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MP60-05 WHEN CAN ONCOLOGIC SURVEILLANCE FOLLOWING RADICAL CYSTECTOMY BE SAFELY DISCONTINUED?
THE JOURNAL OF UROLOGYâ
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(IQR) 30- and 90-day HFDs were 24 (22-25) and 84 (82-85) days, respectively. Patients who experienced any complications (versus none) had significantly fewer 30d HFDs (22 vs. 24 days, p¼0.002) and 90d HFDs (82 vs. 84 days, p<0.001), and patients with higher grade complications had fewer HFDs than those with lower-grade or no complications (p<0.001). With respect to QOL, there was no significant difference in VCI-15 scores at 1 year across strata of number of complications, grade of complications, 30-day HFDs or 90-day HFDs. On multivariable analysis, the only independent predictors of 1 year QOL were female gender and baseline QOL score. CONCLUSIONS: Not surprisingly, patients who experience more severe complications following RC have fewer HFDs over the 30 and 90 day recovery periods. However, experiencing a complication, or spending more time in the hospital within 90 days of surgery does not predict QOL at 1 year among RC patients. Instead, QOL appears to be driven largely by baseline QOL and gender. Source of Funding: None
MP60-04 IMPACT OF PRE-OPERATIVE HEMOGLOBIN VALUES AND PERIOPERATIVE BLOOD TRANSFUSION ON CANCER SPECIFIC AND OVERALL MORTALITY AFTER RADICAL CYSTECTOMY FOR BLADDER CANCER: RESULTS FROM A SINGLE INSTITUTION COHORT Marco Moschini*, Marco Bianchi, Federico Pellucchi, Lorenzo Rocchini, Giorgio Gandaglia, Milan, Italy; Pierre Karakiewicz, Montreal, Canada; , Milan, Italy; Francesco Cantiello, Rocco Damiano, Federico Deho Catanzaro, Italy; Shahrokh François Shariat, Vienna, Austria; Francesco Montorsi, Alberto Briganti, Renzo Colombo, Milan, Italy INTRODUCTION AND OBJECTIVES: Few studies investigated the impact of peri-operative blood transfusions (PBT) on cancer-specific (CSS) and overall survival (OS) in the context of bladder cancer (Bca). However, none of those have taken into account the role of pre-operative hemoglobin levels (Hb), which has been suggested to be related with systemic disease dissemination. Accordingly, the aim of the study was to evaluate the impact of both Hb and PBT on CSS an OS in patients treated with radical cystectomy (RC) for BCa METHODS: The study cohort included 1575 patients treated with RC for BCa between 1990 and 2012 at a single tertiary referral center. Complete clinical, pathological and follow up-data where available for all the patients. First, Kaplan-Meier curves were employed to assess the CSS and OS rates in the overall cohort. Subsequently, univariable (UVA) and multivariable (MVA) Cox regression analyses were used for prediction of CSS and OS. First the effect of PBT and Hb on CSS and OS were analyzed separately. Finally, both the variables were included in the same model. Covariates consisted of patient age at surgery, Hb, PBT, pathological T stage, pathological N stage RESULTS: Mean age at RC was 67 years. Overall, 580 (36.8%) patients received PBT (mean number of blood units received: 3). Mean and median Hb values were 12.4 and 12.6 mg/dL (range 8.0-17.5 mg /dL), respectively. With a mean follow-up time of 41 months, the 2 and 5 years CSS and OS were 83.1 vs. 75.2 and 68.3 vs. 59.8%, respectively. At UVA, patients who received PBT had a 2-fold higher risk of succumbing to CSM (HR: 2.11; p<0.001) and OM (HR 1.98; p<0.001) compared to patients who did not receive any PBT. Similarly, patients with higher Hb levels were more likely to succumb to CSM and OM than patients with lower Hb values (HR 0.84 and 0.85; all p<0.001). At MVA, both PBT and Hb were significantly associated with CSM and OM when included in different models (all p0.02). Conversely, when both variables were included in the same model, only Hb remained significantly associated with CSM and OM (HR 0.89 and 0.91 respectively; all p0.03). CONCLUSIONS: Despite the influence of PBT on CSM and OM appears to be relevant even in bladder cancer, its effect on
Vol. 191, No. 4S, Supplement, Monday, May 19, 2014
oncological outcomes disappears when Hb is taken into account. Further studies are needed to further investigate the possible immunosoppressive effect of PBT as well as the role of Hb and systemic dissemination of BCa Source of Funding: none
