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MP60-13 PSOAS MUSCLE MASS AS A PREDICTOR OF SURVIVAL IN PATIENTS WHO UNDERGO RADICAL CYSTECTOMY
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Monday, May 19, 2014
urinary bladder (UCUB) patients who underwent RC between 1991 and 2009. Multivariable logistic regression analyses were used to assess variables which are associated with higher odds of 30- and 90-day mortality. The applied covariates for the multivariable analyses were T-stage, N-stage, year of surgery, age, gender, race, use of radiotherapy (RT), marital status, urban status, socioeconomic status, tumor grade and Charlson Comorbidity Index (CCI). RESULTS: Overall, 5,207 RC patients were identified. The 30and 90-day mortality rates after RC were 5.2% and 10.6%, respectively. According to age categories (<70, 70-79 and 80 years), the rates of 30-day mortality were 2.8%, 4.8% and 7.7% (p< 0.001) and the rates of 90-day mortality were 6.4%, 10.1% and 14.8% (p< 0.001). In multivariable logistic regression analyses, higher CCI, advanced age (all p < 0.001), unmarried status and higher tumor stage (all p < 0.05) were predictors of higher odds of 30-day mortality. Higher CCI, advanced age, higher tumor stage (all p< 0.001) and unmarried status (p< 0.05) also predicted higher odds of 90-day mortality. CONCLUSIONS: First, very important differences exist between 30- and 90-day mortality rates and the latter should ideally be used to avoid underestimation of perioperative mortality risk. Specific patient and tumor variables may also help in better prediction of particularly high risk individuals. Source of Funding: none
MP60-12 MULTI-INSTITUTIONAL QUALITY CARE INITIATIVE TO IMPROVE THE CARE OF PATIENTS WITH MUSCLE INVASIVE BLADDER CANCER Bernard Bochner*, Dahlia Sperling, Andrew Feifer, Joseph Mashni Jr, Dean Bajorin, Guido Dalbagni, Harry Herr, Sherri M. Donat, Matthew Milowsky, New York, NY; Jay Shah, Ashish Kamat, H. Barton Grossman, Houston, TX; Robert Grubb III, Stephen Brandes, Arnold Bullock, Seth Strope, Bruce Roth, Adam Kibel, Louis Weigand, St Louis, MO; Gary Steinberg, Walter Stadler, Natali Rutiaga, Chicago, IL; Mark Schoenberg, Trinity Bivalacqua, Charlene Rogers, Baltimore, MD; Peter Black, Alan So, Martin Gleave, Vancouver, Canada; Wassim Kassouf, Bassel Bachir, Faysal Yafi, Montreal, Canada; Seth Lerner, Guilherme Godoy, Gilead Amiel, Houston, TX; Alexandre Zlotta, Neil Fleshner, Michael Jewett, Girish Kulkarni, Srikala Sridhar, Ian Tanock, Anthony Joshua, Peter Bostrom, Cynthia Kuk, Toronto, Canada; Yair Lotan, Dallas, TX INTRODUCTION AND OBJECTIVES: Level 1 evidence supports a survival benefit for patients with muscle invasive bladder cancer (BlCa) that receive perioperative cisplatin chemotherapy (Ctx) in addition to radical cystectomy (RC). Underutilization of multimodal therapy has been reported nationally. We instituted a prospective, multicenter Quality Care Initiative (QCI) to improve the use of periop Ctx. METHODS: A two phase effort was initiated at 16 academic institutions. Phase 1 was initiated in 2010 and designed to evaluate baseline patterns of periop Ctx use for T2-4N0M0 BlCa pts that underwent RC between 2003-2008. Phase 2 was a prospective QCI. Data on all eligible pts were collected prospectively for 12 months on a webbased survey system. Both surgeons and medical oncologists participated to determine treatments received and rationale for treatment decisions. The quality indicators included: 1) referral to medical oncology for consideration of multimodality therapy, 2) if recommended, perioperative Ctx be cisplatin based and at least 3 cycles, 3) perform a bilateral pelvic lymph node dissection (BPLND), and 4) all treatment be completed within 6 months. RESULTS: All 16 centers participated in phase 1. Of 4344 pts on whom data was available, 34% received periop Ctx. Neoadjuvant and adjuvant use was 14% and 20%, respectively. 65% of pts receiving Ctx were treated with a cisplatin-based regimen. 95 % of patients received BPLND. 10 institutions completed 12 months of data collection for the QCI. Over 700 pts that underwent RC were evaluated. 388 pts with T2-4N0M0 disease were deemed eligible for data entry. 56% of eligible pts received periop Ctx, 47% received
