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Joshi M, Polimera H, Krupski T, Necchi A. Geography Should Not Be an "Oncologic Destiny" for Urothelial Cancer: Improving Access to Care by Removing Local, Regional, and International Barriers. Am Soc Clin Oncol Educ Book 2022; 42:1-14. [PMID: 35471833 DOI: 10.1200/edbk_350478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Urothelial cancer care is particularly susceptible to geographical health disparity given its complex nature, requiring access to several specialists such as a urologist, a medical oncologist, a radiation oncologist, a surgical oncologist, and multidisciplinary care teams. Furthermore, other barriers to care access in underserved areas include travel burden, longer wait times, late-stage disease at the time of diagnosis, cost, type of treatment, less enrollment in clinical trials, lack of follow-up among cancer survivors, and less research funding in this area. Here, we discuss the impact of geographical location on access to urothelial cancer care, management decisions, and outcomes and we reflect on how to address geographical disparities in care delivery.
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Affiliation(s)
- Monika Joshi
- Division of Hematology-Oncology, Department of Medicine, Penn State Cancer Institute, Hershey, PA
| | - Hyma Polimera
- Division of Hematology-Oncology, Department of Medicine, Penn State Cancer Institute, Hershey, PA
| | - Tracey Krupski
- Department of Urology, University of Virginia, Charlottesville, VA
| | - Andrea Necchi
- Vita-Salute San Raffaele University, Milan, Italy.,IRCCS Ospedale San Raffaele, Milan, Italy
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2
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Shotton R, Birtle A. Selection, Administration and Description of Neoadjuvant versus Adjuvant Therapy for Upper Tract Urothelial Carcinoma. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Barton GJ, Tan WP, Inman BA. The nephroureterectomy: a review of technique and current controversies. Transl Androl Urol 2020; 9:3168-3190. [PMID: 33457289 PMCID: PMC7807352 DOI: 10.21037/tau.2019.12.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The nephroureterectomy (NU) is the standard of care for invasive upper tract urothelial carcinoma (UTUC) and has been around for well over one hundred years. Since then new operative techniques have emerged, new technologies have developed, and the surgery continues to evolve and grow. In this article, we review the various surgical techniques, as well as present the literature surrounding current areas of debate surrounding the NU, including the lymphatic drainage of the upper urinary tract, management of UTUC involvement with the adrenals and caval thrombi, surgical management of the distal ureter, the use of intravesical chemotherapy as well as perioperative systemic chemotherapy, as well as various outcome measures. Although much has been studied about the NU, there still is a dearth of level 1 evidence and the field would benefit from further studies.
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Affiliation(s)
- Gregory J Barton
- Division of Urology, Duke University Medical Center, Durham, NC, USA
| | - Wei Phin Tan
- Division of Urology, Duke University Medical Center, Durham, NC, USA
| | - Brant A Inman
- Division of Urology, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
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4
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Kaag MG. Perioperative chemotherapy in the management of high risk upper tract urothelial cancers. Transl Androl Urol 2020; 9:1881-1890. [PMID: 32944552 PMCID: PMC7475667 DOI: 10.21037/tau.2020.03.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Radical nephroureterectomy (RNU) remains the gold-standard in the treatment of invasive urothelial cancers of the upper tract (>pT2). However, there are stage-related, postoperative recurrence and cancer-specific death rates that are unacceptably high. Multimodality treatment regimens including neoadjuvant and adjuvant cisplatin-based systemic chemotherapy have been studied. While there is a paucity of Level 1 evidence to support either regimen, both have advantages and disadvantages. The provision of chemotherapy in the neoadjuvant setting is supported by extensive bladder cancer literature, but randomized controlled trials in the upper tract have not been completed. Neoadjuvant chemotherapy also risks overtreatment of patients due to the lack of accurate pre-operative staging modalities. On the other hand, adjuvant chemotherapy is supported by the findings of one prospective randomized trial, and eliminates the need for patient selection based on imperfect pre-operative modalities. However, the rigors of surgery and the renal function loss related to nephrectomy, may preclude the provision of adjuvant chemotherapy in a significant subset of patients. One may conclude that multimodal therapy is desirable for oncologic control, but the best means of providing such therapy requires further study.