MP60-05 WHEN CAN ONCOLOGIC SURVEILLANCE FOLLOWING RADICAL CYSTECTOMY BE SAFELY DISCONTINUED? Suzanne Stewart*, Stephen Boorjian, Prabin Thapa, Sarah Psutka, John Cheville, Matthew Tollefson, R. Houston Thompson, Igor Frank, Rochester, MN INTRODUCTION AND OBJECTIVES: The appropriate duration of surveillance following radical cystectomy (RC) remains unknown. Uniform adherence to guidelines has the potential for the over utilization of medical resources in some patients and deficiency of testing in others. Herein, we propose a stage- and recurrence sitespecific surveillance strategy following RC based on recurrence risk over time. METHODS: We reviewed our institutional database of 1798 patients who underwent RC between 1980-2007. Patients were stratified according to pathologic stage: pT0N0, pTa/CIS/T1N0, pT2N0, pT3/ 4N0, and pTanyN+; as well as according to recurrence site: residual urothelium (urethra and upper tract), abdomen, and chest. Decreasing hazard rates of recurrence over time were modeled using a parametric Weibull distribution according to stage- and recurrence site-stratified groups. The appropriate stopping point for surveillance was determined upon patient’s reaching a level of recurrence risk of 1% per year (1 recurrence per 100 patients per year). RESULTS: Median follow-up after RC was 10.6yrs (IQR 6.815.2), during which time 714 (39.7%) patients developed recurrence. The time period required to reach a 1% risk of recurrence per year, stratified by stage and recurrence location, are summarized in the Table. These data demonstrate significant differences in the duration of site-specific follow-up required among different stage groups. For example, while surveillance of the remaining urothelium should continue for 1 year among pT0N0 and pT3/4N0 patients, patients with pTa/CIS/1N0 disease remain at risk for up to 15 years. Likewise for abdominal recurrence, pT0N0 disease reaches the 1% threshold at 2 years, while pT2N0, pT3/4N0, pTanyN+ patients remain at risk significantly longer, necessitating surveillance for 20+ years after surgery. CONCLUSIONS: We present a stage- and site-specific surveillance regimen for patients after RC, developed using a novel statistical approach. Pending external validation, these guidelines may be utilized to individualize oncologic follow-up, thereby optimizing the likelihood of capturing recurrence and facilitating appropriate allocation of resources. Table Time period (in years) required to reach a recurrence risk of 1% per year (1 recurrence per 100 patients per year). Stage pT0N0 pTa/CIS/1N0 pT2N0 pT3/4N0 pTanyN+
Urothelium 1 yr 15 yrs 2 yrs 1 yr 2 yrs
Source of Funding: None
Recurrence Location Abdomen 2 yrs 4 yrs 20 yrs > 20 yrs > 20 yrs
Chest 0 yrs 0 yrs 1 yr 4 yrs 9 yrs
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(IQR) 30- and 90-day HFDs were 24 (22-25) and 84 (82-85) days, respectively. Patients who experienced any complications (versus none) had significantly fewer 30d HFDs (22 vs. 24 days, p¼0.002) and 90d HFDs (82 vs. 84 days, p<0.001), and patients with higher grade complications had fewer HFDs than those with lower-grade or no complications (p<0.001). With respect to QOL, there was no significant difference in VCI-15 scores at 1 year across strata of number of complications, grade of complications, 30-day HFDs or 90-day HFDs. On multivariable analysis, the only independent predictors of 1 year QOL were female gender and baseline QOL score. CONCLUSIONS: Not surprisingly, patients who experience more severe complications following RC have fewer HFDs over the 30 and 90 day recovery periods. However, experiencing a complication, or spending more time in the hospital within 90 days of surgery does not predict QOL at 1 year among RC patients. Instead, QOL appears to be driven largely by baseline QOL and gender. Source of Funding: None
MP60-04 IMPACT OF PRE-OPERATIVE HEMOGLOBIN VALUES AND PERIOPERATIVE BLOOD TRANSFUSION ON CANCER SPECIFIC AND OVERALL MORTALITY AFTER RADICAL CYSTECTOMY FOR BLADDER CANCER: RESULTS FROM A SINGLE INSTITUTION COHORT Marco Moschini*, Marco Bianchi, Federico Pellucchi, Lorenzo Rocchini, Giorgio Gandaglia, Milan, Italy; Pierre Karakiewicz, Montreal, Canada; , Milan, Italy; Francesco Cantiello, Rocco Damiano, Federico Deho Catanzaro, Italy; Shahrokh François Shariat, Vienna, Austria; Francesco Montorsi, Alberto Briganti, Renzo Colombo, Milan, Italy INTRODUCTION AND OBJECTIVES: Few studies investigated the impact of peri-operative blood transfusions (PBT) on cancer-specific (CSS) and overall survival (OS) in the context of bladder cancer (Bca). However, none of those have taken into account the role of pre-operative hemoglobin levels (Hb), which has been suggested to be related with systemic disease dissemination. Accordingly, the aim of the study was to evaluate the impact of both Hb and PBT on CSS an OS in patients treated with radical cystectomy (RC) for BCa METHODS: The study cohort included 1575 patients treated with RC for BCa between 1990 and 2012 at