Abstract
Purpose of Review
In this article, the contemporary knowledge regarding specific issues related to the care of older bladder cancer patients is reviewed. The status of radical cystectomy, bladder-sparing strategies, checkpoint inhibition, prostate-sparing surgery, and BCG distribution pertaining to older adults are discussed.
Recent Findings
The use of minimally invasive approaches for radical cystectomy in patients with invasive bladder cancer is on the rise, including those patients with advanced age. Enhanced recovery pathways are improving time-to-recovery for patients undergoing radical cystectomy which may be especially important in the elderly and frail. Trimodal bladder-sparing strategies are emerging options for patients who are unfit for radical cystectomy. Immunotherapies offer promising options for patients with advanced or treatment-refractory disease. Prostate-sparing surgery does not currently hold a place in the contemporary management of bladder cancer for those patients who are surgical candidates. Older adults may be at risk of disparity in the distribution of scarce BCG resources during times of manufacturing shortage.
Summary
Older adults, as compared with those younger, face special challenges in their bladder cancer care. There is a clinical imperative that practitioners involved in the evaluation and management of older bladder cancer patients be knowledgeable of the unique issues that stand between them and cancer-free survival.
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References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 3rd ed. 2017;67(1):7–30.
• Erlich A, Zlotta AR. Treatment of bladder cancer in the elderly. Investig Clin Urol. 2016;57(Suppl 1):S26–10 An excellent comprehensive review of the numerous issues that elderly patients with bladder cancer face.
Soria F, Moschini M, Korn S, Shariat SF. How to optimally manage elderly bladder cancer patients? Transl Androl Urol. 2016;5(5):683–91.
Fung C, Guancial E, Roussel B, Bergsma D, Bylund K, Sahasrabudhe D, et al. Bladder cancer in the elderly patient: challenges and solutions. Clin Interv Aging 2015;61:939–11. https://doi.org/10.2147/CIA.S743322
Galsky MD. How I treat bladder cancer in elderly patients. J Geriatr Oncol. 2015;6(1):1–7 Dr. Galsky is a thought-leading medical oncologist specializing in bladder cancer whose recommendations for contemporary management of bladder cancer in the elderly are very useful.
Rose TL, Milowsky MI. Management of muscle-invasive bladder cancer in the elderly. Curr Opin Urol. 2015;25(5):459–67.
Rink M, Dahlem R, Kluth L, Minner S, Ahyai SA, Eichelberg C, et al. Older patients suffer from adverse histopathological features after radical cystectomy. Int J Urol John Wiley & Sons, Ltd (101111). 2011;18(8):576–84.
May M, Fritsche H-M, Gilfrich C, Brookman-May S, Burger M, Otto W, et al. Influence of older age on survival after radical cystectomy due to urothelial carcinoma of the bladder: survival analysis of a German multi-centre study after curative treatment of urothelial carcinoma of the bladder. Urologe A. 2011;50(7):821–9.
Nielsen ME, Shariat SF, Karakiewicz PI, Lotan Y, Rogers CG, Amiel GE, et al. Advanced age is associated with poorer bladder cancer-specific survival in patients treated with radical cystectomy. Eur Urol. 2007;51(3):699–706 discussion706–8.
• Noon AP, Albertsen PC, Thomas F, Rosario DJ, Catto JWF. Competing mortality in patients diagnosed with bladder cancer: evidence of undertreatment in the elderly and female patients. Br J Cancer Nature Publishing Group. 2013;108(7):1534–40.
Gore JL, Litwin MS, Lai J, Yano EM, Madison R, Setodji C, et al. Use of radical cystectomy for patients with invasive bladder cancer. J Natl Cancer Inst. 2010;102(11):802–11.
Chamie K, Hu B, de Vere White RW, Ellison LM. Cystectomy in the elderly: does the survival benefit in younger patients translate to the octogenarians? BJU Int John Wiley & Sons, Ltd (101111). 2008;102(3):284–90.
