UROLOGICAL ONCOLOGY

Advanced Age Is Associated With Poorer Bladder Cancer-Specific Survival in Patients Treated With Radical Cystectomy
Nielsen ME, Shariat SF, Karakiewicz PI, Lotan Y, Rogers CG, Amiel GE, Bastian PJ, Vazina A, Gupta A, Lerner SP, Sagalowsky AI, Schoenberg MP, Palapattu GS; Bladder Cancer Research Consortium (BCRC)
The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland, USA
Eur Urol. 2007; 51: 699-706; discussion 706-8

• Objective: Bladder cancer (BCa) is a disease of older persons, the incidence of which is expected to increase as the population ages. There is controversy, however, regarding the outcomes of radical cystectomy (RC), the gold standard treatment of high-risk BCa, in patients of advanced chronological age. The aim of our study was to assess the impact of patient age on pathological characteristics and recurrence-free and disease-specific survival following RC.
• Methods: The records of 888 consecutive patients who underwent RC for transitional cell carcinoma (TCC) were reviewed. Age at RC was analyzed both as a continuous (yr) and categorical (< or =60 yr old, n=240; 60.1-70 yr old, n=331; 70.1-80 yr old, n=266; >80 yr old, n=51) variable. Logistic regression and survival analyses were performed.
• Results: Higher age at RC, analyzed as a continuous or categorical variable, was associated with extravesical disease and pathological upstaging (all p<0.02). Older patients were less likely to receive postoperative chemotherapy (< or =60 yr: 32% vs. >80 yr: 14%, p=0.008). In both pre- and postoperative multivariate models, higher age at RC as a categorical variable was associated with BCa-specific survival (p<0.05). Patients >80 yr old had a significantly greater risk of disease recurrence than patients aged < or =60 yr (p<0.05).
• Conclusion: Greater patient age at the time of RC for BCa is independently associated with adverse outcomes. Better understanding of factors associated with postoperative outcomes in this growing segment of the population is necessary. Prospective corroboration and further refinement of similar analyses in other large datasets is needed.
  
  
• Editorial Comment
  This manuscript gives the results of 888 patients from 4 large centers in the USA and Canada on bladder cancer in the elderly. Some figures may recall the aggressivity of bladder cancer in general e.g. 48% had non-organ confined disease, 42% had pathological upstaging.
  Higher age was associated to worse prognostic factors such as risk of extravesical disease and pathological upstaging. In spite of more advanced disease, older patients were significantly less likely to receive adjuvant chemotherapy. The comment of M. Brausi to this paper is also advocated reading as it dissects the present bias in patient selection. In summary, this paper confers mainly well-known facts to urologists, still it is worthwhile reading as it may remind you not to wait too long to proceed with radical therapy as time may not play in favor of your elderly patients.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany