Prognostic factors and outcome in patients with T1 high‐grade bladder cancer: can we identify patients for early cystectomy?

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although several papers have attempted to identify individual risk factors for T1 high‐grade (T1HG) urothelial carcinoma of the bladder for disease recurrence or progression, and nomograms have been generated to aid in the prediction of disease progression, there has been a lack of systematic examination of which factors predict clinically important outcomes. Treatment of T1HG remains controversial, particularly with regards to timing of radical cystectomy. Patients with T1HG bladder cancer are at a significant risk of progression and death from disease. Primary tumours, sessile architecture, and trigonal location are factors associated with worse outcome and may be used to counsel patients towards early cystectomy. OBJECTIVE To assess outcome in patients with T1 high‐grade (T1HG) bladder cancer treated at a single academic institution and to determine the prognostic factors that can help in counselling patients towards early cystectomy. PATIENTS AND METHODS Records of 2570 patients with bladder cancer treated from 1995 to 2005 were reviewed. Only patients diagnosed with T1HG disease were included in the analysis. Collected variables included various clinicopathological parameters, use of statins, smoking, as well as dates of recurrence, progression, radical cystectomy and death. Recurrence‐free survival (RFS) and worsening‐free survival (WFS) were analyzed. Multivariate Cox proportional regression analysis was employed to verify the prognostic significance of various variables. RESULTS In total, 278 (10.8%) patients were identified as having T1HG disease on transurethral resection. 66% of patients who recurred, and 36.3% developed stage progression after a median (range) follow‐up of 3 (0.1–15.4) years. 30% patients who underwent radical cystectomy, and 9% were dead of disease. The 5‐year RFS and WFS rates were 26.6% and 49.4%, respectively. On multivariate analysis, only non‐trigonal tumour location, restaging transurethral resection, history of previous carcinoma not invading bladder muscle and adjuvant bacille Calmette‐Guérin (BCG) therapy were significantly associated with prolonged RFS, whereas papillary tumour architecture, history of previous carcinoma not invading bladder muscle and adjuvant BCG therapy were significantly associated with prolonged WFS. CONCLUSIONS Patients with T1HG bladder cancer are at a significant risk of progression and death from disease. Primary tumours, sessile architecture and trigonal location are factors associated with a worse outcome and may be used to counsel patients towards early cystectomy.