Analysis Highlights Gaps in Cisplatin-Based Treatment for Advanced Urinary Tract Cancer

An analysis of treatment patterns found that patients with advanced urinary tract cancer (aUTC) who are eligible for cisplatin-based chemotherapy fare better when they do receive such regimens than when they do not. The results highlight the importance of following published treatment criteria, according to the study authors.

“Cisplatin-based chemotherapy is the treatment of choice for aUTC,” wrote authors led by Aristotelis Bamias, MD, of the University of Athens in Greece. “Nevertheless, a (yet not precisely estimated) percentage of patients do not receive any systemic therapy.” A lack of high-level evidence confirming cisplatin’s superiority to carboplatin or other therapies has contributed, and it was unclear to what degree recently published criteria for cisplatin eligibility were being followed in this malignancy.

The authors conducted an analysis using data from the Retrospective International Study of Cancers of the Urothelium (RISC) database. It included 1,794 aUTC patients (primary carcinoma of the urinary bladder, renal pelvis, ureter, or urethra) treated between 2000 and 2013 at 29 centers; of those, 1,333 patients (74%) were treated with first-line chemotherapy. Results of the analysis were published online ahead of print in Annals of Oncology.

Objective responses to the first-line chemotherapy were reported in 41% of 1,039 assessable patients, and complete responses were more frequently seen in those treated with cisplatin (12% vs 5%; P < .001). Cisplatin was administered in a first-line regimen to 669 patients in total; 399 patients received carboplatin-based regimens, and 265 received other therapies. Patients who received cisplatin were younger, more likely to be male, less likely to receive perioperative chemotherapy, had better performance status and renal function as well as less frequent distant metastases.

Among 929 patients who could be assessed, 429 (46%) had at least one criterion for ineligibility for cisplatin therapy, according to published criteria from 2011. Those ineligibility criteria accounted for only 56% of patients who did not receive cisplatin (among 340 cases where reasons were given); advanced age and comorbidities were the most common reasons for avoiding cisplatin.

In the group of 929 patients where cisplatin eligibility could be assessed, 26% did not receive the agent when they were eligible for it. This deviation from the criteria was more likely among those with Charlson Comorbidity Index scores of 3 or higher (P < .001), those who were MSKCC intermediate or high risk (P = .012), those with hypertension (P < .001), diabetes (P < .001), and chronic obstructive pulmonary disorder (P = .001). A total of 176 patients who did receive cisplatin fulfilled at least one criteria for ineligibility.

Cisplatin use was associated with better median overall survival in general. Also, cisplatin-eligible patients who were treated with cisplatin-based regimens lived longer than those eligible patients who were not treated with those regimens, with a hazard ratio of 1.74 (95% CI, 1.36–2.21). This was not seen among ineligible patients.

“All efforts should be made to treat eligible-for-cisplatin patients with aUTC with cisplatin-based chemotherapy,” the authors wrote. “The field should recognize that cisplatin may be underutilized and that adherence to published criteria can help increase appropriate cisplatin use.” They noted the limitations inherent to retrospective studies, and added that novel therapies for those who are ineligible are still needed.