High-intensity local treatment of clinical node-positive urothelial carcinoma of the bladder alongside systemic chemotherapy improves overall survival.

Clinical node-positive urothelial carcinoma of the bladder (cN+UCaB) is a rapidly fatal disease with limited information on comparative-effectiveness of available treatment options. We sought to examine the impact of high-intensity vs.

conservative local treatment (LT) regimens in management of these patients alongside systemic chemotherapy.

We identified 3,227 patients within the National Cancer Data Base who underwent multiagent systemic chemotherapy along with either high-intensity or conservative LT for primary cN+UCaB between 2004-2016. Patients who received no LT, TURBT alone, or <50 Gy radiation therapy to the bladder were included in the conservative group, while patients that received radical cystectomy with pelvic lymphadenectomy or ≥50 Gy radiation therapy with TURBT were included in the high-intensity group. Inverse probability of treatment weighting (IPTW) adjusted Kaplan-Meier and Cox regression analyses were used to assess overall survival (OS). Additionally, to assess whether the benefit of high-intensity LT differs by baseline mortality risk, we tested an interaction between 5-year predicted life-expectancy and the LT type.

Overall, 784 (24.3%) and 2,443 (75.7%) cN+UCaB patients underwent high-intensity and conservative LT, respectively. IPTW-adjusted Kaplan-Meier analysis demonstrated OS to be significantly higher in the high-intensity group compared to the conservative group: 5-year OS 28.4% vs. 18.3%, respectively (Log-rank P<0.001). IPTW-adjusted multivariable Cox regression analysis confirmed the benefit of high-intensity LT in prolonging OS (HR 0.63, P<0.001). Interaction analysis showed that high-intensity LT approach was associated with longer OS in all patients regardless of their baseline 5-year life-expectancy (Pinteraction=0.79).

Eligible patients with cN+UCaB should be considered for aggressive local treatment alongside multiagent systemic chemotherapy. Prospective trials are needed to validate these preliminary findings.

Urologic oncology. 2021 Aug 01 [Epub ahead of print]

Akshay Sood, Jacob Keeley, Isaac Palma-Zamora, Giacomo Novara, Mohamed Elshaikh, Wooju Jeong, Patrick Hensley, Neema Navai, James O Peabody, Quoc-Dien Trinh, Craig G Rogers, Mani Menon, Firas Abdollah

VCORE - Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, Michigan; Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan; Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address: ., VCORE - Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, Michigan., Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan., Department of Surgery, Oncology and Gastroenterology-Urology, University Hospital of Padova, Padova, Italy., Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan., Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas., VCORE - Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, Michigan; Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan., Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusettsa.

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