Radical Cystectomy vs Trimodality Therapy for Muscle-Invasive Bladder Cancer

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In a retrospective analysis reported in The Lancet Oncology, Zlotta et al found that trimodality therapy was associated with similar outcomes compared to radical cystectomy in patients with muscle-invasive bladder cancer.

Study Details

The study involved 722 patients with clinical stage T2–T4N0M0 muscle-invasive urothelial carcinoma of the bladder who would have been eligible for radical cystectomy or trimodality therapy (maximal transurethral resection of bladder tumor followed by concurrent chemoradiation). The patients were treated at three university centers in the United States and Canada between January 2005 and December 2017. All patients had solitary tumors smaller than 7 cm, no or unilateral hydronephrosis, and no extensive or multifocal carcinoma in situ. Among the 722 patients, 440 underwent radical cystectomy and 282 received trimodality therapy; outcomes were assessed by inverse probability treatment weighting (IPTW) analysis in this cohort. Outcomes were also assessed in propensity score matching (PSM) analysis with 3:1 matching for radical cystectomy (n = 837) vs trimodality therapy (n = 282). The primary outcome measure was metastasis-free survival.

Key Findings

Five-year metastasis-free survival was 75% with trimodality therapy vs 74% with radical cystectomy in IPTW analysis and 74% vs 74% in PSM analysis. No significant differences were observed in IPTW analysis (subdistribution hazard ratio [sHR] = 0.89, 95% confidence interval [CI] = 0.67–1.20, P = .40) or PSM analysis (sHR = 0.93, 95% CI = 0.71–1.24, P = .64).  

Five-year cancer-specific survival was 84% with trimodality therapy vs 81% with radical cystectomy on IPTW analysis (sHR = 0.72, 95% CI = 0.50–1.04, P = .071) and 85% vs 83% on PSM analysis (sHR = 0.73, 95% CI = 0.52–1.02, P = .057).

Five-year disease-free survival was 74% vs 73% on IPTW analysis (sHR = 0.87, 95% CI = 0.65–1.16, P = .35) and 76% vs 76% on PSM analysis (sHR = 0.88, 95% CI = 0.67–1.16, P = .37).

Five-year overall survival was 73% vs 66% on IPTW analysis (HR = 0.70, 95% CI = 0.53–0.92, P = .010) and 77% vs 72% on PSM analysis (HR = 0.75, 95% CI = 0.58–0.97, P = .0078).

The investigators concluded, “This multi-institutional study provides the best evidence to date showing similar oncological outcomes between radical cystectomy and trimodality therapy for select patients with muscle-invasive bladder cancer. These results support that trimodality therapy, in the setting of multidisciplinary shared decision-making, should be offered to all suitable candidates with muscle-invasive bladder cancer and not only to patients with significant comorbidities for whom surgery is not an option.”

Alexandre R. Zlotta, MD, of the Division of Urology, Department of Surgery, Mount Sinai Hospital, Sinai Health System, University of Toronto, is the corresponding author for The Lancet Oncology article.

Disclosure: The study was supported by internal institutional finding from Sinai Health Foundation, Princess Margaret Cancer Foundation, and Massachusetts General Hospital. For full disclosures of the study authors, visit

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