Trimodality Therapy Compared to Radical Cystectomy for Muscle-Invasive Bladder Cancer - Expert Commentary
The investigators conducted a literature search across PubMed, Embase, Scopus, and CENTRAL databases for randomized trials or covariate-matched studies comparing RC versus TMT for MIBC to analyze studies with the highest quality evidence available. Using a graphical reconstructive algorithm to obtain overall and cancer-specific survival data from survival curves for individual patients, they performed random-effects individual patient data meta-analysis with Cox models to determine hazard ratios. The analysis included 11 studies comprising mainly cT2-T4, node-negative, nonmetastatic MIBC patients.
For overall survival (OS), the investigators analyzed 9 studies, including 6,780 patients, showing that TMT was associated with lower OS versus RC (shared-frailty HR = 1.14, 95% CI, 1.08−1.21, P < 0.001). At 1, 5, and 10 years, the estimated OS was 86%, 47%, and 18%, respectively, for TMT, compared to 86%, 57%, and 22% for RC. In terms of cancer-specific survival (CSS), analysis of 8 studies (4,776 patients) showed TMT was associated with lower CSS versus RC (shared-frailty HR = 1.09, 95% CI, 1.01−1.18, P = 0.024). Estimated CSS at 1, 5, and 10 years was 92%, 62%, and 29%, respectively, for TMT, compared to 94%, 72%, and 29% for RC.
The investigators concluded that in the absence of large trials, this meta-analysis suggests that RC may potentially offer OS and CSS benefits over TMT in MIBC. RC should remain a standard of care for nonmetastatic MIBC, while TMT remains a valid alternative for carefully selected and informed patients. Ongoing studies combining immunotherapy with chemoradiation or combining antibody-drug conjugates and targeted therapies with radiation therapy will require comparison to radical cystectomy in the future.
Written by: Bishoy M. Faltas, MD, Chief Research Officer, Englander Institute for Precision Medicine, Gellert Family - John P. Leonard, MD, Research Scholar, Associate Professor of Medicine, Cell and Developmental Biology, Weill Cornell Medicine, New York- Presbyterian Hospital, NY
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