A large cohort of patients with high-risk bladder cancer who underwent radical cystectomy and urinary tract reconstruction at Memorial Sloan Kettering Cancer Center (MSK) reported favorable recovery and health-related quality of life (HRQOL) within 24 months across most outcome measures, according to a prospective, longitudinal study published recently in European Urology. (1) The favorable patient-reported outcomes (PROs) and the excellent locoregional control provided by radical cystectomy further confirm it as the gold standard for treating high-risk bladder cancer.
Importantly, patients did not report any large decreases in scores in the immediate recovery period three months after surgery. (1) “Observing only a small drop-off at the first three-month time point is a tribute to the excellent postsurgical care patients received from our dedicated nurses,” says urologic surgeon Bernard Bochner, MD, FACS, the Sir Murray F. Brennan Chair in Surgery and senior author of the study.
“While it’s understandable patients have concerns about their quality of life after radical cystectomy and urinary diversion, our evidence reveals most do not materialize for patients treated by experts at a high-volume center,” says Dr. Bochner, who is also coordinator of the bladder cancer multidisciplinary working group at MSK. “We hope a better understanding of contemporary PROs will help more patients needing radical cystectomy understand the reality of life after surgery, and this will help them make decisions without delay, as surgery can provide a cure in most patients with early lesions.”
“Our study results serve as a report card, demonstrating that we’re providing excellent quality-of-life outcomes over the long term. That’s the home run,” says Dr. Bochner. “We are not treating bladder cancer; we are treating patients with bladder cancer, and we will continue to focus on improving long-term survivorship and quality of life after treatment.”
Most previous quality-of-life studies in this patient population have been small and retrospective. By contrast, for their new study, NCT00745355, Dr. Bochner and colleagues evaluated PROs across 14 validated HRQOL measures collected before and after surgery at various time points over two years in a large group of 411 patients treated at MSK between 2008 and 2014. The tools measured HRQOL in the domains of general quality of life and function, urinary function, bowel function, sexual function, and mental and emotional health at the presurgical visit and at 3, 6, 12, 18, and 24 months after radical cystectomy. The investigators normalized all survey measure scores to a scale of 0% to 100% to facilitate interpretation between domains. (1)
Among the 411 patients, 205 received ileal conduits and 206 received continent diversion with orthotopic neobladder reconstruction. The study authors noted the trial’s primary objective was to characterize the long-term pattern and extent of recovery for patients undergoing radical cystectomy and not to compare HRQOL based on the choice of urinary diversion method. (1)
At MSK, dedicated urologic surgeons perform hundreds of radical cystectomy and urinary diversion procedures annually. The choice of diversion method is determined on an individual patient basis according to surgeon selection and patient preferences. Adults older than 75 with heavy comorbidities, such as diminished cognitive, renal, and hepatic function, are more likely to receive ileal conduits, while younger patients with fewer comorbidities are more likely to receive orthotopic neobladders.
Key Findings and Implications
Overall, patients reported a favorable global HRQOL recovery within 24 months of radical cystectomy and urinary reconstruction in most domains, except for scores related to body image among those who received ileal conduits and sexual function among both groups. (1)
Noteworthy findings by domain were as follows: (1)
- Global quality of life: For the continent diversion cohort, scores were close to the baseline scores at 3 months, then improved further at 12 months. For the ileal conduit group, scores were similar to baseline at 3 months and gradually increased at 24 months.
- Physical function: At 3 months after radical cystectomy, patients in both groups reported no large effects on physical function, resulting in only a 5-point drop in scores. These scores returned to near preoperative levels for the continent diversion group but remained stable for the ileal conduit group.
- Role function: Patients in the ileal conduit group reported they were nearly back to baseline by 24 months for performing work or other activities. Patients in the continent diversion group reported their outcomes at 24 months were higher than baseline.
- Social functioning: Patients receiving continent diversion reported no decrease in social functioning from baseline early on, and scores continuously rose at 12 months. The average score for patients receiving ileal conduits dropped at 6 months but recovered to near baseline by 24 months.
- Urinary function: For patients who received neobladders, scores worsened from baseline at 3 months, then improved gradually over the remaining follow-ups. For the ileal conduit group, urostomy domain scores improved gradually from 3 months out to the 24-month time point.
- Bowel function: The mean total Memorial Sloan Kettering Cancer Center Bowel Function Index (MSK BFI) (2) score for the continent diversion group decreased slightly at six months and stayed stable. For the ileal conduit group, the MSK BFI score remained within 2 points of baseline throughout subsequent follow-ups.
- Sexual function: Ileal conduit patients reported decreased sexual function at 6 months and showed no later improvements. Continent diversion patients also reported decreased sexual function scores, albeit from a higher baseline score, followed by a modest recovery by 12 months and no further improvement. A subset analysis revealed higher sexual-function scores for patients who received vaginal- or nerve-sparing reconstruction, which was more often performed in the continent diversion group: Their higher baseline scores decreased at 6 months, with some measurable recovery to 45 by 24 months.
- Body image and mental health. Body image scores were stable over time for the continent diversion group. Patients in the ileal conduit cohort reported a drop in scores at 3 and 6 months, which did not improve. For both groups, results for scales measuring satisfaction with life and decisional conflict showed minimal changes from baseline to 24 months, and mood and anxiety scores improved over baseline at 6 months and remained stable.
“While body image scores dropped for patients who received ileal conduits, at the same time, their physical function and psychosocial scores were stable or improved compared to baseline, indicating they were adapting and getting back to their normal lives,” Dr. Bochner noted. “Older patients who are not neobladder candidates should know that most ileal conduit patients return to daily activities, including working, golfing, swimming, and traveling, albeit with some changes in body image.”
Clinical Trials for Patients With Bladder Cancer
MSK’s multidisciplinary bladder cancer team continues to conduct research focused on improving treatment options and outcomes for patients with bladder cancer after urologic surgery.
MSK is currently conducting 27 clinical trials for patients with bladder cancer, evaluating novel immunotherapy, chemotherapy, and chemoradiotherapy approaches. For example, Dr. Bochner is a co-investigator of a phase 2 study of dose-dense gemcitabine and cisplatin without surgery in patients with muscle-invasive bladder cancer and DNA damage response gene mutations known to be responsive to this chemotherapy regimen.
Meet Bernard Bochner, MD, FACS, the Sir Murray F. Brennan Chair in Surgery at MSK.
Advancing Bladder Cancer Research
The study was a multidisciplinary collaboration among MSK urologic surgeons and PRO experts as follows. From the Department of Surgery: Matthew Clements, MD; Harry Herr, MD, FACS; S. Machele Donat, MD, FACS; and Jaspreet Sandhu, MD. From the Department of Psychiatry and Behavioral Sciences: Thomas Atkinson, PhD, and Yuelin Li, PhD. From the Department of Epidemiology and Biostatistics: Andrew Vickers, PhD; Daniel Sjoberg, PhD; and Amy Tin, MA. And Bruce Rapkin, PhD, formerly at MSK and now a professor in the Department of Epidemiology & Population Health at the Albert Einstein College of Medicine.
The study was supported by the Sidney Kimmel Center for Prostate and Urologic Cancers, the National Cancer Institute Cancer Center Core grant number P30-CA008748, and the Pin Down Bladder Cancer Fund.
All study authors reported no conflicts.