Article of the Week: Better fit than fat when it comes to radical cystectomy for bladder cancer
Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.
In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.
If you only have time to read one article this week, it should be this one.
Obesity is associated with worse oncological outcomes in patients treated with radical cystectomy
Thomas F. Chromecki1,2*, Eugene K. Cha1*, Harun Fajkovic1,3, Michael Rink1,4, Behfar Ehdaie1, Robert S. Svatek5, Pierre I. Karakiewicz6, Yair Lotan7, Derya Tilki8, Patrick J. Bastian8, Siamak Daneshmand9,Wassim Kassouf10, Matthieu Durand1, Giacomo Novara11, Hans-Martin Fritsche12, Maximilian Burger12, Jonathan I. Izawa13, Antonin Brisuda14, Marek Babjuk14, Karl Pummer2 and Shahrokh F. Shariat1
1Weill Medical College of Cornell University, New York, NY, USA, 2Medical University Graz, Graz, Austria, 3Landeskrankenhaus St Poelten, St Poelten, Austria, 4University Medical Centre Hamburg-Eppendorf, Hamburg, Germany, 5University of Texas Health Science Center San Antonio, San Antonio, TX, USA, 6University of Montréal, Montréal, QC, Canada, 7University of Texas Southwestern Medical Center, Dallas, TX, USA, 8Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany, 9University of Southern California Keck School of Medicine and Norris Comprehensive Cancer Center, Los Angeles, CA, USA, 10McGill University Health Centre, Montréal, QC, Canada, 11University of Padua, Padua, Italy, 12Caritas St Josef Medical Centre, University of Regensburg, Regensburg, Germany, 13University of Western Ontario, London, ON, Canada, and 14Hospital Motol, 2nd Faculty of Medicine, Charles University, Praha, Czech Republic
*These authors contributed equally.
OBJECTIVE
• To investigate the association between body mass index (BMI) and oncological outcomes in patients after radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB) in a large multi-institutional series.
PATIENTS AND METHODS
• Data were collected from 4118 patients treated with RC and pelvic lymphadenectomy for UCB. Patients receiving preoperative chemotherapy or radiotherapy were excluded.
• Univariable and multivariable models tested the effect of BMI on disease recurrence, cancer-specific mortality and overall mortality.
• BMI was analysed as a continuous and categorical variable (<25 vs 25–29 vs 30 kg/m2).
RESULTS
• Median BMI was 28.8 kg/m2 (interquartile range 7.9); 25.3% had a BMI <25 kg/m2, 32.5% had a BMI between 25 and 29.9 kg/m2, and 42.2% had a BMI 30 kg/m2.
• Patients with a higher BMI were older (P < 0.001), had higher tumour grade (P < 0.001), and were more likely to have positive soft tissue surgical margins (P = 0.006) compared with patients with lower BMI.
• In multivariable analyses that adjusted for the effects of standard clinicopathological features, BMI >30 was associated with higher risk of disease recurrence (hazard ratio (HR) 1.67, 95% confidence interval (CI) 1.46–1.91, P < 0.001), cancer-specific mortality (HR 1.43, 95% CI 1.24–1.66, P < 0.001), and overall mortality (HR 1.81, CI 1.60–2.05, P < 0.001). The main limitation is the retrospective design of the study.
CONCLUSIONS
• Obesity is associated with worse cancer-specific outcomes in patients treated with RC for UCB.
• Focusing on patient-modifiable factors such as BMI may have significant individual and public health implications in patients with invasive UCB.
There Is little doubt that weight reduction using good nutrition support and exercise modification leads to considerable health benefits both in the short and longer term. For the purposes of anaesthesia and surgery, whether open or minimally invasive, all comorbidities will be greatly reduced. The metabolic syndrome with its concomitant morbidities is often found underlying surgical complications.
If we use the preoperative assessment time to encourage the patient to become part of the team to optimise their well-being ahead of surgery, then it is perfectly easy in our experience to lose up to 25 kg in weight and greatly increase exercise tolerance within just weeks. The use of cardiopulmonary exercise testing is to be encouraged to document the significant changes which can be achieved. The authors of this paper are to be congratulated in highlighting that the greatest good we can do as doctors is not simply to operate but to improve the lifestyle and hence reduce the life long risk of our patients.
And along with improved fitness there is the additional benefit which every patient with such a malignancy seeks – better cancer specific survival.
One of the most important messages coming from this study is that we really know very little about metabolic syndrome and its consequences both in urogenital cancers and surgical field.
Biologic mechanisms which can be involved in the origin of cancer in patients with obesity and metabolic syndrome need to be well investigated. In this paper the proposed mechnism of increased insulin levels and increased insuline like growth factor on the basis of urothelial cell carcinoma are really intriguing. It would be very important in the next future to do all efforts to improve this knowledge.