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Affiliation(s)
- Matthew G Kaag
- Division of Urology, Department of Surgery, The Pennsylvania State College of Medicine, Hershey, PA, USA
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5
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Matsunaga T, Komura K, Hashimoto T, Muraoka R, Satake N, Tsutsumi T, Tsujino T, Yoshikawa Y, Takai T, Minami K, Taniguchi K, Tanaka T, Uehara H, Hirano H, Nomi H, Ibuki N, Takahara K, Inamoto T, Ohno Y, Azuma H. Adjuvant chemotherapy improves overall survival in patients with localized upper tract urothelial carcinoma harboring pathologic vascular invasion: a propensity score-matched analysis of multi-institutional cohort. World J Urol 2020; 38:3183-3190. [PMID: 32065276 DOI: 10.1007/s00345-020-03118-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 02/03/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Whether adjuvant chemotherapy (AC) for patients with upper tract urothelial carcinoma (UTUC) offers survival benefit is still controversial. To explore the impact of AC on overall survival (OS) of cN0M0 UTUC patients, we conducted a propensity score-matched analysis using the regression model, including pathologic features such as lymphatic and vascular invasion. METHODS A multi-institutional cohort of 413 UTUC patient record was used. Propensity score matching was performed to reduce bias by potential confounding factors for survival, including pathologic features from the specimen of radical nephroureterectomy (RNU), RESULTS: Ninety-eight patients were identified as pair-matched groups (49 patients in RNU and 49 patients in RNU + AC). Kaplan-Meier curves demonstrated that a 5-year OS rate of 72.7% for patients treated with RNU + AC was significantly higher than 51.6% for those treated with RNU (p = 0.0156). On multivariate analysis, pathologic vascular invasion (HR 3.41, 95% CI 1.24-10.66, p = 0.0166) and administration of AC (HR 0.45, 95% CI 0.19-0.98, p = 0.0438) still remained as the significant predictors for OS. In patients with pathologic vascular invasion (51 of 98 patients), a significantly longer OS in RNU + AC groups was observed (median OS of 30 and 70 months in RNU and RNU + AC groups, respectively: p = 0.0432), whereas there was no significant difference in the OS between RNU (median OS: not reached) and RNU + AC (median OS: not reached) groups in patients without the invasion (p = 0.4549). CONCLUSION The result indicates a significant benefit for OS by the administration of AC, and pathologic vascular invasion in the specimen of RNU could help the patient selection to better predict the effect of AC.
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Affiliation(s)
- Tomohisa Matsunaga
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Kazumasa Komura
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan. .,Translational Research Program, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan. .,Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA. .,Translational Research Program, Osaka Medical College, Osaka, Japan.
| | - Takeshi Hashimoto
- Department of Urology, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ryu Muraoka
- Department of Urology, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Naoya Satake
- Department of Urology, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takeshi Tsutsumi
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Takuya Tsujino
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Yuki Yoshikawa
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Tomoaki Takai
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Koichiro Minami
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Kohei Taniguchi
- Translational Research Program, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Tomohito Tanaka
- Translational Research Program, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Hirofumi Uehara
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Hajime Hirano
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Hayahito Nomi
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Naokazu Ibuki
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Kiyoshi Takahara
- Department of Urology, Fujita-Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, Japan
| | - Teruo Inamoto
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Yoshio Ohno
- Department of Urology, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Haruhito Azuma
- Department of Urology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
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Chen L, Ou Z, Wang R, Zhang M, He W, Zhang J, Zu X, Yi L, Xu R, Jiang S, Qi L, Wang L. Neoadjuvant Chemotherapy Benefits Survival in High-Grade Upper Tract Urothelial Carcinoma: A Propensity Score-Based Analysis. Ann Surg Oncol 2019; 27:1297-1303. [PMID: 31853757 DOI: 10.1245/s10434-019-08128-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND To evaluate the benefit of neoadjuvant chemotherapy (NAC) for survival in high-grade upper tract urothelial carcinoma (UTUC), a propensity score-based analysis was performed with high-grade UTUC patients from multiple urologic centers. METHODS From three urologic centers, 48 high-grade UTUC patients who received chemotherapy followed by surgery (NAC group) and 72 high-grade UTUC patients who underwent initial surgery (no-NAC group) were involved in a propensity score-based analysis. After propensity score-based (1:1) matching, 37 patients receiving NAC and 37 patients not receiving NAC were followed. RESULTS The patients who received NAC had improved disease-free survival (DFS) and overall survival (OS), with a 3-year DFS rate of 78.4% and an OS rate of 86.5% versus a 3-year DFS rate of 51.4% and an OS rate of 62.2% for those treated with initial surgery (P = 0.018 and P = 0.02, respectively). In the multivariate analysis, the NAC group had a lower risk for mortality [DFS hazard ratio (HR) 0.25; 95% confidence interval (CI) 0.10-0.62; P = 0.003; OS HR 0.22; 95% CI 0.085-0.57; P = 0.002]. The analysis of patient survival in matched subgroups showed that NAC was beneficial in terms of the 3-year DFS for the group with a cT of 3 or higher (DFS HR 0.37; 95% CI 0.14-0.94; P = 0.036) and the group that had tumor with hydronephrosis (DFS HR 0.31; 95% CI 0.11-0.87; P = 0.026). CONCLUSION The study showed that NAC may be considered as an effective addition to surgery for the treatment in high-grade UTUC patients.
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Affiliation(s)
- Lingxiao Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zhenyu Ou
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Ruizhe Wang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Mengda Zhang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Wei He
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Junjie Zhang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Xiongbing Zu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Lu Yi
- Department of Urology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
| | - Ran Xu
- Department of Urology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
| | - Shusuan Jiang
- Department of Urology, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medical, Central South University, Changsha, Hunan, People's Republic of China
| | - Lin Qi
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Long Wang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.
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7
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Pelcovits A, Mueller-Leonhard C, Mega A, Amin A, Kim SP, Golijanin D, Gershman B. Outcomes of upper tract urothelial carcinoma with isolated lymph node involvement following surgical resection: implications for multi-modal management. World J Urol 2019; 38:1243-1252. [PMID: 31388818 DOI: 10.1007/s00345-019-02897-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/28/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There are limited data on the oncologic outcomes of upper tract urothelial carcinoma with isolated lymph node (LN) involvement (pN+ M0) following surgical resection. We examined pN+ M0 UTUC in a large, nationwide oncology dataset to characterize its natural history, describe trends in utilization of perioperative chemotherapy, and identify clinicopathologic features associated with survival. METHODS We identified 794 patients aged 18-89 years who underwent radical nephroureterectomy with lymph node dissection for pN+ M0 UTUC from 2006 to 2013 in the National Cancer Database. The associations of clinicopathologic features with overall survival (OS) were evaluated using Cox regression models, and a simplified risk score was created. RESULTS Median follow-up among survivors was 39.5 months, during which time 555 (70%) patients died. Over the study period, neoadjuvant chemotherapy utilization increased from 6.7 to 14.2% (p = 0.002), while adjuvant chemotherapy utilization remained stable (42.7 to 44.3%; p = 0.86). One-, 5-, and 8-year OS rates were 63.7%, 24.2%, and 18.7%, respectively. On multivariable analysis, older age, larger tumor size, higher pT stage, positive surgical margins, number of positive LNs, and non-receipt of adjuvant chemotherapy were independently associated with worse OS. A simplified risk score consisting of age, tumor size, pT stage, number of positive LNs, and margin status was created with predicted 5-year OS ranging from 12 to 44%. CONCLUSIONS In this large, contemporary cohort, pN+ M0 UTUC was associated with a 5-year OS of only 24%. Clinicopathologic predictors of survival after surgical resection may improve risk-stratification, counseling, and selection of patients for multimodal management.
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Affiliation(s)
- Aryeh Pelcovits
- Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Medicine, Rhode Island Hospital and The Miriam Hospital, Providence, RI, USA
| | | | - Anthony Mega
- Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Hematology/Oncology, The Miriam Hospital, Providence, RI, USA
| | - Ali Amin
- Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Pathology and Laboratory Medicine, The Miriam Hospital, Providence, RI, USA
| | - Simon P Kim
- Division of Urology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Dragan Golijanin
- Warren Alpert Medical School of Brown University, Providence, RI, USA.,Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI, USA.,Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI, USA
| | - Boris Gershman
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA.
