Comparative effectiveness of selective adjuvant versus systematic neoadjuvant chemotherapy-based strategy for muscle-invasive urothelial carcinoma of the bladder
Seisen T, Sonpavde G, Kachroo N, Lipsitz S, Leow J, Menon M, Gild P, Von Landenberg N, Rouprêt M, Kibel A, Sun M, Pal S, Bellmunt J, Choueiri T, and Trinh QD. Comparative effectiveness of selective adjuvant versus systematic neoadjuvant chemotherapy-based strategy for muscle-invasive urothelial carcinoma of the bladder. Eur Urol, Supplements 2017; 16(3):e291-e292.
Eur Urol Supplements
INTRODUCTION & OBJECTIVES: There is evidence supporting the use of neoadjuvant (NAC) or adjuvant chemotherapy (AC) in combination with radical cystectomy (RC) for muscle-invasive urothelial carcinoma of the bladder (UCB). However, no study has been devised to compare upfront RC followed - performance status and absence of surgical contraindications permitting - by the selective delivery of AC in patients with adverse pathological features, while watching those with organ-confined disease (selAC-based strategy) vs. the systematic delivery of NAC in all eligible individuals followed by surgery if amenable (sysNAC-based strategy). We hypothesized that a selAC-based strategy is associated with an overall survival (OS) benefit when performing an “intention-to-treat” analysis. MATERIAL & METHODS: Within the National Cancer Data Base (2003-2011), we identified 10,056 patients who received selAC- vs. sysNAC-based strategy for cT2-T4N0M0 UCB. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox regression analyses with time-varying covariate were used to compare OS of patients who received selAC- vs. sysNAC-based strategy. Exploratory analyses according to baseline characteristics were additionally performed. RESULTS: Overall, 8,312 (82.7%) vs. 1,744 (17.3%) patients underwent selAC- vs. sysNAC-based strategy, respectively. IPTW-adjusted Kaplan-Meier curves showed that median OS was significantly longer in the selAC- vs. sysNAC-based strategy group (42.0 [95%CI, 39.5-44.6] vs. 33.7 [95%CI, 29.4-38.1] months; P=0.001; Figure 1). The 5-year IPTW-adjusted rates of OS for selAC- vs. sysNACbased strategy were 42.98% [95%CI, 41.8-44.2] vs. 37.45% [95%CI,34.8-40.1], respectively. In IPTWadjusted Cox regression analyses with time-varying covariate, selAC-based strategy was associated with a significant OS benefit after 17 months of follow-up (HR=0.79; 95%CI=[0.70-0.90]; P<0.001). In exploratory analyses, this benefit was significant in cT2 patients (HR=0.78; 95%CI=[0.67-0.88]; P<0.001) while there was no difference between treatment groups in ≥cT3 patients (HR=1.18; 95%CI=[0.95-1.47]; CONCLUSIONS: We report an OS benefit for individuals treated with a selAC- vs. sysNAC-based strategy for muscle-invasive UCB - especially cT2 disease. Our findings warrant further consideration in randomized controlled trials to explore this hypothesis. (Figure Presented).