Survival Outcomes and Temporal Trends of Non-Surgical Management Vs Radical Cystectomy in Non-Organ-Confined Urothelial Bladder Cancer

Objective: To investigate whether bimodal therapy (BMT) or trimodal therapy (TMT) differ from radical cystectomy (RC) + perioperative chemotherapy (CT) in cancer control outcomes among patients with non-organ-confined (NOC; T3-4 and/or N1-3) urothelial carcinoma of the urinary bladder (UCUB). Methods: Within the Surveillance, Epidemiology, and End Results database (2005-2021), rates of BMT vs TMT vs RC + CT use in NOC UCUB patients were tabulated. Nearest-neighbor 1:1 propensity score matching (PSM) for age, sex, stage, and race/ethnicity was applied. Cumulative incidence plots depicted 5-year cancer-specific (CSM) and other-cause mortality (OCM) rates. Univariable and multivariable competing risks regression (CRR) models were fitted. Sensitivity analyses focused within T3-4,N0 patients. Results: Of 7401 NOC UCUB patients, 1645 (22.2%) received BMT vs 884 (11.9%) TMT vs 4872 (65.8%) RC+CT. Over the study period, BMT and TMT rates have not significantly changed. After PSM, the five-year CSM rate was 66.2% after BMT vs 44.9% after RC + CT and BMT was associated with 2.1-fold higher CSM relative to RC + CT (multivariable HR [mHR]: 2.12, P <.001). After PSM, 5-year CSM rates was 61.1% after TMT vs 46.6% after RC and TMT was associated with 1.6-fold higher CSM relative to RC (mHR: 1.63, P <.001). Virtually the same findings were found within T3-4,N0 patients. Conclusion: Approximately three out of ten NOC UCUB patients were treated with either BMT or TMT. However, such practice was invariably associated with higher CSM relative to RC + CT. These observations should be discussed at clinical decision-making and prior to informed consent.