Department of Urology, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York.
Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
J Urol. 2018 Nov;200(5):996-1004. doi: 10.1016/j.juro.2018.06.001. Epub 2018 Jun 4.
We investigated the characteristics and outcomes of patients with muscle invasive bladder cancer treated with transurethral resection plus chemotherapy alone in a large observational cohort reflecting the continuum of practice settings in the United States.
In the National Cancer Database from 2004 to 2015 we identified 1,538 patients treated with transurethral resection plus multi-agent chemotherapy as definitive treatment of cT2-T4aN0M0 urothelial carcinoma of the bladder. For comparison purposes we included in study 17,866 patients treated with radical cystectomy with or without perioperative chemotherapy. Baseline characteristics were compared between the 2 groups by multivariable logistic regression. Treatment outcomes were assessed using Kaplan-Meier analysis and a Cox regression model.
On multivariate analysis several variables, including patient demography (older age, African American race, prior malignancy and lack of insurance), tumor characteristics (higher cT stage) and facility type (nonacademic facilities and lower radical cystectomy volume) were associated with a higher probability of transurethral resection plus chemotherapy for muscle invasive bladder cancer compared to the standard of care. Two and 5-year survival rates in all patients treated with transurethral resection plus chemotherapy were 49.0% and 32.9%, and in patients with cT2 disease the rates were 52.6% and 36.2%, respectively.
This large population level cohort of unselected patients shows that long-term survival can be achieved in a subset of patients treated with transurethral resection plus chemotherapy alone for muscle invasive bladder cancer. However, the best candidates for this approach remain to be defined. Ongoing clinical trials are now being launched to evaluate the ability of biomarkers to accurately select patients who could be treated with this bladder sparing strategy.
我们通过一项大型观察性队列研究，调查了在美国各种实践环境下接受经尿道切除术加化疗的肌层浸润性膀胱癌患者的特征和结局。
在 2004 年至 2015 年期间，我们从国家癌症数据库中确定了 1538 名接受经尿道切除术加多药化疗作为 cT2-T4aN0M0 膀胱尿路上皮癌确定性治疗的患者。为了比较目的，我们还纳入了 17866 名接受根治性膀胱切除术加或不加围手术期化疗的患者。通过多变量逻辑回归比较两组的基线特征。通过 Kaplan-Meier 分析和 Cox 回归模型评估治疗结局。
多变量分析显示，一些变量与接受经尿道切除术加化疗治疗肌层浸润性膀胱癌的可能性较高有关，包括患者人口统计学特征（年龄较大、非裔美国人、既往恶性肿瘤和缺乏保险）、肿瘤特征（较高的 cT 分期）和医疗机构类型（非学术医疗机构和较低的根治性膀胱切除术量）。所有接受经尿道切除术加化疗治疗的患者的 2 年和 5 年总生存率分别为 49.0%和 32.9%，而 cT2 疾病患者的生存率分别为 52.6%和 36.2%。
这项针对未经选择的患者的大型人群水平队列研究表明，对于接受经尿道切除术加化疗的肌层浸润性膀胱癌患者中的一部分，长期生存是可以实现的。然而，这种方法的最佳候选者仍有待确定。目前正在开展新的临床试验，以评估生物标志物是否能够准确选择可以采用这种保膀胱策略治疗的患者。
