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Frailty and the Comparative Effectiveness of Robotic-Assisted Radical Cystectomy Versus Open Radical Cystectomy in Older Adults
Jamil Almohtasib, MD1, Joseph Black, MD2, Sumedh Kaul, MS1, Aaron Fleishman, MPH1, Peter Chang, MD1, Andrew Wagner, MD1, Joaquim Bellmunt, MD3, Ruslan Korets, MD1, Aria F. Olumi, MD1, Boris Gershman, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2MD Anderson Cancer Center, Houston, TX, USA, 3Dana-Farber Cancer Institute, Boston, MA, USA.
BACKGROUND: The role of frailty as a potential effect modifier of the comparative effectiveness of robotic-assisted radical cystectomy (RARC) and open radical cystectomy (ORC) in older adults has not been examined. Radical cystectomy (RC) is associated with high rates of perioperative morbidity, and frailty may serve as a potentially strong modifier of both perioperative and oncologic outcomes. We therefore emulated a pragmatic clinical trial of RARC versus ORC to examine this question.
METHODS: We identified adults 66-89 years with Tis-T4/N0-N1/M0 urothelial carcinoma of bladder from 2008-2017 treated with RC in SEER-Medicare to emulate the iROC trial. Baseline frailty was assessed using the claims-based frailty index (CFI). Associations of RARC and ORC with perioperative and oncologic outcomes was examined in the overall cohort after inverse probability of treatment re-weighting (IPW). Baseline frailty was examined as an effect modifier using interaction terms in separate models.
RESULTS: A total of 1,750 patients were included in the study cohort, of whom 229 underwent RARC and 1521 underwent ORC. Adjusted rates of perioperative blood transfusion or 90-day ER utilization, hospital readmission, and complications were not statistically significantly different between RARC and ORC. Similarly, there was no statistically significant difference in cancer-specific or all-cause mortality (Figure 1). Notably, there were no statistically significant differences in perioperative morbidity or oncologic outcomes across baseline frailty level (Table 1).
CONCLUSIONS: In observational analyses designed to emulate the iROC trial, RARC was not associated with improved perioperative morbidity or oncologic outcomes in older adults, regardless of baseline frailty level
Associations of RARC vs ORC with perioperative and oncologic outcomes stratified by CFI level (effec | Blood Transfusion HR (95% CI) | 90-Day Readmission HR (95% CI) | 90-Day ER utilization HR (95% CI) | 90-Day Complications HR (95% CI) | Cancer specific mortality HR (95% CI) | All-cause mortality HR (95% CI) |
| CFI | | | | | | |
| < 0.15 | 0.57 (0.24, 1.36) | 0.86 (0.44, 1.68) | 0.90 (0.46, 1.76) | 0.82 (0.39, 1.72) | 1.11 (0.63, 1.97) | 1.45 (0.89, 2.38) |
| ≥0.15 - < 0.25 | 1.48 (0.52, 4.22) | 1.90 (0.86, 4.23) | 2.08 (0.88, 4.75) | 1.00 (0.45, 2.20) | 0.58 (0.28, 1.18) | 0.73 (0.47, 1.15) |
| ≥0.25 | 1.18 (0.24, 5.75) | 0.44 (0.11, 1.68) | 0.35 (0.08, 1.48) | 2.33 (0.50, 10.91) | 1.11 (0.44, 2.78) | 0.73 (0.32, 1.66) |
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