A risk-stratified approach to neoadjuvant chemotherapy in muscle-invasive bladder cancer

implications for patients classified with low-risk disease

Timothy D. Lyon, Igor Frank, Vidit Sharma, Paras H. Shah, Matthew K. Tollefson, R. Houston Thompson, Robert Jeffrey Karnes, Prabin Thapa, John Cheville, Stephen A. Boorjian

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Purpose: To validate published risk criteria for informing use of neoadjuvant chemotherapy (NAC) in patients with muscle-invasive bladder cancer (MIBC), and to examine outcomes of low-risk (LR) patients treated with immediate radical cystectomy (RC). Methods: We identified 1931 patients who underwent RC for MIBC from 1980 to 2016. Patients were considered high risk (HR) with hydronephrosis, lymphovascular invasion, variant histology and/or cT3/4 disease. Kaplan–Meier survival estimates were compared to patients classified as LR, and logistic regression was used to examine factors associated with pathologic downstaging. Results: A total of 1025 LR and 906 HR patients were identified. Median follow-up was 6.3 years (IQR 2.6–12), during which time 1321 (68%) patients died, 753 (39%) from bladder cancer. HR patients had significantly lower 5-year CSS than LR patients (50% vs. 68%, p = 0.001). Of 561 cisplatin-eligible LR patients treated with RC without NAC, 293 (52%) had pathologic non-organ confined disease; of these, 81 (14%) received adjuvant chemotherapy; 78 (14%) did not due to a perioperative event, while 134 (24%) did not due to patient/provider choice. NAC in LR patients was associated with greater odds of pT0 (OR 3.05; p < 0.001) and < pT2 (OR 2.53; p < 0.001) disease, but was not significantly associated with CSS (p = 0.31). Conclusions: Our results validate the proposed risk groups. Among LR patients treated without NAC, 52% experienced pathologic upstaging, and 14% were unable to receive adjuvant chemotherapy due to a perioperative event. These data support offering NAC to both HR and LR MIBC patients, and may be useful for patient counseling.

Original languageEnglish (US)
JournalWorld Journal of Urology
DOIs
StateAccepted/In press - Jan 1 2018

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Urinary Bladder Neoplasms
Drug Therapy
Muscles
Cystectomy
Adjuvant Chemotherapy
Hydronephrosis
Cisplatin
Counseling
Histology
Logistic Models

Keywords

  • Bladder cancer
  • Neoadjuvant therapy
  • Radical cystectomy

ASJC Scopus subject areas

  • Urology

Cite this

A risk-stratified approach to neoadjuvant chemotherapy in muscle-invasive bladder cancer : implications for patients classified with low-risk disease. / Lyon, Timothy D.; Frank, Igor; Sharma, Vidit; Shah, Paras H.; Tollefson, Matthew K.; Thompson, R. Houston; Karnes, Robert Jeffrey; Thapa, Prabin; Cheville, John; Boorjian, Stephen A.

In: World Journal of Urology, 01.01.2018.

Research output: Contribution to journalArticle

Lyon, Timothy D. ; Frank, Igor ; Sharma, Vidit ; Shah, Paras H. ; Tollefson, Matthew K. ; Thompson, R. Houston ; Karnes, Robert Jeffrey ; Thapa, Prabin ; Cheville, John ; Boorjian, Stephen A. / A risk-stratified approach to neoadjuvant chemotherapy in muscle-invasive bladder cancer : implications for patients classified with low-risk disease. In: World Journal of Urology. 2018.
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abstract = "Purpose: To validate published risk criteria for informing use of neoadjuvant chemotherapy (NAC) in patients with muscle-invasive bladder cancer (MIBC), and to examine outcomes of low-risk (LR) patients treated with immediate radical cystectomy (RC). Methods: We identified 1931 patients who underwent RC for MIBC from 1980 to 2016. Patients were considered high risk (HR) with hydronephrosis, lymphovascular invasion, variant histology and/or cT3/4 disease. Kaplan–Meier survival estimates were compared to patients classified as LR, and logistic regression was used to examine factors associated with pathologic downstaging. Results: A total of 1025 LR and 906 HR patients were identified. Median follow-up was 6.3 years (IQR 2.6–12), during which time 1321 (68{\%}) patients died, 753 (39{\%}) from bladder cancer. HR patients had significantly lower 5-year CSS than LR patients (50{\%} vs. 68{\%}, p = 0.001). Of 561 cisplatin-eligible LR patients treated with RC without NAC, 293 (52{\%}) had pathologic non-organ confined disease; of these, 81 (14{\%}) received adjuvant chemotherapy; 78 (14{\%}) did not due to a perioperative event, while 134 (24{\%}) did not due to patient/provider choice. NAC in LR patients was associated with greater odds of pT0 (OR 3.05; p < 0.001) and < pT2 (OR 2.53; p < 0.001) disease, but was not significantly associated with CSS (p = 0.31). Conclusions: Our results validate the proposed risk groups. Among LR patients treated without NAC, 52{\%} experienced pathologic upstaging, and 14{\%} were unable to receive adjuvant chemotherapy due to a perioperative event. These data support offering NAC to both HR and LR MIBC patients, and may be useful for patient counseling.",
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T2 - implications for patients classified with low-risk disease

