Patterns of care in patients with muscle-invasive bladder cancer – a retrospective cohort study

Introduction

In Central Europe patients with muscle-invasive bladder cancer (MIBC) have relatively poor prognosis [1]. This includes also patients initially undergoing radical surgical treatment [2]. In order to find underlying reasons, we have previously estimated the timing of radical cystectomy in a multicentre study involving 575 Polish patients [3]. However, one of the most important limitations of the abovementioned study was the inclusion criterion of being cystectomised instead of being diagnosed with MIBC. Consequently, the data on final treatment in the whole population of MIBC patients are still limited. Within this short communication we address this important issue.
The aim of this study was to describe patterns of care in Polish patients with newly diagnosed MIBC.

Material and methods

This is a multicentre retrospective cohort study involving 296 consecutive patients with primary MIBC diagnosed in the years 2012–2013 in 13 Polish urological centres. In all patients the diagnosis was made based on histological examination of surgical specimens from transurethral resection of the bladder tumour. No additional staging tool was considered within this study. The mean age of the cohort was 72.1 years and male-to-female ratio was 3.2 : 1 (225 vs. 71).
Therapeutic decisions, as well as potential underlying clinical factors, were analysed. Differences between cystectomised and non-cystectomised patients were evaluated with U Mann-Whitney test and 2 test for quantitative and qualitative variables, respectively. P values below 0.03 were considered statistically significant.

Results

Full clinical data were available for 285 patients. 164/285 (57.5%) patients were qualified for radical cystectomy (RC). Table 1 presents detailed data comparing subgroups of patients depending on qualification for RC.
Among 121/285 (42.5%) patients disqualified from RC, 32/121 (26.4%) patients were qualified for a second step of transurethral resection of the bladder tumour (TURBT) intentionally followed by systemic chemotherapy, four (3.3%) patients after complete TURBT were qualified for adjuvant intravesical chemotherapy only, while the remaining 85 (70.2%) patients were qualified for palliative treatment in the form of chemotherapy and/or radiotherapy and/or best supportive care.

Discussion

Despite poor outcomes of treatment of patients with MIBC in Central Europe, data on patterns of surgical and medical management, as well as its quality, are still unavailable. We performed a retrospective study aimed at the description of further treatment in patients diagnosed with primary MIBC.
The most important finding of our analysis is the high percentage of patients qualified for radical treatment. A clinically important fact is that that these numbers would probably be higher if we excluded from the analysis patients with metastatic disease, who are not candidates for RC by definition. Available data on patterns of care in MIBC patients published in the last 10 years present significantly lower rates of curative treatment, covering 21–52.5% of patients [4–7]. However, the studies cited above included more patients and/or were based on cancer or national registries. This potentially improves their reliability and reproducibility. On the other hand, some portion of patients included in these analyses was treated with radiotherapy alone, which nowadays is not regarded as a radical approach.
We have also found that patients disqualified from curative treatment were older, had lower BMI values, lower haemoglobin concentration, and declared lower rate of nicotine abuse and shorter time interval between first symptom to diagnosis. While age alone should not influence clinical decisions, it is suggested that older MIBC patients are less frequently qualified for radical surgery [8], and it is well established that the morbidity related to RC is increased within this group [9–12]. Low haemoglobin concentration, as well as malnutrition is associated with shorter survival after RC [9, 13, 14]. Moreover, abnormal BMI value increases the risk of surgical complications [12, 15, 16]. Our findings on nicotine use and time from first symptom to diagnosis are both surprising and unexplainable. Considering the pathogenesis and clinical course of the disease, one can suspect that these results are fortuitous. Finally, they are of no practical significance.
The study’s strengths are its multi-institutional character, involvement of both academic and non-academic urological departments, and enrolment of a representative cohort of patients. The most important limitation of the study is the lack of data on lymph node and distant metastases. As available clinical staging is limited to regional status, among patients disqualified from surgery there are both patients unfit for surgery and patients with initially metastatic disease. Their differentiation in the present study was not performed.

Conclusions

Because the majority of Polish patients with primary MIBC receive curative treatment, the stage of the disease alone seems not to be the leading cause of poor survival. However, the appropriateness of qualification for RC and treatment quality needs to be assessed for a final conclusion on the factors influencing outcomes of treatment in Poland.
The results presented within this paper come from post hoc analysis of data collected during a multicentre study aimed at oncological characterisation of a large cohort of Polish patients with primary urothelial carcinoma of the bladder [17].