Fedeli U, Fedewa SA, Ward EM. Treatment of muscle invasive bladder cancer: evidence from the National Cancer Database, 2003 to 2007. J Urol Wolters Kluwer Philadelphia, PA. 2011;185(1):72–8.
Horovitz D, Turker P, Bostrom PJ, Mirtti T, Nurmi M, Kuk C, et al. Does patient age affect survival after radical cystectomy? BJU Int John Wiley & Sons, Ltd (101111). 2012;110(11 Pt B):E486–93.
Siddiqui KM, Izawa JI. Ileal conduit: standard urinary diversion for elderly patients undergoing radical cystectomy. World J Urol. 2016;34(1):19–24.
Froehner M, Brausi MA, Herr HW, Muto G, Studer UE. Complications following radical cystectomy for bladder cancer in the elderly. Eur Urol. 2009;56(3):443–54.
• Daneshmand S, Ahmadi H, Schuckman AK, Mitra AP, Cai J, Miranda G, et al. Enhanced recovery protocol after radical cystectomy for bladder cancer. J Urol. 2014;192(1):50–5.
• Schiffmann J, Gandaglia G, Larcher A, Sun M, Tian Z, Shariat SF, et al. Contemporary 90-day mortality rates after radical cystectomy in the elderly. Eur J Surg Oncol. 2014;40(12):1738–45.
Shariat SF, Milowsky M, Droller MJ. Bladder cancer in the elderly. Urol Oncol. 2009;27(6):653–67.
Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833–42.e1 3.
• Hurria A, Cirrincione CT, Muss HB, Kornblith AB, Barry W, Artz AS, et al. Implementing a geriatric assessment in cooperative group clinical cancer trials: CALGB 360401. J Clin Oncol. 2011;29(10):1290–6 Resource for practitioners seeking to learn more about the Comprehensive Geratric Assessment tool.
Isbarn H, Jeldres C, Zini L, Perrotte P, Baillargeon-Gagne S, Capitanio U, et al. A population based assessment of perioperative mortality after cystectomy for bladder cancer. J Urol Wolters KluwerPhiladelphia, PA. 2009;182(1):70–7.
Feng MA, McMillan DT, Crowell K, Muss H, Nielsen ME, Smith AB. Geriatric assessment in surgical oncology: a systematic review. J Surg Res. 2015;193(1):265–72.
Stroumbakis N, Herr HW, Cookson MS, Fair WR. Radical cystectomy in the octogenarian. J Urol. 1997;158(6):2113–7.
Clark PE, Stein JP, Groshen SG, Cai J, Miranda G, Lieskovsky G, et al. Radical cystectomy in the elderly: comparison of clincal outcomes between younger and older patients. Cancer. 2005;104(1):36–43.
Tang K, Li H, Xia D, Hu Z, Zhuang Q, Liu J, et al. Laparoscopic versus open radical cystectomy in bladder cancer: a systematic review and meta-analysis of comparative studies. Gakis G, editor. PLoS One Public Library of Science. 2014;9(5):e95667.
Bachman AG, Parker AA, Shaw MD, Cross BW, Stratton KL, Cookson MS, et al. Minimally invasive versus open approach for cystectomy: trends in the utilization and demographic or clinical predictors using the National Cancer Database. Urology. 2017;103:99–105.
Parekh DJ, Reis IM, Castle EP, Gonzalgo ML, Woods ME, Svatek RS, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet. 2018;391(10139):2525–36.
Nguyen DP, Hussein Al Awamlh Al B, Charles Osterberg E, Chrystal J, Flynn T, Lee DJ, et al. Postoperative complications and short-term oncological outcomes of patients aged ≥80 years undergoing robot-assisted radical cystectomy. World J Urol. 2015;33(9):1315–21.
•• Maloney I, Parker DC, Cookson MS, Patel S. Bladder cancer recovery pathways: a systematic review. Bladder Cancer IOS Press. 2017;3(4):269–81 A nice review of ERAS pathways for bladder cancer.
Chen RC, Shipley WU, Efstathiou JA, Zietman AL. Trimodality bladder preservation therapy for muscle-invasive bladder cancer. J Natl Compr Cancer Netw. 2013;11(8):952–60.
