Impact of age on radical cystectomy outcomes for bladder cancer in an Australian cohort.

Abstract

Introduction & Objectives: Bladder cancer is more prevalent in older patients, and increasing age is a recognised prognostic factor for oncological outcomes. However, the specific impact of age on survival and perioperative outcomes following radical cystectomy (RC) across all bladder cancer stages in an Australian population remains unclear. This study aimed to evaluate the effect of age on survival and potential mechanisms driving outcome disparities in patients undergoing RC. Method(s): Patients who underwent RC for histologically confirmed bladder cancer between 2008 and 2021 were included. Patient demographics, age, tumour characteristics, and survival outcomes were collected and analysed using Chi-squared tests, Kaplan-Meier survival curves, and Cox regression. Patients were stratified into two age groups: <75 years and >=75 years. Result(s): A total of 135 patients were included, with a median follow-up of 34.0 months (IQR 8.7-67.9). Among them, 108 (80.0%) were <75 years and 27 (20.0%) were >=75 years, with a median age of 68 years. Baseline characteristics, including gender, nodal status and chemotherapy use, were comparable across age groups (P > 0.05). Muscleinvasive bladder cancer (MIBC) at initial TURBT was comparable (45.0% vs 52.0%, P = 0.53), as was post-RC tumour stage >=T2 (41.7% vs 51.9%, P = 0.34), albeit slightly higher staging in older patients. Older patients were also less likely to receive neoadjuvant chemotherapy (6.5% vs 0%, P = 0.35) and adjuvant chemotherapy (23.1% vs 7.4%, P = 0.07). Kaplan-Meier analysis demonstrated significantly worse overall survival (HR: 2.75; 95% CI: 1.49-5.08) and cancer specific survival (HR: 2.35 95% C 1.01-5.46) in older age (P < 0.05). However, on multivariable Cox regression tumour stage >=2 was the only prognostic factor for CSS (HR 2.78; 95% CI: 0.96-8.01, P = 0.045). Likewise, in Fine-Grey competing risk regression for CSS, patients >=75 had a subdistribution hazard ratio of 1.94 (95% CI 0.87-4.33, P = 0.10). Older patients had higher rates of noncancer-related mortality rates (8.3% vs 18.5%, P = 0.10) with no significant differences in progression-free survival (HR: 1.4, 95% CI 0.7-2.9, P = 0.33). Conclusion(s): Older patients (>=75 years) have worse OS and CSS after RC, likely driven by a combination of reduced chemotherapy usage and higher non-cancer-related mortality. Nonetheless, tumour stage remains the dominant prognostic factor for CSS highlighting the importance of early detection. These findings emphasise the need for enhanced perioperative optimization and that older patients should be considered equally for chemotherapy if they are fit for a RC.