Approximately 11% of patients with localized upper tract urothelial carcinoma (UTUC) are managed without surgery, and their survival is worse compared with patients who undergo surgery, according to a recent study.
Chemotherapy and radiation therapy, which are used only in a small proportion of nonsurgical patients, offers no survival advantage, the study found.
Using the National Cancer Database, investigators at Yale School of Medicine in New Haven, Connecticut, led by Brian M. Shuch, MD, identified 28,910 patients with localized UTUC. Of these, 3157 (10.9%) received non-operative management, the investigators reported in The Canadian Journal of Urology. This group was significantly older than the patients who underwent surgery (mean age at diagnosis: 76.7 vs 71.8 years). The no-surgery group had a significantly shorter median survival time than those who underwent surgery (2.0 vs 5.6 years). At 3 years following UTUC diagnosis, the survival rate was 40.2% in the no-surgery group compared with 66.6% in the surgery arm.
Additionally, patients with high-grade tumors had significantly worse survival than those with low-grade tumors (1.9 vs 3.8 years). The 3-year survival rates were 38.1% and 53%, respectively, Dr Shuch and his collaborators reported.
The no-surgery cohort had a median age of 79 years, which was significantly higher than that of the surgery group (73 years);and 55% of patients were male. Of the 3157 patients, 294 (9.3%) received chemotherapy and 197 (6.3%) received radiation therapy. Patients treated with radiation had a significantly shorter median overall survival (OS) compared with those not treated with radiation (1.4 vs 2.0 years). OS did not differ significantly between patients who received chemotherapy and those who did not.
In the no-surgery group, male sex, older age, larger tumor size, and higher comorbidity score (2 or higher vs 0) independently predicted worse OS.
In a finding that the investigators considered surprising, the distribution of comorbidity scores did not differ between the surgery and no-surgery groups.
In a discussion of study limitations, Dr Shuch’s team noted that they did not have access to information regarding disease-specific survival, chemotherapy or radiotherapy indications, reasons for not pursuing surgery, and detailed staging methodology. In addition, the study was limited to only to patients with pathologic diagnoses, and tumor histology was not assessed under central pathology review.
“Despite our limitations,” the authors wrote, “the large sample size and detailed clinical followup has allowed us to describe relevant survival outcomes and may be useful for counseling patients who are not surgical candidates.”
Syed JS, Nguyen KA, Suarez-Sarmiento A, et al. Outcomes of upper tract urothelial cancer managed non-surgically. Can J Urol. 2019;26:9699-9701.