The Role of Radical Cystectomy in Clinically Node Positive Bladder Cancer: A US Veterans Health Administration Study

Introduction The role of local definitive therapy in addition to systemic treatment in clinically positive regional lymph node (cN+) bladder cancer is yet to be determined. Herein, we sought to investigate the role of radical cystectomy (RC) in management of patients with cN+ bladder cancer at US Veterans Health Administration Facilities. Methods We identified patients diagnosed with cN+ bladder cancer between 2000-2017 using the Department of Veterans Affairs (VA) Informatics and Computing Infrastructure (VINCI). We employed a combination of database/registry coded values and chart review for data collection. To minimize mortality bias, we excluded patients who died within 90 days of diagnosis. We divided the patients into cystectomy (C) versus “no cystectomy” (NOC) cohorts. Propensity score matching was performed based on predictors of undergoing RC. Multivariable Cox models and Kaplan-Meier survival curves were used to estimate overall survival (OS) and cancer specific survival (CCS). Result After matching, 158 patients were included in the C and NOC groups. In the C-group, 85(54%) patients received pre-cystectomy chemotherapy, and 73(46%) patients underwent post-cystectomy chemotherapy. In the C-group, 65(41%) patients and in the NOC-group, 66(42%) patients had clinical N1 disease (p=0.77). In multivariable Cox model, undergoing RC was associated with improved OS (HR0.62; 95%CI 0.47-0.81), p<0.001) and CSS (HR0.58; 95%CI 0.42-0.80; P<0.001). Conclusion As part of multimodal treatment, undergoing RC was associated with improved OS and CSS in subset of patients with cN+ bladder cancer. Prospective randomized trials are warranted to further investigate the role of local definitive therapy in this specific patient population.