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these criteria are not followed, TMT outcomes will appear
worse. Second, the actual indication for TMT is not specified
and may be a ‘‘last ditch effort’’ for sicker patients, again
potentially biasing towards worse TMT outcomes. Third, the
NCDB lacks granular data points such as type of chemothera-
py or number of cycles administered, in addition to indicators
for why complete chemotherapy regimens were not
completed (ie, renal function, performance status). Ideally,
chemotherapy for TMT should be a cisplatin-based regimen
. Additionally, timing of chemotherapy (ie, neoadjuvant vs
adjuvant vs concomitant) is not specified in the database,
only whether ‘‘single or multiagent chemotherapy was
administered as first course therapy.’’ Thus, whether patients
received ‘‘complete TMT’’ is speculative. Finally, OS was the
end-point used in the current study, since disease-specific
survival (DSS) outcomes are not feasible in the NCDB.
Arguably, OS is an ‘‘all-encompassing’’ and clinically relevant
endpoint; however, when comparing efficacy of two
treatment approaches head-to-head for superiority, evaluat-
ing DSS may be considered a more appropriate outcome that
provides more convincing conclusions.
While we agree with the authors that in a perfect world
randomized control trials comparing TMT with RC would be
ideal, the likelihood of accruing to and completing such a trial
will be difficult, particularly if superiority is not the ultimate
study goal. With these shortcomings in mind, there are two
institutional studies that have compared outcomes of TMT to
RC using propensity score matching analysis. Our group at
the University of Toronto recently matched 56 TMT patients
(of 59 eligible) to RC patients using propensity scores
. Included in the matching were cT and cN-stage, Eastern
Cooperative Oncology Group score, comorbidity, extent of CIS
and hydronephrosis, and year of therapy. These granular
details allowed for a robust comparison of RC versus TMT
outcomes, where the latter was given as a bladder-preserving
curative treatment. After a median 4.5 yr of follow-up, there
was no significant difference in DSS between the two groups
(HR for TMT: 0.92, 95% CI: 0.41–2.04). Authors from South
Korea recently published a cohort of 29 TMT patients who
were propensity score matched to 50 patients undergoing RC
, noting comparable 5-yr DSS between the two groups
(RC 69% vs TMT 63%; HR: 0.96, 95% CI: 0.38–2.47). Albeit
smaller institutional studies, these analyses ensure strict TMT
selection criteria adherence, demonstrating no difference
between TMT and RC in highly selected MIBC patients.
Ultimately, in the absence of randomized control trials,
we must rely on methodologically sound observational
studies with granular data to help guide treatment decisions.
Undoubtedly, RC remains the surgical gold-standard for
localized MIBC. However, patients who are candidates for
both treatment modalities should at least be engaged in a
discussion about the merits of both approaches. With sound
clinical judgement to appropriately select patients and
judicious informed consent discussions, patients with
localized MIBC may actually have a second treatment option
beyond our traditional gold standard.
Conflicts of interest: The authors have nothing to disclose.
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Platinum Priority
Reply from Authors re: Girish S. Kulkarni,
Zachary Klaassen. Trimodal Therapy is Inferior to
Radical Cystectomy for Muscle-invasive Bladder
Cancer [34_TD$DIFF]using Population-level Data: Is There Evidence in
the (Lack of) Details? Eur Urol 2017;72:488–9
Using the National Cancer Data Base to Compare Treat-
ment Modalities for Localized Muscle-invasive Bladder
Cancer
Thomas Seisen, Alexander P. Cole, Quoc-Dien Trinh
Division of Urological Surgery and Center for Surgery and Public Health,
Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
DOIs of original articles: ,
.
* Corresponding author. Division of Urological Surgery, Brigham and
Women’s Hospital, 45 Francis Street, Boston, MA 02115, USA.
Tel. +1 617 5257350; Fax: +1 617 5256348.
E-mail address: (Q.-D. Trinh).
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