Upper tract urothelial carcinoma (UTUC) is a rare malignancy with poor prognosis. Radical nephroureterectomy (RNU) remains the standard treatment for high-risk UTUC. Considering the decline in renal function with RNU and results from prospective trials, NAC has emerged as a favored perioperative treatment for chemo-eligible patients with UTUC. However, strong evidence of the efficacy of NAC and predictors for its use are scarce. We aimed to assess trends in NAC utilization and pathologic outcomes and survival with NAC use.
The National Cancer Database was queried for patients with high-grade cTanyNanyM0 UTUC treated with RNU from 2004 to 2019. Outcomes included overall survival (OS), pathologic response (pR) and pathologic complete response (pCR), defined as ≤pT1pN0/X and pT0pN0/X, respectively.
Of 6,645 patients treated with RNU, 209 received RNU NAC. Greater distance from treatment facility decreased the likelihood of receiving NAC. Higher cT stages (OR 1.72, P = .028), cN+ status (OR 7.40, P < .001) and treatment at an academic facility (OR 2.02, P < .001) predicted NAC treatment. NAC was associated with 34.0% pR and 5.3% pCR. In multivariable analysis, patients with pR and pCR had improved OS (HR = 0.176, P < .014).
We report significant response rates with NAC and improved OS in patients who experienced pR or pCR. Over a 15-year study period, NAC was underutilized, especially in nonacademic settings and among patients living farther from care facilities, underscoring the need for improved regionalization and multidisciplinary approaches in UTUC management.
Clinical genitourinary cancer. 2024 Sep 17 [Epub ahead of print]
Vincent E Xu, Oluwafolajimi Adesanya, Sarah Azari, Samita Islam, Matthew Klein, Arthur Drouaud, Ryan M Antar, Phat Chang, Armine Smith, Michael J Whalen
Department of Urology, George Washington University School of Medicine and Health Sciences, Washington, DC. Electronic address: ., Department of Urology, University of Illinois Urbana-Champaign, Champaign, IL., Department of Urology, George Washington University School of Medicine and Health Sciences, Washington, DC., Department of Urology, Drexel University College of Medicine, Philadelphia, PA., Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD.