Radical Cystectomy: Risk Versus Reward for Patients With Bladder Cancer

Standard treatment for patients with muscle-invasive bladder cancer is radical cystectomy, which involves surgery to remove all the bladder and nearby tissues and organs. But researchers from Mount Sinai in New York explained that the standard procedure is associated with life-altering implications because of the need to create a new way to pass urine out of the body after the organ has been removed and, potentially, considerable risk of death.

“Radical cystectomy is a curative backbone of treatment for muscle-invasive bladder cancer,” Matthew Galsky, M.D., professor of medicine, hematology and medical oncology at Mount Sinai, said in an interview with CURE. “However, the median age of onset bladder cancer in the United States is the mid- to late-70s. Cystectomy is a major operation and not without risks.”

In a study published in JNCI Cancer Spectrum, they examined the risk of early death post-cystectomy in nearly 8,000 patients with muscle-invasive bladder cancer who underwent radical cystectomy without perioperative chemotherapy within the National Cancer Database from 2003-2012.

Patients were mostly white men with a median age of 69, and eight days was the median length of hospital stays. Cystectomy cases were reviewed from lower volume hospitals (less than five cases per year), intermediate volume hospitals (5-14 cases per year) and higher volume hospitals (more than 15 cases per year). Within the group, 1,758 patients (22.2 percent) underwent cystectomy at a lower volume hospital, 2,726 (34.4 percent) at an intermediate volume hospital and 2,798 (35.3 percent) at a higher volume hospital.

Researchers found that radical cystectomy is associated with relatively high early risk of death. The 90-day mortality was 7.6 percent (8 percent for lower volume hospitals and 6.7 percent for higher volume hospitals). Increasing age, disease stage, comorbidities and lower volume hospitals were associated with higher 90-day mortality, according to the researchers.

“We were a bit surprised by the proportion of patients in this large (group) who would be considered at high risk for cystectomy-related mortality,” Galsky said.

Although there are risks, patients have some ways to try to improve outcomes after cystectomy. For instance, Galsky explained newer strategies, such as prehabilitation — improving a patient's fitness before medical intervention — and enhanced recovery after surgery programs, have decreased the risk of cystectomy.

It’s crucial for patients to consider the risks and benefits with each treatment approach for muscle-invasive bladder cancer, Galsky explained.

“Our study provides a general picture of the frequency of such risk across a large (group) of patients in the U.S. and identifies some patient and system specific factors that might place patients at higher risk,” Galsky said. “This is important as other treatment modalities are available for muscle-invasive bladder cancer (i.e., radiation) and trying to balance the potential impact of treatment-related mortality versus cancer-related mortality is critical to informed shared decision-making for individual patients.”