EURURO Vol. 73 No. 1

Introduction

Bladder cancer is the ninth most frequently diagnosed

cancer worldwide. Although the mortality rate of bladder

cancer tends to decrease, bladder cancer still ranks 13th in

terms of causes of death

[1]

. The incidence of bladder cancer

increases steadily with age and due to an increase in overall

life expectancy, population ages exponentially. Conse-

quently, the number of elderly patients with bladder cancer

is expected to further increase in the future.

Radical cystectomy (RC) with extended pelvic lymph

node dissection is considered to be the standard of care for

nonmetastatic muscle invasive bladder cancer (MIBC)

[2]

. External beam radiotherapy combined with concomi-

tant chemotherapy is an alternative to RC for carefully

selected patients

[2]

Existing guidelines for the management of MIBC do not

preclude curative treatments for elderly patients and it is

suggested that the decision to treat cancer patients should

not be based solely on age, though life expectancy should be

considered

[3]

. A thorough geriatric assessment (GA) can

help avoid both undertreatment and overtreatment of

elderly patients, both of which could result in decreased

health-related quality of life

[3]

The aim of this systematic review is to report on overall

survival (OS) and cancer specific survival (CSS) as well as

morbidity after curative treatment in elderly patients,

defined as age

70 yr, with nonmetastatic MIBC, and to

compare this with the outcome observed in a younger

population with MIBC.

Evidence acquisition

2.1.

Study design

A systematic review was conducted to identify studies of

relevance for the predefined research questions:

1) Does a GA improve outcome in elderly patients with

MIBC?

2) Do elderly patients have inferior survival, both cancer

specific survival (CSS) and overall survival (OS), after

curative therapy compared with younger patients with

MIBC?

3) Do elderly patients have an increased complication rate,

defined as perioperative mortality (POM) and both early

and late complication rate, after curative therapy

compared to younger patients with MIBC?

2.2.

Search strategy

Search strings were used to interrogate the following

databases: Medline, PubMed, and Embase. Potential articles

were identified using the National Library of Medicine’s

Medical Subject Headings: ‘‘(urinary bladder neoplasms[mh]

bladder$* adj3 (cancer$ or carcinoma$ or neoplasm$ or

tumor$)[mp]

) AND (Frail Elderly[mh] OR Aged[mh] OR

elder$.ti,ab OR Geriatric$.ti,ab[tw] OR older person.ti,ab[tw]

OR older adult.ti,ab[tw] OR octogenerians.ti,ab. [tw]) AND

(Cystectomy[mh] OR surgery[mh] OR radiotherapy[mh] OR

drug therapy[mh] OR resection.ti,ab OR radiotherapy.ti,ab OR

radiation. ti,ab OR chemothera$ .ti,ab OR antineoplastic$.ti,ab)

AND (treatment outcome[mh] OR survival rate[mh] OR

effectiveness.ti,ab OR efficacy.ti,ab OR survival benefit ti,ab).

The search was finalized on December 21, 2016. Relevant

articles found in the reference section of the retrieved articles

were also retained for evaluation.

2.3.

Eligibility criteria

Longitudinal and population-based studies as well as

consecutive and nonconsecutive surgical series, reporting

on CSS, OS, POM, or complication rate after radical

treatment for MIBC, were included.

Articles needed to be published in English. Only full papers

were included. Articles reporting on at least 100 patients were

maintained. Articles could still be rejected, despite inclusion

100 patients, if the total number of patients in the

younger or elderly group separately was

50 patients. Only

articles comparing outcomes between different age groups

were considered for inclusion. Age stratification was thus

mandatory for being eligible.

2.4.

Selection of relevant articles

The selection of relevant articles was conducted in two

steps. As a first step, one reviewer (V.F.) excluded clearly

irrelevant studies or studies not meeting the eligibility

criteria based on title and abstract. Two reviewers (V.F. and

P.O.) performed the final selection based on review of the

full text manuscripts.

2.5.

Data extraction

Point estimates,

values, and confidence intervals for

effectiveness (CSS and OS) and safety outcomes (POM and

complication rate) were extracted. It was decided a priori to

late morbidity is less clear. Prospective studies evaluating geriatric assessments are

critically needed to optimize MIBC management in the elderly.

Patient summary:

We performed a systematic review to evaluate the outcome and

complication rate in elderly patients with muscle invasive bladder cancer. We observed

that overall survival and cancer specific survival significantly decrease and perioperative

mortality significantly increases with age. The impact of age on late morbidity is less clear.

There is a need for geriatric assessments to select those patients that will benefit from

curative treatment.

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