Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
Urol Oncol. 2023 Oct;41(10):432.e11-432.e20. doi: 10.1016/j.urolonc.2023.06.004. Epub 2023 Jul 26.
Traditional surveillance protocols do not adequately account for the decreasing risk of mortality over time in aggressive malignancies, such as bladder cancer. Rather, the risk of death depends on both the baseline risk of mortality and the time survived since treatment. We therefore evaluated the conditional survival of patients diagnosed with urothelial carcinoma of the bladder (UCB) following radical cystectomy (RC).
We identified patients aged 18 to 75 with Charlson 0-1 and pTany pN0-3 cM0 UCB diagnosed from 2006 to 2015 in the National Cancer Database and treated with RC. The 2- and 5-year conditional overall survival (COS)-i.e., the probability of surviving an additional 2- or 5-years given a specified time survived since treatment-was estimated using the Kaplan-Meier method. Multivariable Cox regression models with landmark time analysis were used to evaluate the associations of baseline characteristics with OS over time.
A total of 15,594 patients were included in the study. Median follow-up was 27.8 months. The 2- and 5-year COS for the overall cohort increased through 36 months follow-up and then plateaued. When stratified by pT and pN stage, the COS gain increased with higher pT and pN stage, demonstrating the greatest increase over time for patients with pTany N1-3 disease (5-year COS of 23% at baseline, 58% at 36-months, and 71% at 60-months). In multivariable Cox regression modeling, pT and pN stage were significantly associated with higher all-cause mortality at baseline (HR 3.27 for pT4, HR 2.57 for pT3 vs. ≤pT2; HR 2.26 for pN2-3, HR 1.77 for pN1 vs. pN0), but these associations were attenuated in magnitude with increasing landmark times of 36- and 60-months (HR 1.63 for pT4, HR 1.35 for pT3 vs. ≤pT2; HR 1.34 for pN2-3, HR 1.27 for pN1 vs. pN0). Our study is limited by the retrospective design and the lack of cancer-specific survival data.
Risk of death after RC varies with time elapsed since treatment and disease stage. Accordingly, stage-specific COS may be used to improve prognostication and surveillance protocols.
传统的监测方案不能充分考虑侵袭性恶性肿瘤（如膀胱癌）随时间推移死亡率降低的情况。相反，死亡风险取决于基线死亡率和治疗后存活时间。因此，我们评估了根治性膀胱切除术（RC）后诊断为膀胱尿路上皮癌（UCB）患者的条件生存率。
我们从国家癌症数据库中确定了 2006 年至 2015 年间年龄在 18 至 75 岁之间、Charlson 0-1 分、pTany pN0-3 cM0 UCB 的患者，并接受了 RC 治疗。使用 Kaplan-Meier 方法估计 2 年和 5 年条件总生存率（COS）-即给定治疗后特定存活时间，再存活 2 年或 5 年的概率。使用带有时间标记分析的多变量 Cox 回归模型来评估基线特征与随时间变化的 OS 之间的关联。
共纳入 15594 例患者。中位随访时间为 27.8 个月。全队列的 2 年和 5 年 COS 在 36 个月随访时增加，然后趋于平稳。按 pT 和 pN 分期分层，COS 获益随 pT 和 pN 分期的升高而增加，表明 pTany N1-3 疾病患者的获益随时间增加最大（5 年 COS 基线为 23%，36 个月时为 58%，60 个月时为 71%）。在多变量 Cox 回归模型中，pT 和 pN 分期与较高的基线全因死亡率显著相关（pT4 的 HR 为 3.27，pT3 的 HR 为 2.57，≤pT2；pN2-3 的 HR 为 2.26，pN1 的 HR 为 1.77，pN0），但随着 36 个月和 60 个月时间标记的增加，这些关联的幅度减弱（pT4 的 HR 为 1.63，pT3 的 HR 为 1.35，≤pT2；pN2-3 的 HR 为 1.34，pN1 的 HR 为 1.27，pN0）。我们的研究受到回顾性设计和缺乏癌症特异性生存数据的限制。
RC 后死亡风险随治疗后时间和疾病分期的变化而变化。因此，可使用特定于分期的 COS 来改善预后和监测方案。
