Trimodal Tx may benefit some bladder Ca patients

November 3, 2017

Trimodal therapy could offer superior overall survival versus radical cystectomy in certain subsets of patients with bladder cancer, according to a retrospective analysis presented at the 2017 Society of Urologic Oncology annual meeting in Washington.

Trimodal therapy could offer superior overall survival versus radical cystectomy in certain subsets of patients with bladder cancer, according to a retrospective analysis presented at the 2017 Society of Urologic Oncology annual meeting in Washington.

Although bladder cancer-related mortality was generally higher in patients undergoing trimodal therapy versus radical cystectomy, four subsets of patients had superior overall survival with trimodal therapy in this particular analysis, which was based on Medicare-linked Surveillance, Epidemiology, and End Results (SEER) data from 2004 to 2013.

Interestingly, the subgroups included patients who either had clinically node-positive bladder cancer (cN+) or had high risk of occult lymphadenopathy (≥T3), suggesting that radiation and chemotherapy may benefit those patients, according to presenter Matthew Clements, MD, MS, a fourth-year urology resident at the University of Virginia, Charlottesville.

“With how high the complication rate is with the cystectomy, this may be a better option (for those subsets) and they may actually have improved survival with keeping the bladder in place,” Dr. Clements said in an interview with Urology Times.

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The gold standard for invasive bladder cancer remains radical cystectomy with pelvic lymph node dissection, Dr. Clements noted.

However, an increasing body of research is examining the potential role of trimodal therapy, including endoscopic management and chemoradiation, particularly as an option for patients who can’t undergo extirpative surgery.

The SEER data evaluated by Dr. Clements and colleagues included patients 65-90 years of age diagnosed with non-metastatic urothelial carcinoma of the bladder.

Using a Cox proportional hazards model, they compared predicted overall survival for 306 patients receiving trimodal therapy and 5,684 patients undergoing radical cystectomy.

On multivariable analysis, they found trimodal therapy was associated with increased bladder cancer mortality risk, both in the treatment group (hazard ratio [HR]: 1.75; p<.001) and the intent-to-treat group (HR: 1.58; p<.001), according to a poster presentation of the results.

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However, several patient populations had significantly superior survival with trimodal therapy versus radical cystectomy, according to Dr. Clements and his co-authors. These populations included cN+ positive males 78 years of age or older; any node-positive female; females with high-stage disease and comorbidities; and node-positive males with high-stage disease.

“The female patients really jumped out in our modeling as doing better with the trimodal therapy,” Dr. Clements said. “Whichever subset we looked at, they seemed to do better.”

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That might reflect the quality of cystectomy performed in female patients.

“A lot of people coming by [the poster) were saying that they do think it's a harder operation in females,” he noted.

 

Taken together, these findings might inform decisions regarding management of patients with invasive bladder cancer who fall into one of those populations that did better with trimodal therapy, according to Dr. Clements and co-authors Timothy Showalter, MD, MPH, and Stephen Culp, MD, PhD, MS.