Cystectomy or conservative therapy for patients with high-risk, T1G3 bladder cancer?
Original article
Kulkarni GS et al. (2007) Optimal management of high-risk T1G3 bladder cancer: a decision analysis. PLoS Med 4: e284 PubMed
The optimum treatment for high-risk T1G3 bladder cancer is controversial. Cystectomy might offer a better probability of cure than conservative therapy, but could also be associated with worse post-treatment quality-of-life (e.g. poor sexual function). Kulkarni et al. performed a validated decision analysis that compared the outcomes of both treatment approaches.
Published outcome probability data were used to estimate the life expectancy and quality-adjusted life expectancy (QALE; i.e. the number of years with good quality-of-life) of patients who undergo either immediate nerve-sparing cystectomy with orthotopic neobladder creation or initial conservative therapy with intravesical bacillus Calmette–Guérin. The base case was defined as a 60-year-old male with no comorbidity, good potency and newly diagnosed high-risk T1G3 transitional cell carcinoma of the bladder.
Compared with conservative management, immediate cystectomy yielded a higher mean life expectancy (14.3 years versus 13.6 years) and QALE (12.32 years versus 11.97 years) when the model was applied to the base case. Additional comorbidities and increased age reduced the benefit of immediate cystectomy: in terms of life-expectancy, conservative treatment was the preferred option above the age of 70 years; in terms of QALE, conservative treatment was preferred above the age of 65 years. In patients with significant concerns about postcystectomy adverse effects (i.e. sexual and/or gastrointestinal dysfunction), conservative treatment yielded the best QALE.
The authors conclude that immediate cystectomy seems to result in a longer life expectancy and QALE than conservative management; however, the treatment decision should be considered in light of the patient's age, comorbidity and wishes regarding post-treatment health status.
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