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8
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Almassi N, Gao T, Lee B, Stein RJ, Haber G, Ornstein MC, Rini BI, Gilligan TD, Garcia JA, Stephenson AJ, Grivas P. Impact of Neoadjuvant Chemotherapy on Pathologic Response in Patients With Upper Tract Urothelial Carcinoma Undergoing Extirpative Surgery. Clin Genitourin Cancer 2018; 16:e1237-42. [DOI: 10.1016/j.clgc.2018.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 08/06/2018] [Accepted: 08/08/2018] [Indexed: 11/18/2022]
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9
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Safadi A, Elias I, Visoki A, Zick A, Schwalb S, Katz R. Synchronous ipsilateral renal cell carcinoma and transitional cell carcinoma of the renal pelvic with complete remission of TCC after neoadjuvant chemotherapy. Urol Case Rep 2018; 19:28-30. [PMID: 29888183 PMCID: PMC5991336 DOI: 10.1016/j.eucr.2018.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 05/01/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ali Safadi
- Department of Urology, Ziv Medical Center, Zefat, Israel
| | - Ibrahim Elias
- Department of Urology, Ziv Medical Center, Zefat, Israel
| | | | - Anat Zick
- Department of Diagnostic Radiology, Ziv Medical Center, Zefat, Israel
| | - Sergio Schwalb
- Department of Pathology, Ziv Medical Center, Zefat, Israel
| | - Ran Katz
- Department of Urology, Ziv Medical Center, Zefat, Israel
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10
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Goldberg H, Klaassen Z, Chandrasekar T, Sayyid R, Kulkarni GS, Hamilton RJ, Fleshner NE. Does perioperative chemotherapy improve survival in upper tract urothelial carcinoma? A population based analysis. Oncotarget 2018; 9:18797-18810. [PMID: 29721162 PMCID: PMC5922356 DOI: 10.18632/oncotarget.24694] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 02/24/2018] [Indexed: 01/01/2023] Open
Abstract
Objectives To evaluate the utilization and outcomes of perioperative chemotherapy in non-metastatic UTUC patients over the past decade using a large national database. Methods All patients aged 18 and older diagnosed with non-metastatic UTUC between 2004 and 2013 were identified within the Surveillance, Epidemiology and End Results (SEER) database. Relevant clinical data was collected and predictors of cancer specific mortality (CSM) and other cause mortality (OCM) were analyzed. Results The total cohort included 8,762 patients. Of these, 1,402 (16%) patients received chemotherapy, including only 35% of high-risk patients (>pT2 or N1). Treated patients had higher CSM (21.3% vs. 13.1%, p<0.001). Predictors of chemotherapy utilization included residence in Midwest states, tumor located in the ureter, higher stage and grade. Predictors of CSM included older age, residence in southern states, receipt of chemotherapy (HR = 1.151, 95% CI: 1.003-1.32, p=0.044), higher stage and grade. OCM was predicted by male gender, older age, ureteral tumor, and higher stage. A subset analysis of patients younger than 65 showed similar predictors, while an analysis of high risk patients demonstrated that chemotherapy receipt did not predict CSM or OCM. Conclusions In this large contemporary non-metastatic UTUC cohort, chemotherapy utilization was found to be quite infrequent, but increasing steadily. Perioperative chemotherapy had no effect on CSM in high-risk patients, while correlated to higher CSM in the younger patients.
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Affiliation(s)
- Hanan Goldberg
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Zachary Klaassen
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Thenappan Chandrasekar
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Rashid Sayyid
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Girish S Kulkarni
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Robert J Hamilton
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Neil E Fleshner
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
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11
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Necchi A, Lo Vullo S, Mariani L, Moschini M, Hendricksen K, Rink M, Sosnowski R, Dobruch J, Raman JD, Wood CG, Margulis V, Roupret M, Briganti A, Montorsi F, Xylinas E, Shariat SF. Adjuvant chemotherapy after radical nephroureterectomy does not improve survival in patients with upper tract urothelial carcinoma: a joint study by the European Association of Urology-Young Academic Urologists and the Upper Tract Urothelial Carcinoma Collaboration. BJU Int 2017; 121:252-259. [PMID: 28940605 DOI: 10.1111/bju.14020] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To analyse the outcomes of adjuvant chemotherapy vs observation in a multicentre cohort of patients with upper tract urothelial carcinoma (UTUC) in order to clarify whether such patients benefit from adjuvant chemotherapy after radical nephroureterectomy (RNU). PATIENTS AND METHODS Data from 15 centres were collected for a total of 1544 patients, treated between 2000 and 2015. Criteria for patient selection included pT2-4N0/x stage, or lymph node-positive disease, and prior RNU. The standardized difference approach was used to compare subgroup characteristics. Overall survival (OS) was the primary endpoint. The primary analysis used 1:1 propensity score matching, with inverse probability of treatment weighting in addition to this in the secondary analysis. The latter was also performed with the inclusion of covariates, i.e. with 'doubly robust' estimation. A 6-month landmark analysis was performed to exclude early events. RESULTS A total of 312 patients received adjuvant chemotherapy and 1232 underwent observation. Despite differences between the two groups, the standardized difference was generally <10% after matching. In the matched analysis no difference was observed in OS between adjuvant chemotherapy and observation (hazard ratio [HR] 1.14, 95% confidence inverval [CI] 0.91-1.43; P = 0.268). In the doubly robust estimate-adjusted comparison, adjuvant chemotherapy was significantly associated with shorter OS (HR 1.26, 95% CI 1.02-1.54; P = 0.032). Similar findings were confirmed in subgroup analyses stratified by pathological stage, and after landmark analysis. Results should be interpreted with consideration given to the inherent limitations of retrospective studies. CONCLUSION Adjuvant chemotherapy did not improve OS compared with observation in the present study. These results contribute to the uncertainties regarding postoperative chemotherapy in UTUC, and suggest dedicated prospective trials, new more potent therapies, and the identification of enhanced patient selection criteria are required.
