Cystectomy Favored for Younger Patients with High-Risk Bladder Cancer

TORONTO, Sept. 28 -- For high-risk bladder cancer, a decision on aggressive versus conservative therapy depends on age and quality-of-life preferences, according to investigators here.

Their findings suggest that patients with stage T1G3 bladder cancer, ages 60 and younger, live longer and have better quality of life with immediate surgery, whereas a conservative approach seems to offer the most benefits for older patients, Shabbir M. H. Alibhai, M.D., of the University of Toronto, and colleagues, concluded online in Public Library of Science - Medicine.

"The decision to pursue immediate cystectomy versus conservative therapy should be based on discussions that consider patient age, comorbid status, and an individual's preference for particular postcystectomy health states," the authors wrote. "Patients over the age of 70 years or those who place high value on sexual function, gastrointestinal function, or bladder preservation may benefit from a more conservative initial therapeutic approach."

Treatment of T1G3 bladder cancer remains controversial. Improved survival with immediate cystectomy may be offset by potential detrimental effects on quality of life and by competing mortality risks in older patients and those with significant comorbidities.

Noting an absence of decision analyses for T1G3 bladder cancer, Dr. Alibhai and colleagues used Markov models to evaluate different approaches to treatment. The models were developed on the basis of a hypothetical 60-year-old, otherwise healthy, compliant, and sexually potent man with newly diagnosed disease.

The investigators evaluated two treatment strategies:

• Immediate cystectomy and creation of a neobladder
• Conservative management with intravesical administration of bacillus Calmette-Guerin and cystectomy reserved for patients with resistant or progressive disease.

Probabilities and utilities were derived from published literature when available and otherwise from expert opinion. The investigators performed extensive sensitivity analyses to identify variables most likely to influence a given decision.

Immediate cystectomy resulted in a mean life expectancy of 14.3 years for the base patient compared with 13.6 years for conservative treatment. The addition of utilities resulted in a mean quality-adjusted life expectancy of 12.32 years for cystectomy, which remained superior to conservative treatment by 0.35 year.

Worsening comorbidities diminished the overall benefit of immediate cystectomy. However, worsening comorbidities altered the life expectancy-based preferred treatment only for patients older than 70 and the quality-adjusted life expectancy only for patients older than 65.

Sensitivity analyses showed that conservative treatment offered superior quality-adjusted life expectancy for patients older than 70 or those strongly averse to loss of sexual function, to gastrointestinal dysfunction, or to life without a bladder.