Cystectomy over age 80: Patient selection is key

New Orleans-For very elderly patients with bladder cancer, good outcomes with radical cystectomy are possible primarily through appropriate patient selection, timely surgical management, and meticulous postoperative care. These factors are essential to sustain long-term survival, according to a retrospective review from the University of Chicago Medical Center.

Results of the study, led by Gary Steinberg, MD, were presented at the American College of Surgeons Clinical Congress here by Mark H. Katz, MD, a clinical fellow in urologic oncology at the University of Chicago.

Bladder cancer is a disease of the elderly. While radical cystectomy is standard care for invasive disease, it is a complex procedure with a significant rate of complications. Several studies have demonstrated the operation's safety and efficacy in the elderly, but few studies have included patients ≥80 years old.

The study reviewed the perioperative results and long-term survival outcomes of all patients ≥80 years of age who underwent radical cystectomy from 1995 to 2003 at the University of Chicago. Of 517 patients in this group, 49 (9%) were at least 80 years old, with a mean age of 83 years. At least two comorbidities were present in 31 (63%) of the very elderly. All patients underwent cystectomy with urinary diversion performed by a single surgeon. The study excluded patients with non-urothelial bladder cancer, benign disease, or additional concomitant surgery.

Delays affect risk, complications

Among the patients 80 years of age or older, researchers found that mean blood loss was 985 mL, blood transfusions were required in 32 of the 49 patients (76%), and average length of the surgery was 279 minutes. Peri-operative mortality occurred in five patients (11%).

Intraoperative complications occurred in two patients (4.7%), while early postoperative complications (<90 days) occurred in 24 patients (57%). In approximately one-third of the cases, these complications included ileal conduit or bowel leak/fistula, and in another one-third, postoperative ileus. Late postoperative complications were seen in seven patients (17%). Four patients (9.5%) died within 30 days, Dr. Katz reported.

The main histologic subtype was urothelial carcinoma, seen in 36 patients (86%). Organ-confined disease was observed in 21 patients (58%), and non-organ-confined disease was reported in 15 patients (42%).

After a mean follow-up of 38 months, mean time to death in patients ≥80 years of age was 19.5 months (range, 6 to 51 months). Overall survival was 44%, and disease-free survival was 36%. Comparing survival in cases with organ-confined versus extravesical disease, researchers showed that overall survival was 62% in organ-confined disease and dropped to 20% in patients with extravesical disease (p<.01). Disease-free survival was 52% versus 13%, respectively (p=.02). No differences in survival were noted when patients were stratified by number of comorbidities.

"Radical cystectomy in patients age 80 and older is associated with significant short- and long-term morbidity, and local control and survival are heavily dependent on pathologic stage," Dr. Katz concluded.

Treatment or palliation?

Extravesical disease was common in this population, and led to poor outcomes in many cases, he added, possibly because of reluctance and consequent delay by surgeons in deciding to take these elderly patients into surgery.

"This topic is increasingly important, and this study highlights the difficulties of treating this patient group," commented Raj S. Pruthi, MD, associate professor of surgery and urology at the University of North Carolina, Chapel Hill. "There has to be a balance between trying to obtain good disease-specific survival and palliation. The incidence of bladder cancer has risen 40% over the past several decades. We know our patients are getting older, and we need to begin to rethink concepts regarding age and treatments."

He noted that the mortality rate in this review seemed high at 11% compared to 4.5% seen in most other series. Dr. Katz agreed, and pointed out that three of the four patients who died within 30 days of surgery actually never left the hospital.

Jerome P. Richie, MD, professor of surgery and chief of urology at Harvard Medical School, Boston, noted that 40% of the patients had T4 disease on intake.

"Are these really good candidates for cystectomy?" he asked. "I'm not sure you should be doing cystectomies on them. Perhaps they should be receiving other treatment."