A comparison of post-cystectomy recurrence and survival in NAC-responsive MIBC vs. high-risk NMIBC patients: similar pathologic stage yet different outcomes
Sources of Funding: Greenberg Bladder Cancer Institute
Introduction
Patients with muscle-invasive bladder cancer (MIBC) who are down-staged after neoadjuvant chemotherapy (NAC) have improved survival over those who remain ≥pT2. It is uncertain whether subgroups of patients with high-risk non-MIBC (NMIBC) would also benefit from NAC. We compared post-surgical outcomes in high-risk NMIBC patients who did not receive NAC with MIBC patients who were down-staged with NAC and without NAC.
Methods
We identified 334 patients with urothelial bladder cancer who were pT0, pTis, pTa, or pT1 and N0 at cystectomy from 2005-2015: 111 with cT2 who received NAC (NAC-responsive), 37 with cT2 who did not receive NAC (non-NAC-responsive), and 186 with high-grade cTis, cTa, or cT1 (high-risk NMIBC). Comparisons were made using Kruskal-Wallis for continuous and chi-squared for categorical variables. Log-rank and Cox regression analyses were used to evaluate survival.
Results
Compared to NAC-responsive and non-NAC-responsive patients, high-risk NMIBC patients had higher prevalence of intravesical therapy (70.4% vs. 14.1% and 13.5%, p<0.01), pure urothelial histology (92.5% vs. 80.2% and 64.9%, p<0.01), tumor ≥2 cm (19.9% vs. 6.6% and 10.8%, p<0.01), and lower prevalence of pT0 pathology (11.8% vs. 41.3% and 46%, p<0.01). Location of recurrence did not differ significantly between the groups (p=0.53), and 23.5% of recurrences in high-risk NMIBC patients occurred outside of the pelvis. Log-rank comparisons showed improved recurrence-free and overall survival in NAC-responsive vs. high-risk NMIBC patients (p<0.02 and p<0.02) but not in non-NAC-responsive vs. high-risk NMIBC patients (p=0.34 and p=0.43). In Cox regression, tumor ≥2 cm was independently associated with increased risk of cancer recurrence (HR=2.31, p=0.02) and overall mortality (HR=2.10, p=0.02)
Conclusions
Patients with NAC-responsive MIBC had better post-surgical outcomes than patients with high-risk NMIBC. High-risk NMIBC patients had a higher prevalence of tumor ≥2 cm, which was an independant predictor of cancer recurrence. Despite being node negative, almost a quarter of recurrences in patients with high-risk NMIBC occurred distantly. Further work is needed to identify whether patients with unresectable or high volume NMIBC could benefit from NAC.
Funding
Greenberg Bladder Cancer Institute
Max Kates
Meera Chappidi
Nikolai Sopko
Trinity Bivalacqua