The authors declare no conflict of interest.
All authors, except for S.P. and P.R., contributed equally to the study. The study was produced under the auspices of the Residents Section of the Polish Urological Association. All the investigators, but two (M.S. and P.R.), were urologists in training.

References

1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010; 127: 2893-917.
2. Dybowski B, Ossolinski K, Ossolinska A, Peller M, Bres-Niewada E,Radziszewski P. Impact of stage and comorbidities on five-year survival after radical cystectomy in Poland: single centre experience. Cent European J Urol 2015; 68: 278-83.
3. Poletajew S, Lisinski J, Moskal K, et al. The time from diagnosis of bladder cancer to radical cystectomy in Polish urological centres – results of CysTiming Poland study. Cent European J Urol 2014; 67: 329-32.
4. Gore JL, Litwin MS, Lai J, Yano EM, Madison R, Setodji C, Adams JL, Saigal CS; Urologic Diseases in America Project. Use of radical cystectomy for patients with invasive bladder cancer. J Natl Cancer Inst 2010; 102: 802-11.
5. Gray PJ, Fedewa SA, Shipley WU, Efstathiou JA, Lin CC, Zietman AL, Virgo KS. Use of potentially curative therapies for muscle-invasive bladder cancer in the United States: results from the National Cancer Data Base. Eur Urol 2013; 63: 823-9.
6. Jahnson S, Damm O, Hellsten S, et al. A population-based study of patterns of care for muscle-invasive bladder cancer in Sweden. Scand J Urol Nephrol 2009; 43: 271-6.
7. Smith AB, Deal AM, Woods ME, Wallen EM, Pruthi RS, Chen RC, Milowsky MI, Nielsen ME. Muscle-invasive bladder cancer: evaluating treatment and survival in the National Cancer Data Base. BJU Int 2014; 114: 719-26.
8. Prout GR, Jr, Wesley MN, Yancik R, Ries LA, Havlik RJ, Edwards BK. Age and comorbidity impact surgical therapy in older bladder carcinoma patients: a population-based study. Cancer 2005; 104: 1638-47.
9. Hara T, Matsuyama H, Kamiryo Y, et al. Use of preoperative performance status and hemoglobin concentration to predict overall survival for patients aged ≥ 75 years after radical cystectomy for treatment of bladder cancer. Int J Clin Oncol 2016; 21: 139-47.
10. Novotny V, Zastrow S, Koch R, Wirth MP. Radical cystectomy in patients over 70 years of age: impact of comorbidity on perioperative morbidity and mortality. World J Urol 2012; 30: 769-76.
11. Roghmann F, Sukumar S, Ravi P, et al. Radical cystectomy in the elderly: national trends and disparities in perioperative outcomes and quality of care. Urol Int 2014; 92: 27-34.
12. Svatek RS, Fisher MB, Williams MB, et al. Age and body mass index are independent risk factors for the development of postoperative paralytic ileus after radical cystectomy. Urology 2010; 76: 1419-24.
13. Gregg JR, Cookson MS, Phillips S, et al. Effect of preoperative nutritional deficiency on mortality after radical cystectomy for bladder cancer. J Urol 2011; 185: 90-6.
14. Sejima T, Morizane S, Yao A, Isoyama T, Saito M, Amisaki T, Koumi T, Takenaka A. Prognostic impact of preoperative hematological disorders and a risk stratification model in bladder cancer patients treated with radical cystectomy. Int J Urol 2014; 21: 52-7.
15. Bagrodia A, Grover S, Srivastava A, Gupta A, Bolenz C, Sagalowsky AI, Lotan Y. Impact of body mass index on clinical and cost outcomes after radical cystectomy. BJU Int 2009; 104: 326-30.
16. Lee CT, Dunn RL, Chen BT, Joshi DP, Sheffield J, Montie JE. Impact of body mass index on radical cystectomy. J Urol 2004; 172: 1281-5.
17. Poletajew S, Biernacki R, Buraczynski P, et al. Stage of bladder cancer in Central Europe – Polish perspective. Neoplasma 2016; 63: 642-7.

Address for correspondence

Sławomir Poletajew MD PhD
Department of Urology
Medical University of Warsaw
Lindleya 4
02-005 Warsaw, Poland
tel. +48 22 502 17 02
fax +48 22 502 21 48
e-mail: slawomir.poletajew@wum.edu.pl

Submitted: 11.03.2016
Accepted: 1.08.2016