A Comparison of Trimodality Therapy to Radical Cystectomy for Muscle Invasive Bladder Cancer - Expert Commentary
Differences in survival outcomes by treatment were analyzed using propensity scores incorporated in propensity score matching (PSM) using logistic regression and 3:1 matching with replacement and inverse probability treatment weighting (IPTW).
The investigators identified 440 patients who underwent radical cystectomy and 282 patients who underwent trimodality therapy. Variables such as clinical T stage and chemotherapy treatment were different across the two groups and were therefore adjusted for by matching.
The median follow-up time was 4.38 years in the radical cystectomy cohort and 4.88 years in the trimodality therapy cohort. The 5-year cancer-specific survival for radical cystectomy versus trimodality therapy was 81% (95% CI 77–85) versus 84% (79–89) with IPTW and 83% (80–86) versus 85% (80–89) with PSM. 5-year disease-free survival was 73% (95% CI 69–77) versus 74% (69–79) with IPTW and 76% (72–80) versus 76% (71–81) with PSM. This also applied to distant failure-free survival, regional failure-free survival, and disease-free survival. However, there was a significantly lower overall survival rate among the radical cystectomy group (66%, 61 – 71) compared to the trimodality therapy group (73%, 68 – 78; p = 0.010). Similarly, the 5-year cancer-specific survival rate was significantly lower in the radical cystectomy group (p = 0.071). Furthermore, there were no significant differences in any outcome measure when researchers compared radical cystectomy plus neoadjuvant or adjuvant chemotherapy cohort with the trimodality therapy cohort.
Among those who underwent radical cystectomy, the 90-day perioperative mortality was 2.5% (n = 11), and local recurrence was observed in 3% of patients. Most patients had cT2 disease, and the final pathological stage was pT2 in 28% of patients and pT3–4 in 44% of patients. Node-positive disease was found in 26% of patients who underwent radical cystectomy. Among patients in the trimodality therapy cohort, 13% underwent salvage cystectomy. After trimodal therapy, 20% of patients had non-muscle-invasive recurrence, while 11% had muscle-invasive recurrence. No patients died in the 90 days following trimodality therapy. Neoadjuvant or adjuvant chemotherapy did not affect 5-year metastasis-free survival among patients who received trimodality therapy.
This study provides a comparative and well-controlled comparison of trimodality therapy versus radical cystectomy. Multidisciplinary shared decision-making is critical for determining the optimal treatment choice for patients with MIBC.
Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine
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