Highlights
- •On posthoc analysis, intravesical chemotherapy (Gemcitabine) reduces the risk of nonmuscle invasive bladder cancer recurrence in suspected low-grade, stage Ta or T1 bladder cancer.
- •We propose regression-tree analysis generated non-muscle invasive bladder cancer risk groups. This risk stratification shows distinct oncological outcomes with Gemcitabine.
- •Regression tree analysis suggests older patients (≥ 57 years) with a single tumor maximally benefit from immediate postresection instillation of intravesical chemotherapy (Gemcitabine).
Abstract
Background
Nonmuscle invasive bladder cancer (NMIBC) has an elevated risk of recurrence, and
immediate postresection intravesical instillation of chemotherapy (IVC) significantly
reduces the risk of recurrence. Questions remain about which subpopulation may maximally
benefit from IVC. Our aim was to develop risk groups based on recurrence risk in NMIBC,
and then evaluate the impact of a single, postoperative instillation of IVC on the
subsequent risk of recurrence for each risk group.
Material and Methods
Using the SWOG S0337 trial cohort, we performed a posthoc analysis of 345 patients
who were diagnosed with suspected low-grade NMIBC, underwent transurethral resection
of the bladder tumor (TURBT), and received post-operative IVC (gemcitabine vs. saline).
Using regression tree analysis, the regression tree stratified patients based on their
risk of recurrence into low-risk – single tumor and aged < 57 years, intermediate-risk
– single tumor and aged ≥ 57 years, and high-risk – multiple tumors. We used Cox proportional
hazard models to test the impact of recurrence-free rate, and after adjustment to
available covariates.
Results
Median age of the cohort was 66.5 (IQR: 59.7-75.8 years) with 85% of patients being
males. Median overall follow-up time was 3.07 years (IQR: 0.75-4.01 years). When testing
the impact of treatment in each risk group separately, we found that patients in the
intermediate-risk treated with gemcitabine had a 24-month recurrence free rate of
77% (95% CI: 68%-86%) vs. 59% (95% CI: 49%-70%) in the saline group. This survival
difference was confirmed on multivariable analysis (hazard ratio: 0.39, 95% CI: 23%-66%,
P < 0.001). This group represented 53% of our cohort. Conversely, we did not observe
a significant difference in recurrence-free survival among patients in the low- (P = 0.7) and high-risk (P = 0.4) groups.
Conclusion
Our findings indicate that older patients with a single tumor of suspected low-grade
NMIBC at TURBT maximally benefit from immediate postresection IVC (gemcitabine).
Key Words
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Article info
Publication history
Published online: June 24, 2022
Accepted:
June 20,
2022
Received in revised form:
June 3,
2022
Received:
April 25,
2022
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