AU - Lyon, Timothy D.

AU - Frank, Igor

AU - Sharma, Vidit

AU - Shah, Paras H.

AU - Tollefson, Matthew K.

AU - Thompson, R. Houston

AU - Karnes, Robert Jeffrey

AU - Thapa, Prabin

AU - Cheville, John

AU - Boorjian, Stephen A.

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N2 - Purpose: To validate published risk criteria for informing use of neoadjuvant chemotherapy (NAC) in patients with muscle-invasive bladder cancer (MIBC), and to examine outcomes of low-risk (LR) patients treated with immediate radical cystectomy (RC). Methods: We identified 1931 patients who underwent RC for MIBC from 1980 to 2016. Patients were considered high risk (HR) with hydronephrosis, lymphovascular invasion, variant histology and/or cT3/4 disease. Kaplan–Meier survival estimates were compared to patients classified as LR, and logistic regression was used to examine factors associated with pathologic downstaging. Results: A total of 1025 LR and 906 HR patients were identified. Median follow-up was 6.3 years (IQR 2.6–12), during which time 1321 (68%) patients died, 753 (39%) from bladder cancer. HR patients had significantly lower 5-year CSS than LR patients (50% vs. 68%, p = 0.001). Of 561 cisplatin-eligible LR patients treated with RC without NAC, 293 (52%) had pathologic non-organ confined disease; of these, 81 (14%) received adjuvant chemotherapy; 78 (14%) did not due to a perioperative event, while 134 (24%) did not due to patient/provider choice. NAC in LR patients was associated with greater odds of pT0 (OR 3.05; p < 0.001) and < pT2 (OR 2.53; p < 0.001) disease, but was not significantly associated with CSS (p = 0.31). Conclusions: Our results validate the proposed risk groups. Among LR patients treated without NAC, 52% experienced pathologic upstaging, and 14% were unable to receive adjuvant chemotherapy due to a perioperative event. These data support offering NAC to both HR and LR MIBC patients, and may be useful for patient counseling.

AB - Purpose: To validate published risk criteria for informing use of neoadjuvant chemotherapy (NAC) in patients with muscle-invasive bladder cancer (MIBC), and to examine outcomes of low-risk (LR) patients treated with immediate radical cystectomy (RC). Methods: We identified 1931 patients who underwent RC for MIBC from 1980 to 2016. Patients were considered high risk (HR) with hydronephrosis, lymphovascular invasion, variant histology and/or cT3/4 disease. Kaplan–Meier survival estimates were compared to patients classified as LR, and logistic regression was used to examine factors associated with pathologic downstaging. Results: A total of 1025 LR and 906 HR patients were identified. Median follow-up was 6.3 years (IQR 2.6–12), during which time 1321 (68%) patients died, 753 (39%) from bladder cancer. HR patients had significantly lower 5-year CSS than LR patients (50% vs. 68%, p = 0.001). Of 561 cisplatin-eligible LR patients treated with RC without NAC, 293 (52%) had pathologic non-organ confined disease; of these, 81 (14%) received adjuvant chemotherapy; 78 (14%) did not due to a perioperative event, while 134 (24%) did not due to patient/provider choice. NAC in LR patients was associated with greater odds of pT0 (OR 3.05; p < 0.001) and < pT2 (OR 2.53; p < 0.001) disease, but was not significantly associated with CSS (p = 0.31). Conclusions: Our results validate the proposed risk groups. Among LR patients treated without NAC, 52% experienced pathologic upstaging, and 14% were unable to receive adjuvant chemotherapy due to a perioperative event. These data support offering NAC to both HR and LR MIBC patients, and may be useful for patient counseling.

KW - Bladder cancer

KW - Neoadjuvant therapy

KW - Radical cystectomy

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