Cystectomy in the elderly: does the survival benefit in younger patients translate to the octogenarians?

To determine whether the survival benefit achieved with radical cystectomy (RC, the reference standard for treating muscle-invasive bladder cancer) in younger patients justifies its use in octogenarians.

We used the Surveillance Epidemiology and End Results data of the National Cancer Institute and identified 10 807 patients from 1992-2004 who were diagnosed with muscle-invasive bladder cancer, and were treated with either RC or radiotherapy. The data were analysed for age, gender, race, extent of lymphadenectomy and cause of death. We stratified the patients by age groups (<60, 60-69, 70-79 and >79 years), and used Kaplan-Meier survival analysis to compare treatment strategies by age group.

In all, 8034 patients had RC and 2773 radiotherapy; RC was the primary method of treatment in all age groups except for octogenarians. Those who had RC had a sizeable overall survival advantage in all age groups, except for the octogenarians (18 vs 15 months). This small survival advantage improved only slightly (23 vs 15 months) when excluding patients having nodal or distant metastasis. The octogenarians who have RC with a limited pelvic lymph node dissection or RC alone receive little (16 vs 15 months) or no survival benefit. However, cancer-specific survival was significantly higher in those who had RC, including octogenarians.

Octogenarians have some benefit to cancer-specific survival from RC if it includes a standard lymphadenectomy. The issue is how to better select the patients, as the overall survival advantage in these patients over radiotherapy is negligible.