Vattikuti Urology Institute, VUI Center for Outcomes Research, Analysis, and Evaluation, Henry Ford Health System, Detroit, MI; Department of Urology and Renal Transplantation, University of Foggia, Foggia, Italy.
Department of Public Health Sciences, Public Health Sciences, Henry Ford Health System, Detroit, MI.
Urol Oncol. 2025 Jan;43(1):61.e1-61.e9. doi: 10.1016/j.urolonc.2024.08.001. Epub 2024 Sep 6.
Comparative effectiveness studies comparing trimodal therapy (TMT) to radical cystectomy (RC) are typically hindered by selection bias where TMT is usually reserved to patients with poor overall health status. We developed a novel approach by matching patients based on their calculated other-cause mortality (OCM) risk. Using this homogeneous cohort, we tested the impact of TMT vs RC on cancer-specific mortality (CSM).
The Surveillance, Epidemiology and End Results (SEER) 2004-2018 database was queried to identify patients diagnosed with cT2-4N0M0 muscle-invasive bladder cancer (MIBC). A Fine-Gray competing-risk regression model calculating the 5-year OCM risk was used to create a 1:1 propensity-score matched-cohort of patients treated with RC or TMT. Cumulative incidence and competing-risk regression analyses tested the impact of treatment type (RC vs TMT) on CSM. Patients were further stratified according to clinical T stage (cT2 vs cT3-4) in sensitivity analyses.
We identified 6,587 patients (76%) treated with RC and 2,057 (24%) with TMT. The median follow-up was 3.0 years. In the unmatched-cohort, 5-year OCM and CSM rates were 14% and 40% for RC vs 23% and 47% in TMT group, respectively (all P < 0.001). Our matched-cohort included 4,074 patients, equally distributed for treatment type, with no difference in 5-year OCM (HR: 0.98, 95% CI: 0.86-1.11, P = 0.714). In clinical-stage specific sensitivity analyses, 5-year CSM rate was significantly worse for cT2N0M0 patients treated with TMT (HR: 1.52, 95% CI: 1.21-1.91, P < 0.001) than those treated with RC. For cT3-4N0M0 patients, there was no difference in CSM among the 2 approaches (HR: 0.98, 95% CI: 0.63-1.52, P = 0.900).
Our findings demonstrate an oncologic advantage of RC over TMT for cT2 MIBC patients. Conversely, we did not find a cancer-specific survival difference for cT3-T4 MIBC patients, regardless of treatment.
比较三联疗法（TMT）与根治性膀胱切除术（RC）的疗效的对比效果研究通常受到选择偏倚的阻碍，因为 TMT 通常保留给整体健康状况较差的患者。我们通过基于计算得出的其他原因死亡率（OCM）风险来匹配患者，开发了一种新方法。使用这种同质队列，我们测试了 TMT 与 RC 对癌症特异性死亡率（CSM）的影响。
从 2004 年至 2018 年的监测、流行病学和最终结果（SEER）数据库中检索到诊断为 cT2-4N0M0 肌肉浸润性膀胱癌（MIBC）的患者。使用 Fine-Gray 竞争风险回归模型计算 5 年 OCM 风险，以创建接受 RC 或 TMT 治疗的患者 1:1 倾向评分匹配队列。累积发病率和竞争风险回归分析测试了治疗类型（RC 与 TMT）对 CSM 的影响。根据临床 T 分期（cT2 与 cT3-4）在敏感性分析中进一步分层患者。
我们确定了 6587 名（76％）接受 RC 治疗和 2057 名（24％）接受 TMT 治疗的患者。中位随访时间为 3.0 年。在未匹配队列中，RC 组的 5 年 OCM 和 CSM 率分别为 14％和 40％，而 TMT 组分别为 23％和 47％（均 P <0.001）。我们的匹配队列包括 4074 名患者，按治疗类型平均分配，5 年 OCM 无差异（HR：0.98，95％CI：0.86-1.11，P=0.714）。在临床分期特异性敏感性分析中，与接受 RC 治疗的 cT2N0M0 患者相比，接受 TMT 治疗的 cT2N0M0 患者的 5 年 CSM 率明显更高（HR：1.52，95％CI：1.21-1.91，P<0.001）。对于 cT3-4N0M0 患者，两种方法之间的 CSM 无差异（HR：0.98，95％CI：0.63-1.52，P=0.900）。
我们的研究结果表明，RC 治疗 cT2 MIBC 患者在肿瘤学上优于 TMT。相反，我们没有发现 cT3-T4 MIBC 患者的癌症特异性生存率差异，无论治疗方法如何。
