EAU 2017: Is neoadjuvant chemotherapy beneficial before radical cystectomy? Examining the external validity of the SWOG-8710 trial
Patients with non-metastatic MIBC diagnosed between 2004 and 2012 were identified, and stratified based on receipt of NAC – all patients were cT2N0M0 to cT4aN0M0 to match the SWOG study. All 8732 patients underwent RC, though only 19% received NAC – consistent with prior studies demonstrating underutilization. Importantly, the cohort was older, more commonly female, and had higher clinical stage – the older age and higher clinical stage is likely a better representation of the typical patient population. To account for comorbidities and confounding factors, the authors used a propensity score adjustment to compare the NAC+RC cohort to the RC alone cohort.
The primary endpoint was overall survival (OS) - receipt of NAC was associated with an OS benefit (HR 0.88, p=0.017). It was also associated with higher downstaging rates (13.3% in NAC+RC cohort vs. 2.3% in RC alone) and lower 90-day postoperative mortality.
Limitations / Discussion Points:
1. They only included patients with Charlson Comorbidity Index = 0 (healthy patients). In my mind, they negated any benefit of looking at the general population by excluding patients with worse comorbidities. While a subset analysis of this group would have been ok, but not looking at all patients, it becomes less generalizable.
2. The authors, and the moderators, attribute the 90-day mortality benefit to selection bias – despite being older and more female, they were also patients who were likely closely followed at an academic institution and had more pre-operative clearance prior to undergoing surgery.
3. While confirming the importance of the studies in a more “typical”patient population, this study doesn’t change clinical practice.
4. The underutilization of NAC remains a significant issue that needs to be addressed.
Presented by: N. Hanna
Co-Authors: Trinh Q.-D., Sammon J., Seisen T., Vetterlein M., Moreira R., Preston M., Lipsitz S., Bellmunt J., Menon M., Choueiri T., Abdollah F.
Institution(s):
1. Brigham and Women's Hospital, Harvard Medical School, Dept. of Urology, Boston, United States of America
2. Henry Ford Hospital, Dept. of Urology, Detroit, United States of America
3. Dana-Farber Cancer Institute, Dept. of Medical Oncology, Boston, United States of America
Written by: Thenappan Chandrasekar, Clinical Fellow, University of Toronto
Twitter: @tchandra_uromd
at the #EAU17 -March 24-28, 2017- London, England