Utilization and Outcomes of Radical Cystectomy for High-grade Non–muscle-invasive Bladder Cancer in Elderly Patients

The management of non–muscle-invasive bladder cancer is complex when considering the older patient. We reviewed both the National Cancer Database and a multi-intuitional cohort of patients with high-grade non–muscle-invasive bladder cancer to review associations between age and perioperative and oncologic outcomes among patients managed with radical cystectomy. We found that age was not associated with adverse perioperative outcomes, an increased risk of pathologic upstaging, or inferior survival independent of pathologic outcomes. These data support the safety and oncologic efficacy of radical cystectomy among well-selected patients regardless of age. Background: Radical cystectomy (RC) represents a treatment option for patients with high-grade non–muscle-invasive bladder cancer (HG-NMIBC); however, perioperative morbidity is not insignificant, particularly in elderly patients. We sought to evaluate the associations of age with utilization and outcomes of RC for HG-NMIBC. Patients and Methods: Patients with HG-NMIBC diagnosed between 2004 and 2013 were identified in the National Cancer Database and stratified by age: ≤ 60, 61-70, 71-80, and > 80 years. Association between age and treatment with RC was assessed by multivariable logistic regression. Associations between age and overall survival were assessed using the Kaplan-Meier method. A multi-institutional analysis was performed to evaluate the associations of age with perioperative outcomes and survival among patients managed with RC for HG-NMIBC. Results: On multivariable analysis, age was associated with RC utilization, with the lowest usage in patients > 80 years (2.1%; P <.01). Upstaging at RC occurred in 40% of patients with HG-NMIBC, and no association of age with upstaging risk was noted. Significantly inferior overall survival was observed in the patients who were upstaged across age strata (all P <.01). In the multi-institutional cohort, age was not associated with risks of upstaging, receipt of transfusion, 30-/90-day complications, or recurrence-free or cancer-specific survival (all P >.05), whereas upstaging was associated with inferior recurrence-free and cancer-specific survival regardless of age. Conclusion: RC for HG-NMIBC is used less frequently in older adults, despite similar risks of pathologic upstaging. As upstaging is associated with inferior survival regardless of age, these data suggest that elderly patients with HG-NMIBC may be at risk for undertreatment.