Surgical Approach And Adjuvant Treatment Effects On Survival In Individuals With Primary Urothelial Carcinoma Of The Ureter

Primary upper tract urothelial carcinoma (UTUC) is rare, accounting for less than 5% of all urothelial cancers. While definitive surgery is recommended for all localized tumors, the importance of the type of surgical procedure (open, laparoscopic or robotic) as well as the role of adjuvant therapies following surgery is unclear. We hypothesize that surgical approach may be associated with differing outcomes and that adjuvant therapy would be utilized differently among various subpopulations and would be associated with improved overall survival (OS) among those with high risk features. Patients who underwent surgical therapy for UTUC from 2010 through 2015 were identified in the National Cancer Data Base. Demographic, disease and treatment characteristics are described. Multivariable logistic regression was used to identify variables significantly associated with receipt of adjuvant radiation and/or chemotherapy. Cox proportional hazards regression was performed to identify factors associated with OS for the entire population as well as a subgroup with positive surgical margins (PSM). We identified 938 patients with a median age of 72 years; 63% were male, 34% had a Charlson/Deyo comorbidity index of >1. Seventy-one percent had >pT2 disease, 14% had node positive disease, 21% had PSM. Forty-three percent were treated at academic medical centers. Open procedures were performed on 42% of patients, while standard laparoscopic and robotic laparoscopic procedures were both performed in 29% of the patients studied. Younger age, more recent year of diagnosis, low comorbidity score, higher T-stage, higher n-stage and PSM are associated with increased odds of receiving adjuvant therapy on multivariable analysis. Factors associated with improved OS include robotic surgery (HR 0.72; 95% CI 0.57-0.92), being treated at an academic medical center (HR 0.76; 95% CI 0.63-0.93) and being treated with adjuvant chemotherapy (HR 0.76; 95% CI 0.59-0.98). Patients with PSM were less likely to die if they were treated with adjuvant radiation (HR 0.48; 95% CI, 0.28-0.81), chemotherapy (HR 0.55; 95% CI 0.35–0.87) or treated at an academic medical center (HR 0.57; 95% CI 0.4-0.82). Given the relative rarity of UTUC there is little data to support recommendations for treatment, specifically with respect to the type of surgical approach or the use of adjuvant treatment. This data review reveals that robotic surgery, being treated at an academic medical center and receiving adjuvant chemotherapy are associated with improved survival. Patients with PSM were less likely to die if treated with adjuvant radiation or chemotherapy or at an academic medical center after controlling for pertinent covariates. Notably, while treatment at academic centers was associated with improved survival, it was not associated with increased use of robotic surgery or the use of adjuvant treatments, suggesting other differences in care may be significant.