BACKGROUND: Radical cystectomy (RC) is the standard treatment for muscle invasive bladder cancer, but approximately half of all patients will ultimately succumb to disease progression despite apparent cure with extirpative surgery. Elderly patients are at especially high risk of advanced disease and may benefit from perioperative systemic therapy. OBJECTIVE: To assess the real-world benefit of adjuvant chemotherapy (AC) in patients ≥75 years old. METHODS: We retrospectively reviewed patients who underwent RC for non-metastatic urothelial carcinoma of the bladder (UCB) from 12 participating international medical institutions. Kaplan-Meier survival curves and Cox regression models were used to assess the association between age groups, administration of AC and oncological outcome parameters such as recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). RESULTS: 4,335 patients were included in the analyses, of which 820 (18.9%) were ≥75 years old. These elderly patients had a higher rate of adverse pathologic features. In an univariable subgroup analysis in patients ≥75 years with lymph node metastasis, 5-year OS was significantly higher in patients who had received AC (41% vs. 30.9%, p = 0.02). In a multivariable Cox model that was adjusted for several established outcome predictors, there was a significant favorable association between the administration of AC in elderly patients and OS, but no RFS or CSS. CONCLUSIONS: In this large observational study, the administration of AC was associated with improved OS, but not RFS or CSS, in elderly patients treated with RC for UCB. This is of clinical importance, as elderly patients are more likely to have adverse pathologic features and experience worse survival outcomes. Treatment of UCB should include both a multidisciplinary approach and a geriatric evaluation to identify patients who are most likely to tolerate and benefit from AC.

Cancer Prognostics and Health Outcomes Unit Division of Urology University of Montreal Health Center Montreal QC Canada

Department of Urology and Division of Experimental Oncology Urological Research Institute Vita Salute San Raffaele University IRCCS San Raffaele Scientific Institute Milan Italy

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria

Department of Urology Hospital Motol 2nd Faculty of Medicine Charles University Prague Czech Republic

Department of Urology Institut Mutualiste Montsouris Paris France

Department of Urology King Fahad Specialist Hospital Dammam Saudi Arabia

Department of Urology Luzerner Kantonsspital Lucerne Switzerland

Department of Urology The Jikei University School of Medicine Tokyo Japan

Department of Urology University Hospital Frankfurt Frankfurt Germany

Department of Urology University Hospital of Tours Tours France

Department of Urology University Medical Center Hamburg Eppendorf Hamburg Germany

Department of Urology University of Texas Southwestern Dallas TX USA

Department of Urology Urological Research Institute Vita Salute University San Raffaele Scientific Institute Milan Italy

Department of Urology Weill Cornell Medical College New York NY USA

Division of Urological Surgery and Center for Surgery and Public Health Brigham and Women's Hospital Harvard Medical School Boston MA USA

Division of Urology Department of Special Surgery Jordan University Hospital The University of Jordan Amman Jordan

European Association of Urology Research Foundation Arnhem Netherlands

Institute for Urology and Reproductive Health Sechenov University Moscow Russia

Karl Landsteiner Institute of Urology and Andrology Vienna Austria

Martini Klinik Prostate Cancer Center University Hospital Hamburg Eppendorf Hamburg Germany

Research Center for Evidence Based Medicine Tabriz University of Medical Sciences Tabriz Iran

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