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Affiliation(s)
- Andrea Necchi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Luigi Mariani
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marco Moschini
- Department of Urology, IRCCS San Raffaele Hospital, Vita Salute San Raffaele University, Milan, Italy
| | | | - Michael Rink
- Department of Urology, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Sosnowski
- Centre of Postgraduate Medical Education, European Health Centre Otwock, Warsaw, Poland
| | - Jakub Dobruch
- M. Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Jay D Raman
- Division of Urology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | - Vitaly Margulis
- Department of Urology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Morgan Roupret
- Academic Department of Urology, Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France.,Pierre et Marie Curie Medical School, University Paris 6, Paris, France
| | - Alberto Briganti
- Department of Urology, IRCCS San Raffaele Hospital, Vita Salute San Raffaele University, Milan, Italy
| | - Francesco Montorsi
- Department of Urology, IRCCS San Raffaele Hospital, Vita Salute San Raffaele University, Milan, Italy
| | - Evanguelos Xylinas
- Cochin Hospital, Assistance-Publique Hôpitaux de Paris, Paris Descartes University, Paris, France
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12
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Ding T, Zheng Z, Xu R, Zhou C. Prognostic factors and outcomes of primary transitional cell carcinoma of the ureter: a population-based study. Oncotarget 2017; 8:65983-65996. [PMID: 29029487 PMCID: PMC5630387 DOI: 10.18632/oncotarget.19623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/30/2017] [Indexed: 11/27/2022] Open
Abstract
Objective This study investigated the prognostic factors and outcomes of a large observational cohort of patients with primary transitional cell carcinoma of the ureter, which was obtained from the Surveillance, Epidemiology, and End Results database. Methods We used the Surveillance, Epidemiology, and End Results program to identify 1910 patients who had available clinical and follow-up information and were diagnosed for primary transitional cell carcinoma of the ureter between 2004 and 2013. Descriptive statistics were used to explore the epidemiology, treatment practices, and tumor characteristics of the patients. Univariate and multivariable Cox regression models were used to analyze the patient data. Results The median overall survival (OS) was 46 months, and the 5-year OS rate was 41.8%. The median CSS was 78 months, and the 5-year CSS rate was 54.3%. Multivariate analysis identified tumor grade, tumor size, AJCC stage, M stage, cancer-directed surgical procedure and radiation as independent factors of primary transitional cell carcinoma of the ureter. For early stage patients, the surgical procedure was associated with fairly longer survival and additional radiation may cause more harm than benefit. Meanwhile, for advanced stage patients, the impact of surgery on OS and CSS greatly decreased. Radiation exerted a very limited impact on clinical outcomes. Patients with bad tumor differentiation or a large tumor size were more likely to have advanced stage disease. Conclusion Durable cancer control can be expected in patients treated with surgery for early stage UTUC. The presence of advanced stage disease exerts a profound detrimental effect on the survival of patients.
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Affiliation(s)
- Tao Ding
- Department of Urology, Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Zhuojun Zheng
- Department of Hematology, Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Renfang Xu
- Department of Urology, Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Cuixing Zhou
- Department of Urology, Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
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