El-Achkar A, Souhami L, Kassouf W. Bladder preservation therapy: review of literature and future directions of trimodal therapy. Curr Urol Rep Springer US. 2018;19(12):108.
•• Giacalone NJ, Shipley WU, Clayman RH, Niemierko A, Drumm M, Heney NM, et al. Long-term outcomes after bladder-preserving tri-modality therapy for patients with muscle-invasive bladder cancer: an updated analysis of the Massachusetts General Hospital experience. Eur Urol. 2017;71(6):952–60 Oncologic outcomes from trimodal therapy.
Mak RH, Hunt D, Shipley WU, Efstathiou JA, Tester WJ, Hagan MP, et al. Long-term outcomes in patients with muscle-invasive bladder cancer after selective bladder-preserving combined-modality therapy: a pooled analysis of Radiation Therapy Oncology Group protocols 8802, 8903, 9506, 9706, 9906, and 0233. J Clin Oncol. 2014;32(34):3801–9.
Turgeon G-A, Souhami L. Trimodality therapy for bladder preservation in the elderly population with invasive bladder cancer. Front Oncol Frontiers. 2014;4(4):206.
Babjuk M, Böhle A, Burger M, Capoun O, Cohen D, Compérat EM, et al. EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder: update 2016. Eur Urol. 2017;71(3):447–61.
Power NE, Izawa J. Comparison of guidelines on non-muscle invasive bladder cancer (EAU, CUA, AUA, NCCN, NICE). Bladder Cancer IOS Press. 2016;2(1):27–36.
Oddens JR, Sylvester RJ, Brausi MA, Kirkels WJ, van de Beek C, van Andel G, et al. The effect of age on the efficacy of maintenance bacillus Calmette-Guérin relative to maintenance epirubicin in patients with stage Ta T1 urothelial bladder cancer: results from EORTC genito-urinary group study 30911. Eur Urol. 2014;66(4):694–701.
Gontero P, Sylvester R, Pisano F, Joniau S, Vander Eeckt K, Serretta V, et al. Prognostic factors and risk groups in T1G3 non-muscle-invasive bladder cancer patients initially treated with Bacillus Calmette-Guérin: results of a retrospective multicenter study of 2451 patients. Eur Urol. 2015;67(1):74–82.
Herr HW. Age and outcome of superficial bladder cancer treated with bacille Calmette-Guérin therapy. Urology. 2007;70(1):65–8.
Davies BJ, Hwang TJ, Kesselheim AS. Ensuring access to injectable generic drugs - the case of intravesical BCG for bladder cancer. N Engl J Med. 2017;376(15):1401–3 Exploring some of the distributive justice issues during BCG manufacturing shortages.
Modgil V, Cashman S, Gommersall L. The BCG shortage - what isn’t the fuss about? Trends Urol Men's Health. 2016;7(4):22–4.
Bandari J, Maganty A, MacLeod LC, Davies BJ. Manufacturing and the market: rationalizing the shortage of Bacillus Calmette-Guérin. Eur Urol Focus. 2018;4(4):481–484. https://doi.org/10.1016/j.euf.2018.06.018
Chism DD. Urothelial carcinoma of the bladder and the rise of immunotherapy. J Natl Compr Cancer Netw. 2017;15(10):1277–84.
Hanna KS. A review of immune checkpoint inhibitors for the management of locally advanced or metastatic urothelial carcinoma. Pharmacotherapy 26 ed. 2017;163(3):761–1405.
Singh P, Black P. Emerging role of checkpoint inhibition in localized bladder cancer. Urol Oncol. 2016;34(12):548–55.
Balar AV, Castellano D, O’Donnell PH, Grivas P, Vuky J, Powles T, et al. First-line pembrolizumab in cisplatin-ineligible patients with locally advanced and unresectable or metastatic urothelial cancer (KEYNOTE-052): a multicentre, single-arm, phase 2 study. Lancet Oncol. 2017;18(11):1483–92.
