Chemo After Nephroureterectomy Improves Survival in Upper Tract Urothelial Carcinoma

In patients with upper tract urothelial carcinoma (UTUC), adjuvant chemotherapy following radical nephroureterectomy (RNU) confers a survival advantage compared with observation following RNU, according to a new observational study.

Though some patients with low-risk disease can undergo kidney-sparing surgery, RNU with bladder cuff removal is considered the standard of care for most UTUC patients.

“Striving to improve the survival of individuals with adverse clinical and/or pathologic features, the role of perioperative chemotherapy as an adjunct to RNU has been explored by several observational studies over the past decade,” wrote study authors led by Steven L. Chang, MD, of Brigham and Women’s Hospital in Boston. Those studies have shown limited benefit, but suffered from some methodological issues; the authors of the new study hypothesized that adjuvant chemotherapy would offer a benefit in patients with locally advanced and/or positive regional lymph node UTUC.

The study involved 3,253 patients with pT3/T4 and/or pN+ UTUC who underwent RNU and were included in the National Cancer Database from 2004 to 2012. Of those, 762 patients (23.42%) received adjuvant chemotherapy, and 2,491 patients (76.58%) were treated with observation only after RNU. The results were published online ahead of print in the Journal of Clinical Oncology.

The median follow-up period was 49.54 months. Chemotherapy did yield a better overall survival, with a median of 47.41 months compared with 35.78 months with observation (P < .001). The 5-year overall survival rate was 43.9% with chemotherapy and 35.85% without.

An adjusted analysis yielded a hazard ratio (HR) with chemotherapy of 0.77 (95% CI, 0.68–0.88; P < .001). This was confirmed after propensity score adjustment, where the HR was 0.82 (95% CI, 0.73–0.93; P = .002). The significant overall survival benefit was seen across all subgroups examined, including divisions by age, gender, comorbidity scores, pathologic stage, and surgical margins.

“We found that individuals who received adjuvant chemotherapy were nearly 25% less likely to die than their counterparts who received observation,” the authors wrote. “Although our results are limited by the usual biases related to the observational study design, we believe that the present findings should be considered when advising post-RNU management of advanced UTUC, pending level 1 evidence.”