of 2314 patients, 319 (13.8%) underwent RC. After 2:1 propensity score matching, CSM-free survival was 14 versus 8 months (P < .001), and overall mortality-free survival was 12 versus 7 months (P < .001) for, respectively, RC and non-RC patients. In multivariable CRMs, lower CSM (hazard ratio = 0.48; P < .001) and lower overall mortality (hazard ratio = 0.49; P < .001) rates were recorded in RC patients. LND status did not affect CSM-free survival (13 vs. 10 months; P = .1). Cubic splines-derived cutoff of ≥ 13 number of removed nodes showed better CSM-free survival (20 vs. 11 months; P = .02) and reduced CSM in CRMs (hazard ratio = 0.67; P = .02).

CONCLUSION

Our study validates the survival benefit of RC in mUCB and highlights the importance of more extensive LND. These findings may corroborate the hypothesis of potential cytoreductive effect of surgery in the context of metastatic disease.

To resect or not to resect: The hamletic dilemma of primary tumor resection in patients with asymptomatic stage IV colorectal cancer

Primary tumor resection (PTR) in advanced asymptomatic colorectal cancer (CRC) has been a matter of intense debate for long time. With the advances in systemic treatments, this practice has decreased over the years, although it remains still pervasive. Although the removal of primary tumor has been extensively interrogated both in retrospective and prospective studies, it still remains a clinical conundrum. There are many arguments for and against PTR in CRC both from the preclinical and the clinical point of view. Two scoring models have been published aiming at identifying patients who are suitable candidate for PTR, but they deserve further investigations in larger datasets. While awaiting the results of ongoing randomized clinical trials (RCTs) on this controversial topic, both upfront systemic treatment and PTR followed by chemotherapy should be considered valid options in patients with asymptomatic mCRC. Clinical selection and a shared-decision making approach are the keys to success.

Retroperitoneal vs Transperitoneal Robot-assisted Partial Nephrectomy: Comparison in a Multi-institutional Setting

OBJECTIVES

To evaluate retroperitoneal robot-assisted partial nephrectomy (RAPN) against transperitoneal approach in a multi-institutional prospective database, after accounting for potential selection bias that may affect this comparison.

PATIENTS AND METHODS

Post-hoc analysis of the prospective arm of the Vattikuti Collective Quality Initiative database from 2014 to 2018. Six hundred and ninety consecutive patients underwent RAPN by 22 surgeons at 14 centers in 9 countries. Patients who had surgery at centers not performing retroperitoneal approach (n = 197) were excluded. Inverse probability of treatment weighting was done to account for potential selection bias by adjusting for age, gender, body mass index, comorbidities, side of surgery, location/size/complexity of tumor, renal function, American Society of Anesthesiologists score, and year of surgery. Operative and perioperative outcomes were compared between weighted transperitoneal and retroperitoneal cohorts.

RESULTS

Ninety-nine patients underwent retroperitoneal RAPN; 394 underwent transperitoneal RAPN. Hospital stay in days-median 3.0 (Interquartile range [IQR] 2.0-4.0) transperitoneal vs 1.0 (1.0-3.0) retroperitoneal; P < .001, and blood loss in mL-125 (50-250) transperitoneal vs 100 (50-150) retroperitoneal; P = .007-were lower in the retroperitoneal group. There were no differences in operative time (P = .6), warm ischemia time (P = .6), intraoperative complications (P = .99), conversion to radical nephrectomy (P = .6), postoperative major complications (P = .6), positive surgical margins (P = .95), or drop in estimated glomerular filtration rate (P = .7).

CONCLUSION

In a multi-institutional setting, both retroperitoneal and transperitoneal approach to RAPN have comparable operative and perioperative outcomes, except for shorter hospital stay with the retroperitoneal approach.

Definitive local therapy is associated with improved overall survival in metastatic cervical cancer

PURPOSE

Definitive local therapy is often used in metastatic cervical cancer to reduce morbidity associated with local tumor progression. However, the potential benefit of this therapeutic approach has not been rigorously investigated. We hypothesized that definitive local therapy is associated with improved overall survival (OS) in metastatic cervical cancer.

METHODS AND MATERIALS

Patients aged ≥18 years with newly diagnosed metastatic cervical cancer who were treated with chemotherapy were identified from the National Cancer Database. Patients were dichotomized into the following cohorts: definitive local therapy (defined as either concurrent chemoradiation therapy or definitive surgery) or conservative therapy (defined as systemic therapy with or without palliative radiation therapy). The association between definitive local therapy and OS was assessed using propensity score-weighted Cox proportional hazards models. Potential unmeasured confounding was assessed through sensitivity analyses. Factors associated with the receipt of definitive local therapy were identified with multivariable logistic regression.

RESULTS

A total of 2838 patients were identified, of whom 1194 (42%) and 1644 (58%) were treated with definitive local and conservative therapy, respectively. Receipt of definitive local therapy was statistically significant, associated with less comorbidity, lower clinical T stage, and node negative disease. Compared with conservative therapy, definitive local therapy was associated with improved OS (hazard ratio: 0.57; 95% confidence interval, 0.52-0.62; P ≤ .001). The median OS rate was 19.2 months in the definitive local therapy cohort and 10.1 months in the conservative therapy cohort. These findings were robust to potential unmeasured confounding in sensitivity analyses and on landmark analyses of patients who survived at least 12 months (hazard ratio: 0.71; 95% confidence interval, 0.62-0.82; P ≤ .001).

CONCLUSIONS

Definitive local therapy is associated with improved OS in patients with metastatic cervical cancer. These findings suggest a novel setting for the use of definitive local therapy in the metastatic setting.

Location of Metastatic Bladder Cancer as a Determinant of In-hospital Mortality After Radical Cystectomy

BACKGROUND

A recent study of a highly select cohort suggested a survival benefit when local treatment is delivered in patients with metastatic bladder cancer (BCa).

OBJECTIVE

We examined in-hospital mortality (IHM) rates according to the presence, absence, and location of metastatic disease in a similar highly select cohort of BCa patients treated with radical cystectomy (RC).

DESIGN, SETTING, AND PARTICIPANTS

We used data for 25 004 BCa patients included in the National Inpatients Sample (NIS) database between 1998 and 2013.

INTERVENTION

Radical cystectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We tested postoperative IHM rates according to the presence of metastases and the location of metastatic disease (exclusive nodal vs distant metastases). Multivariable logistic regression analyses were adjusted for age, gender, race, comorbidities, length of hospitalization, hospital location, teaching status, hospital surgical volume, and bed size.

RESULTS AND LIMITATIONS

Among 25 004 BCa patients treated with RC, 3830 (14.4%) had nonregional lymph node metastases (NRNM), 693 (2.8%) had distant metastases (DM), and 19 965 (79.8%) had nonmetastatic disease. Virtually all patients with metastatic BCa had a single metastatic focus (n=4020; 93.7%). In multivariable logistic regression analyses, DM (odds ratio [OR] 2.31, 95% confidence interval [CI] 1.57-3.28; p<0.001) but not NRNM (OR 0.88, 95% CI 0.66-1.15; p=0.4) was associated with higher risk of IHM. The absence of information on preoperative chemotherapy and the retrospective study design may limit our findings.

CONCLUSIONS

The risk of IHM for highly select individuals with NRNM treated with RC is similar to that for patients with nonmetastatic BCa. Conversely, patients with DM are at higher risk of IHM compared to patients with NRNM.

PATIENT SUMMARY

According to existing data, radical cystectomy in the metastatic bladder cancer setting should be limited to patients with nonregional lymph node metastases, if at all indicated.