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Eur Urol Oncol. 2018 May;1(1):83-90. doi: 10.1016/j.euo.2018.03.001. Epub 2018 May 15.

Effectiveness of Neoadjuvant Chemotherapy for Muscle-invasive Bladder Cancer in the Current Real World Setting in the USA.

Author information

1
Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
2
Center for Outcomes Research, Analytics and Evaluation, Vattikuti Institute of Urology, Henry Ford Hospital, Detroit, MI, USA.
3
Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
4
Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA. Electronic address: toni_choueiri@dfci.harvard.edu.
5
Center for Outcomes Research, Analytics and Evaluation, Vattikuti Institute of Urology, Henry Ford Hospital, Detroit, MI, USA. Electronic address: firas.abdollah@gmail.com.

Abstract

BACKGROUND:

The use of neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) is supported by results from several randomized control trials, including SWOG-8710.

OBJECTIVE:

To look at the effectiveness of NAC before RC in current real world practice in the USA.

DESIGN, SETTING, AND PARTICIPANTS:

We used the National Cancer Data Base (NCDB) to identify patients with nonmetastatic muscle-invasive urothelial carcinoma of the bladder who underwent RC between 2004 and 2012.

INTERVENTION:

Receipt of NAC before RC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:

The primary endpoint was overall survival (OS). Secondary endpoints were rates of complete pathologic response (pT0), positive pathologic lymph nodes (pN+), and margin status. Using a landmark analysis to adjust for an immortal-time bias, OS comparison was performed using Cox regression analysis. Furthermore, logistic regression models examining secondary outcomes were fitted. To adjust for potential selection bias, propensity score-weighted analyses were performed.

RESULTS AND LIMITATIONS:

Of 8732 patients who underwent RC, 1619 (19%) received NAC. Following propensity score adjustment, receipt of NAC was not associated with an OS benefit (hazard ratio 0.97; p=0.591). On secondary outcome analysis, higher pT0 rates (odds ratio 5.03; p<0.001) were recorded among patients who received NAC, although rates of pT0 were lower than for patients treated with NAC within the SWOG-8710 trial (13% vs 38%). Limitations include the retrospective design and limited details available regarding type of chemotherapy.

CONCLUSIONS:

Important baseline differences between patients from the SWOG-8710 trial and those in general urologic practice exist. After adjusting for immortal-time bias, we did not find a clear survival advantage of NAC before RC when compared to RC alone in current general urology practice in the USA.

PATIENT SUMMARY:

The benefit of chemotherapy before radical cystectomy is supported by few randomized control trials. In this study, using a large national data set from the USA we found that preoperative chemotherapy is not associated with a survival benefit in all patients in general urology practice. Hence, better selection criteria are needed to determine who will benefit the most from chemotherapy before radical cystectomy.

KEYWORDS:

Bladder cancer; Neoadjuvant chemotherapy; Radical cystectomy

PMID:
31100232
DOI:
10.1016/j.euo.2018.03.001

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