Overall survival appears comparable after radical cystectomy (RC) and trimodal therapy (TMT) for muscle-invasive bladder cancer (MIBC) among patients who receive chemotherapy, except in the case of higher-stage disease, according to investigators.

Among 2048 patients (aged 40 to 79 years) with cT2-3 N0 M0 urothelial carcinoma in the 2006-2015 National Cancer Database, 1812 patients were treated with multiagent neoadjuvant chemotherapy and RC with lymphadenectomy (RC arm) and 236 were treated with transurethral resection of bladder tumor (TURBT), multi-agent chemotherapy, and 3D conformal radiation therapy (TMT arm). The median follow-up was 29 months.

After propensity-score adjustment, overall survival did not differ significantly between the RC and TMT arms, Boris Gershman, MD, of Beth Israel Deaconess Medical Center, Boston, Massachusetts, and colleagues reported in Urologic Oncology. Among patients with cT3 disease, however, the risk for all-cause mortality was a significant 58% lower for patients who underwent RC vs TMT. Survival did not differ by age or comorbidity burden.

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Among the study’s limitations, the database lacked information on tumor characteristics and completeness of TURBT. Clinical staging often comprised exam and CT imaging, rather than MRI, which is more sensitive for detecting cT3 disease. Additionally, the investigators were unable to exclude patients with hydronephrosis.

“In observational analyses designed to emulate the SPARE trial, there was no statistically significant difference in OS between RC and TMT,” Dr Gershman’s team concluded. “Heterogeneity of treatment effects suggested improved survival with RC only for cT3 disease.”


Softness K, Kaul S, Fleishman A, et al. Radical cystectomy versus trimodality therapy for muscle-invasive urothelial carcinoma of the bladder. Urol Oncol. Published online January 17, 2022. doi:10.1016/j.urolonc.2021.12.015