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neoadjuvant Ctx and 9% received adjuvant Ctx. This represented a 64.7% increase in the use of any periop Ctx and a 3.4 fold increase in neoadjuvant Ctx compared to baseline data. Again 95% of patients received BPLND, with at least 72% of those yielding 12 or more lymph nodes. CONCLUSIONS: We have successfully completed a multiinstitutional prospective QCI to improve the use of periop Ctx in pts undergoing RC for resectable, non-metastatic bladder cancer. Our data demonstrates that significant improvements can be achieved in not only overall use of periop Ctx but most notably in the use of neoadjuvant Ctx. As a result of this study, granular data will be forthcoming explaining differences in practice patterns. Source of Funding: Supported by Weiner Family Foundation and the Bladder Cancer Advocacy Network
MP60-13 PSOAS MUSCLE MASS AS A PREDICTOR OF SURVIVAL IN PATIENTS WHO UNDERGO RADICAL CYSTECTOMY Hamed Ahmadi*, los Angeles, CA; Michael Terjimanian, Anna Sadie Chernin, Stephanie Daignault-Newton, Neal All-Attar, Stephen Dailey, Jeffery Montgomery, Alon Z. Weizer, James E. Montie, Cheryl T. Lee, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Morphomic measures of abdominal muscle mass, as physical component of frailty evaluation, are reportedly accurate predictors of early and late operative outcome in patients who undergo major abdominal surgeries. We evaluated the association between CT scan-based psoas muscle mass area and operative outcome of radical cystectomy (RC) and urinary diversion reconstruction. METHODS: In a retrospective single center study, 442 bladder cancer patients who underwent RC and urinary diversion reconstruction at Department of Urology, University of Michigan between 2007 and 2012 were enrolled. Cross-sectional areas of the left and right psoas muscles at the level of L4 were determined and summed to generate the total cross sectional area of the psoas muscles (TPA). Outcome measures of interest were short-term outcome including length of hospital stay (LOS), 30-day readmission rate (RR) and complication rate (CR); Intermediate-term outcome including 90-day RR and CR as well as 6-month mortality; and long-term outcome including 3-yr overall survival (OS). Multivariate logistic and Cox proportional-hazards regression models were used to determine predictors of operative outcome and OS, respectively. Predictive accuracy of different survival models were also compared using Receiver Operating Characteristic (ROC) curves. RESULTS: Mean age of participants and follow up time was 66 y/o (range, 31 e 91) and 2.3 yrs (range, 0.04 e 6.3), respectively. Mean TPA was 2363 mm2 (range, 552 e 4322). Mean LOS was 10 days. 30day RR and CR were 63/466 (13.5%) and 196/440 (44.5%), respectively. TPA was not associated with any early operative outcome measures. (P>0.05) 90-day RR and CR were 95/466 (20%) and 238/ 466 (51%), respectively. Thirty patients (6.4%) died within first 6-months from surgery of whom, 21 (70%) died of UCB. TPA was not associated with any intermediate operative outcome measures. (P>0.05) 3-year OS rate was 0.62 (range, 0.56e0.67). TPA (HR¼ 0.96, 95%CI: 0.93 e 0.98; P¼ 0.005) was significantly associated with 3-year OS. Patients with TPA at highest quartile had 0.18 survival advantage over those with TPA at lowest quartile 3 years from RC. (P¼ 0.02) Predictive accuracy of 3-year survival model composed of pathologic stage, age, and comorbidity was increased from 0.74 to 0.80 when TPA was included in the model. CONCLUSIONS: Muscle mass does not seem to be an independent predictor of early morbidity and mortality following RC. However, it is an independent predictor of long term survival, regardless of age, pathologic stage, and comorbidities. Source of Funding: None
