Candidate for the Lee B. Lusted Student Prize Competition
Purpose: To compare quality-adjusted survival between three treatment strategies for advanced bladder cancer that differ in side effects and survival. There exists considerable controversy over which factors should direct shared decision making for these patients.
Method: We evaluated three treatment strategies for advanced bladder cancer using a decision-analytic Markov model based on a formal literature review. The base case was assumed to be a 65-year-old person with newly diagnosed MIBC. The model used a patient perspective a lifetime time horizon, and one month cycle-length. Three strategies were evaluated: (1) immediate radical cystectomy followed by adjuvant chemotherapy for high risk (>=T3) findings on pathology (RC); 2. immediate neoadjuvant chemotherapy followed by radical cystectomy (NC&RC); 3. trimodal therapy consisting of immediate pelvic and nodal radiation therapy with concurrent systemic chemotherapy followed by cystectomy for patients who do not enter remission (TMT). Outcomes were life expectancy (LE) and quality-adjusted life expectance (QALE).
Result: LE of 11.9 year was optimized with TMT treatment, while the discounted QALE of 8.3 years was maximized with NC&RC treatment. RC had the lowest LE (10.7 years) and QALE (7.6 years) compared to both other treatments, a difference that was sensitive to changes in both perioperative death from radical cystectomy and long term surgical complications. When we adjusted for effectiveness of BCG, remission rate post-TMT, and metastatic potential of the tumour, TMT maximized QALE over NC&RC.
Conclusion: For patients with newly diagnosed invasive bladder cancer, management with either neoadjuvant chemotherapy with radical cystectomy or radical radiation therapy with concurrent systemic chemotherapy with or without cystectomy offers improved life expectancy and quality-adjusted life expectancy compared to radical cystectomy alone. Thus, patients with localized, aggressive bladder cancer benefit from the use of systemic chemotherapy in addition to either radiotherapy or radical surgery early in their treatment. Deciding between surgical-based and radiation-based interventions is very sensitive to patient preferences.