Point/Counterpoint:

Quality of Life Considerations for Patients with

Muscle Invasive Bladder Cancer

Pro Cystectomy

Angela B. Smith, MD, MS, FACS

Assistant ProfessorUniversity of North Carolina, Department of Urology

Lineberger Comprehensive Cancer Center

Quality of Life from All Angles

• Before and after cystectomy

• Urinary diversions

• QoL domains• Global

• Urinary, Bowel, Sexual Health

• Physical Health

• Emotional Health

• Social Function

• Body Image

• Financial Burden

Before and After Cystectomy

• Majority of QOL literature retrospective

• Prospective QOL study• University of Chicago (n=73) • FACT-VCI – baseline, 6 months after RC

• No differences in overall HRQOL

• Improved emotional HRQOL

• Randomized trials• MSKCC (n=118) - EORTC QLQ-C30

• No differences from baseline, 3, 6 mos

• University of Miami (n=40) - FACT-VCI• No differences from baseline, 3, 6, 9, 12 mos

Porter, JU, 2005Large, Urology, 2014Bochner, EU, 2015Messer, BJUI, 2014

Urinary Diversions

• Many studies compare QOL between diversions• Neobladder, ileal conduit, continent catheterizable channel

• Most show little differences between groups historically

• Recent meta-analysis favors neobladder in all domains• Comparisons after 2012 favor neobladder

Cerruto, EJSO, 2016 Ghosh, Urology, 2016

Urinary Function

• Postoperative drop with gradual return to baseline by 2 months (BCI)

• Comparison between native bladders (n=127), NB (n=122), and conduit (n=66)• Similar between native bladders & conduit, worse for NB

• Mean BCI urinary function: 86 (IC) vs. 50 (NB) (higher better)

• Mean BCI urinary bother similar: 88 (IC) vs. 86 (NB)

Poch, BJUI, 2014 Gilbert, Cancer, 2007Hedgepeth, Urol, 2010

Bowel Function

• Negatively impacted when compared to native bladder with intravesical treatment (BCI)• Native bladder: 89.2 (function) 93.4 (bother)

• Conduit: 77.6 (function) 80.8 (bother)

• Neobladder: 76.6 (function) 85.7 (bother)

• No differences between diversion type

Poch, BJUI, 2014 Gilbert, Cancer, 2007Hedgepeth, Urol, 2010

Sexual Function

• NB and conduit with lower scores in function and bother compared to native bladders (BCI)• Function: 45.7 (native) vs. 20.0 (IC) vs. 25.5 (NB)

• Bother: 67.4 (native) vs. 50.3 (IC) vs. 49.9 (NB)

• Scores drop immediately after surgery, remain low• Women and younger patients with better scores

• Conduit: worsen over time

• Neobladder: improve over time

Gilbert, Cancer, 2007Gilbert, J Urol, 2010Poch, BJUI, 2014

Physical Health

• Physical health remains similar after cystectomy (FACT-VCI)• Prospective study (Large): 22.6 (baseline) – 22.2 (median 6 months)• Randomized trial (Messer): 26.5 (baseline) – 27 (12 months)

• Additional studies show minimal impairment in long-term physical health• EORTC QLQ-C30 physical domain 81.1 average (100 = perfect health)

Large, Urology, 2014Messer, BJUI, 2014.Imbimbo, Urology, 2015

Emotional Distress

• Quality of life• Worse preop mental health complications• Minimal differences from baseline to 12 months

• Natural history of distress among cystectomy patients • No change in depression, anxiety, spiritual well-being• Personal and existential growth postop but not sustained

• Caregiver burden • Low and did not change significantly over time (peak 2 mos.)• Satisfaction high

Sharma, J Urol, 2016Messer, BJUI, 2014Benner, J Urol, 2014

Social Function

• In most cases, stable– few show worsened function• Return to baseline by 1 year suggests adaptation

• EORTC QLQ C30: 72.5 70 (6 mo) 76.6 (12 mo)

• FACT-VCI 23 (baseline) and 23 (3-12 months)

• May be related to diversion• Conduit w/ ↓ social function compared to NB

• Possibly related to baseline status

• EORTC QLQ-C30 76.6 (IC) vs. 92.8 (NB) at 18mo (higher better)

Singh, BJUI, 2014Messer, BJUI, 2014

Body Image• Effect of diversion on body image

• Initial decrease, improves over time

• Majority show no difference based on diversion

• Only 2 of 40 studies suggest better body image with NB

• Body image not a significant driver of QOL after cystectomy• Qualitative interviews with cystectomy patients

• Family, health, finance considered ABOVE body image

Somani, Urol, 2009Poch, BJUI, 2014 Kikuchi, Jpn J Clin Oncol, 2006Hedgepeth, Urol, 2010

Financial Impact

• Not extensively studied

• Prospective QOL Study comparing NB vs. conduit (n=164)• Financial burden lower in neobladders vs. conduit• Extended to 18 months follow-up

Singh, BJUI, 2014

Comparisons to TrimodalityTherapy

VS.