Vol. 191, No. 4S, Supplement, Monday, May 19, 2014
urinary bladder (UCUB) patients who underwent RC between 1991 and 2009. Multivariable logistic regression analyses were used to assess variables which are associated with higher odds of 30- and 90-day mortality. The applied covariates for the multivariable analyses were T-stage, N-stage, year of surgery, age, gender, race, use of radiotherapy (RT), marital status, urban status, socioeconomic status, tumor grade and Charlson Comorbidity Index (CCI). RESULTS: Overall, 5,207 RC patients were identified. The 30and 90-day mortality rates after RC were 5.2% and 10.6%, respectively. According to age categories (<70, 70-79 and 80 years), the rates of 30-day mortality were 2.8%, 4.8% and 7.7% (p< 0.001) and the rates of 90-day mortality were 6.4%, 10.1% and 14.8% (p< 0.001). In multivariable logistic regression analyses, higher CCI, advanced age (all p < 0.001), unmarried status and higher tumor stage (all p < 0.05) were predictors of higher odds of 30-day mortality. Higher CCI, advanced age, higher tumor stage (all p< 0.001) and unmarried status (p< 0.05) also predicted higher odds of 90-day mortality. CONCLUSIONS: First, very important differences exist between 30- and 90-day mortality rates and the latter should ideally be used to avoid underestimation of perioperative mortality risk. Specific patient and tumor variables may also help in better prediction of particularly high risk individuals. Source of Funding: none
MP60-12 MULTI-INSTITUTIONAL QUALITY CARE INITIATIVE TO IMPROVE THE CARE OF PATIENTS WITH MUSCLE INVASIVE BLADDER CANCER Bernard Bochner*, Dahlia Sperling, Andrew Feifer, Joseph Mashni Jr, Dean Bajorin, Guido Dalbagni, Harry Herr, Sherri M. Donat, Matthew Milowsky, New York, NY; Jay Shah, Ashish Kamat, H. Barton Grossman, Houston, TX; Robert Grubb III, Stephen Brandes, Arnold Bullock, Seth Strope, Bruce Roth, Adam Kibel, Louis Weigand, St Louis, MO; Gary Steinberg, Walter Stadler, Natali Rutiaga, Chicago, IL; Mark Schoenberg, Trinity Bivalacqua, Charlene Rogers, Baltimore, MD; Peter Black, Alan So, Martin Gleave, Vancouver, Canada; Wassim Kassouf, Bassel Bachir, Faysal Yafi, Montreal, Canada; Seth Lerner, Guilherme Godoy, Gilead Amiel, Houston, TX; Alexandre Zlotta, Neil Fleshner, Michael Jewett, Girish Kulkarni, Srikala Sridhar, Ian Tanock, Anthony Joshua, Peter Bostrom, Cynthia Kuk, Toronto, Canada; Yair Lotan, Dallas, TX INTRODUCTION AND OBJECTIVES: Level 1 evidence supports a survival benefit for patients with muscle invasive bladder cancer (BlCa) that receive perioperative cisplatin chemotherapy (Ctx) in addition to radical cystectomy (RC). Underutilization of multimodal therapy has been reported nationally. We instituted a prospective, multicenter Quality Care Initiative (QCI) to improve the use of periop Ctx. METHODS: A two phase effort was initiated at 16 academic institutions. Phase 1 was initiated in 2010 and designed to evaluate baseline patterns of periop Ctx use for T2-4N0M0 BlCa pts that underwent RC between 2003-2008. Phase 2 was a prospective QCI. Data on all eligible pts were collected prospectively for 12 months on a webbased survey system. Both surgeons and medical oncologists participated to determine treatments received and rationale for treatment decisions. The quality indicators included: 1) referral to medical oncology for consideration of multimodality therapy, 2) if recommended, perioperative Ctx be cisplatin based and at least 3 cycles, 3) perform a bilateral pelvic lymph node dissection (BPLND), and 4) all treatment be completed within 6 months. RESULTS: All 16 centers participated in phase 1. Of 4344 pts on whom data was available, 34% received periop Ctx. Neoadjuvant and adjuvant use was 14% and 20%, respectively. 65% of pts receiving Ctx were treated with a cisplatin-based regimen. 95 % of patients received BPLND. 10 institutions completed 12 months of data collection for the QCI. Over 700 pts that underwent RC were evaluated. 388 pts with T2-4N0M0 disease were deemed eligible for data entry. 56% of eligible pts received periop Ctx, 47% received