Balar AV, Galsky MD, Rosenberg JE, Powles T, Petrylak DP, Bellmunt J, et al. Atezolizumab as first-line treatment in cisplatin-ineligible patients with locally advanced and metastatic urothelial carcinoma: a single-arm, multicentre, phase 2 trial. Lancet. 2017;389(10064):67–76.
Lalani A-KA, Bossé D, McGregor BA, Choueiri TK. Immunotherapy in the elderly. Eur Urol Focus. 2017;3(4-5):403–12.
Bellmunt J, de Wit R, Vaughn DJ, Fradet Y, Lee J-L, Fong L, et al. Pembrolizumab as second-line therapy for advanced urothelial carcinoma. N Engl J Med Massachusetts Medical Society. 2017;376(11):1015–26.
Sharma P, Retz M, Siefker-Radtke A, Baron A, Necchi A, Bedke J, et al. Nivolumab in metastatic urothelial carcinoma after platinum therapy (CheckMate 275): a multicentre, single-arm, phase 2 trial. Lancet Oncol. 2017;18(3):312–22.
Sharma P, Callahan MK, Bono P, Kim J, Spiliopoulou P, Calvo E, et al. Nivolumab monotherapy in recurrent metastatic urothelial carcinoma (CheckMate 032): a multicentre, open-label, two-stage, multi-arm, phase 1/2 trial. Lancet Oncol. 2016;17(11):1590–8.
Powles T, O’Donnell PH, Massard C, Arkenau H-T, Friedlander TW, Hoimes CJ, et al. Efficacy and safety of durvalumab in locally advanced or metastatic urothelial carcinoma: updated results from a phase 1/2 open-label study. JAMA Oncol. 2017;3(9):e172411.
Apolo AB, Infante JR, Balmanoukian A, Patel MR, Wang D, Kelly K, et al. Avelumab, an anti-programmed death-ligand 1 antibody, in patients with refractory metastatic urothelial carcinoma: results from a multicenter, phase Ib study. J Clin Oncol. 2017;35(19):2117–24.
Rosenberg JE, Hoffman-Censits J, Powles T, van der Heijden MS, Balar AV, Necchi A, et al. Atezolizumab in patients with locally advanced and metastatic urothelial carcinoma who have progressed following treatment with platinum-based chemotherapy: a single-arm, multicentre, phase 2 trial. Lancet. 2016;387(10031):1909–20.
• Stein JP, Hautmann RE, Penson D, Skinner DG. Prostate-sparing cystectomy: a review of the oncologic and functional outcomes. Contraindicated in patients with bladder cancer. Urol Oncol. 2009;27(5):466–72 Review of contemporary data surrounding prostate-sparing cystectomy.
Revelo MP, Cookson MS, Chang SS, Shook MF, Smith JA, Shappell SB. Incidence and location of prostate and urothelial carcinoma in prostates from cystoprostatectomies: implications for possible apical sparing surgery. Journal of Urology. Wolters KluwerPhiladelphia. PA. 2004;171(2 Pt 1):646–51.
Dy GW, Gore JL, Forouzanfar MH, Naghavi M, Fitzmaurice C. Global burden of urologic cancers, 1990-2013. Eur Urol. 2017;71(3):437–46.
Steers WD. Voiding dysfunction in the orthotopic neobladder. World J Urol. 2000;18(5):330–7.
Hautmann RE, Stein JP. Neobladder with prostatic capsule and seminal-sparing cystectomy for bladder cancer: a step in the wrong direction. Urol Clin North Am. 2005;32(2):177–85.
Kessler TM, Burkhard FC, Studer UE. Clinical indications and outcomes with nerve-sparing cystectomy in patients with bladder cancer. Urol Clin North Am. 2005;32(2):165–75.
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Parker, D.C., Patel, S.G. & Cookson, M.S. Evolving Concepts in the Evaluation and Management of Bladder Cancer in Elderly Men. Curr Geri Rep 8, 331–337 (2019). https://doi.org/10.1007/s13670-019-00301-w
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DOI: https://doi.org/10.1007/s13670-019-00301-w