Predicting 90-day and long-term mortality in octogenarians undergoing radical cystectomy

Abstract

Background: Radical cystectomy bears a considerable perioperative mortality risk particularly in elderly patients. In this study, we searched for predictors of perioperative and long-term competing (non-bladder cancer) mortality in elderly patients selected for radical cystectomy.

Methods: We stratified 1184 consecutive patients who underwent radical cystectomy for high risk superficial or muscle-invasive urothelial or undifferentiated carcinoma of bladder into two groups (age < 80 years versus 80 years or older). Multivariable and cox proportional hazards models were used for data analysis.

Results: Whereas Charlson score and the American Society of Anesthesiologists (ASA) physical status classification (but not age) were independent predictors of 90-day mortality in younger patients, only age predicted 90-day mortality in patients aged 80 years or older (odds ratio per year 1.24, p = 0.0422). Unlike in their younger counterparts, neither age nor Charlson score or ASA classification were predictors of long-term competing mortality in patients aged 80 years or older (hazard ratios 1.07-1.10, p values 0.21-0.77).

Conclusions: This data suggest that extrapolations of perioperative mortality or long-term mortality risks of younger patients to octogenarians selected for radical cystectomy should be used with caution. Concerning 90-day mortality, chronological age provided prognostic information whereas comorbidity did not.

Keywords: 90-day mortality; Age; Bladder cancer; Comorbidity; Competing mortality; Radical cystectomy.

Fig. 1

Cumulative mortality curves from bladder cancer and from causes other than bladder cancer (competing causes) stratified by the age cutoff of 80 years

Fig. 2

Impact of the stratification of patients younger than 80 years by the ASA classification on 90-day mortality and 5-year competing (non-bladder cancer) mortality rates after primary stratification by the age-adjusted Charlson score [16] (in brackets: 95% confidence intervals). Within the same risk group indicated by the age-adjusted Charlson score, the 90-day mortality differed by the factor 5-8 and 5-year competing mortality differed approximately by the factor 3 between patients with an ASA class 1-2 versus those with a ASA class 3-4. Such large differences are probably relevant for clinical decision making. For age-adjustment of the Charlson score, 1 point is added for an age of 50-59 years, 2 points for an age of 60-69 years, 3 points for an age of 70-79 years, 4 points for an age of 80-89 years and 5 points for an age of 90-99 years [16]