e637
neoadjuvant Ctx and 9% received adjuvant Ctx. This represented a 64.7% increase in the use of any periop Ctx and a 3.4 fold increase in neoadjuvant Ctx compared to baseline data. Again 95% of patients received BPLND, with at least 72% of those yielding 12 or more lymph nodes. CONCLUSIONS: We have successfully completed a multiinstitutional prospective QCI to improve the use of periop Ctx in pts undergoing RC for resectable, non-metastatic bladder cancer. Our data demonstrates that significant improvements can be achieved in not only overall use of periop Ctx but most notably in the use of neoadjuvant Ctx. As a result of this study, granular data will be forthcoming explaining differences in practice patterns. Source of Funding: Supported by Weiner Family Foundation and the Bladder Cancer Advocacy Network
MP60-13 PSOAS MUSCLE MASS AS A PREDICTOR OF SURVIVAL IN PATIENTS WHO UNDERGO RADICAL CYSTECTOMY Hamed Ahmadi*, los Angeles, CA; Michael Terjimanian, Anna Sadie Chernin, Stephanie Daignault-Newton, Neal All-Attar, Stephen Dailey, Jeffery Montgomery, Alon Z. Weizer, James E. Montie, Cheryl T. Lee, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Morphomic measures of abdominal muscle mass, as physical component of frailty evaluation, are reportedly accurate predictors of early and late operative outcome in patients who undergo major abdominal surgeries. We evaluated the association between CT scan-based psoas muscle mass area and operative outcome of radical cystectomy (RC) and urinary diversion reconstruction. METHODS: In a retrospective single center study, 442 bladder cancer patients who underwent RC and urinary diversion reconstruction at Department of Urology, University of Michigan between 2007 and 2012 were enrolled. Cross-sectional areas of the left and right psoas muscles at the level of L4 were determined and summed to generate the total cross sectional area of the psoas muscles (TPA). Outcome measures of interest were short-term outcome including length of hospital stay (LOS), 30-day readmission rate (RR) and complication rate (CR); Intermediate-term outcome including 90-day RR and CR as well as 6-month mortality; and long-term outcome including 3-yr overall survival (OS). Multivariate logistic and Cox proportional-hazards regression models were used to determine predictors of operative outcome and OS, respectively. Predictive accuracy of different survival models were also compared using Receiver Operating Characteristic (ROC) curves. RESULTS: Mean age of participants and follow up time was 66 y/o (range, 31 e 91) and 2.3 yrs (range, 0.04 e 6.3), respectively. Mean TPA was 2363 mm2 (range, 552 e 4322). Mean LOS was 10 days. 30day RR and CR were 63/466 (13.5%) and 196/440 (44.5%), respectively. TPA was not associated with any early operative outcome measures. (P>0.05) 90-day RR and CR were 95/466 (20%) and 238/ 466 (51%), respectively. Thirty patients (6.4%) died within first 6-months from surgery of whom, 21 (70%) died of UCB. TPA was not associated with any intermediate operative outcome measures. (P>0.05) 3-year OS rate was 0.62 (range, 0.56e0.67). TPA (HR¼ 0.96, 95%CI: 0.93 e 0.98; P¼ 0.005) was significantly associated with 3-year OS. Patients with TPA at highest quartile had 0.18 survival advantage over those with TPA at lowest quartile 3 years from RC. (P¼ 0.02) Predictive accuracy of 3-year survival model composed of pathologic stage, age, and comorbidity was increased from 0.74 to 0.80 when TPA was included in the model. CONCLUSIONS: Muscle mass does not seem to be an independent predictor of early morbidity and mortality following RC. However, it is an independent predictor of long term survival, regardless of age, pathologic stage, and comorbidities. Source of Funding: None