a single tertiary referral center. Complete clinical, pathological and follow up-data where available for all the patients. First, Kaplan-Meier curves were employed to assess the CSS and OS rates in the overall cohort. Subsequently, univariable (UVA) and multivariable (MVA) Cox regression analyses were used for prediction of CSS and OS. First the effect of PBT and Hb on CSS and OS were analyzed separately. Finally, both the variables were included in the same model. Covariates consisted of patient age at surgery, Hb, PBT, pathological T stage, pathological N stage RESULTS: Mean age at RC was 67 years. Overall, 580 (36.8%) patients received PBT (mean number of blood units received: 3). Mean and median Hb values were 12.4 and 12.6 mg/dL (range 8.0-17.5 mg /dL), respectively. With a mean follow-up time of 41 months, the 2 and 5 years CSS and OS were 83.1 vs. 75.2 and 68.3 vs. 59.8%, respectively. At UVA, patients who received PBT had a 2-fold higher risk of succumbing to CSM (HR: 2.11; p<0.001) and OM (HR 1.98; p<0.001) compared to patients who did not receive any PBT. Similarly, patients with higher Hb levels were more likely to succumb to CSM and OM than patients with lower Hb values (HR 0.84 and 0.85; all p<0.001). At MVA, both PBT and Hb were significantly associated with CSM and OM when included in different models (all p0.02). Conversely, when both variables were included in the same model, only Hb remained significantly associated with CSM and OM (HR 0.89 and 0.91 respectively; all p0.03). CONCLUSIONS: Despite the influence of PBT on CSM and OM appears to be relevant even in bladder cancer, its effect on
Vol. 191, No. 4S, Supplement, Monday, May 19, 2014
oncological outcomes disappears when Hb is taken into account. Further studies are needed to further investigate the possible immunosoppressive effect of PBT as well as the role of Hb and systemic dissemination of BCa Source of Funding: none
MP60-05 WHEN CAN ONCOLOGIC SURVEILLANCE FOLLOWING RADICAL CYSTECTOMY BE SAFELY DISCONTINUED? Suzanne Stewart*, Stephen Boorjian, Prabin Thapa, Sarah Psutka, John Cheville, Matthew Tollefson, R. Houston Thompson, Igor Frank, Rochester, MN INTRODUCTION AND OBJECTIVES: The appropriate duration of surveillance following radical cystectomy (RC) remains unknown. Uniform adherence to guidelines has the potential for the over utilization of medical resources in some patients and deficiency of testing in others. Herein, we propose a stage- and recurrence sitespecific surveillance strategy following RC based on recurrence risk over time. METHODS: We reviewed our institutional database of 1798 patients who underwent RC between 1980-2007. Patients were stratified according to pathologic stage: pT0N0, pTa/CIS/T1N0, pT2N0, pT3/ 4N0, and pTanyN+; as well as according to recurrence site: residual urothelium (urethra and upper tract), abdomen, and chest. Decreasing hazard rates of recurrence over time were modeled using a parametric Weibull distribution according to stage- and recurrence site-stratified groups. The appropriate stopping point for surveillance was determined upon patient’s reaching a level of recurrence risk of 1% per year (1 recurrence per 100 patients per year). RESULTS: Median follow-up after RC was 10.6yrs (IQR 6.815.2), during which time 714 (39.7%) patients developed recurrence. The time period required to reach a 1% risk of recurrence per year, stratified by stage and recurrence location, are summarized in the Table. These data demonstrate significant differences in the duration of site-specific follow-up required among different stage groups. For example, while surveillance of the remaining urothelium should continue for 1 year among pT0N0 and pT3/4N0 patients, patients with pTa/CIS/1N0 disease remain at risk for up to 15 years. Likewise for abdominal recurrence, pT0N0 disease reaches the 1% threshold at 2 years, while pT2N0, pT3/4N0, pTanyN+ patients remain at risk significantly longer, necessitating surveillance for 20+ years after surgery. CONCLUSIONS: We present a stage- and site-specific surveillance regimen for patients after RC, developed using a novel statistical approach. Pending external validation, these guidelines may be utilized to individualize oncologic follow-up, thereby optimizing the likelihood of capturing recurrence and facilitating appropriate allocation of resources. Table Time period (in years) required to reach a recurrence risk of 1% per year (1 recurrence per 100 patients per year). Stage pT0N0 pTa/CIS/1N0 pT2N0 pT3/4N0 pTanyN+
Urothelium 1 yr 15 yrs 2 yrs 1 yr 2 yrs
Source of Funding: None
Recurrence Location Abdomen 2 yrs 4 yrs 20 yrs > 20 yrs > 20 yrs
Chest 0 yrs 0 yrs 1 yr 4 yrs 9 yrs