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Meta-Analysis
. 2019 Apr 29;14(4):e0216255.
doi: 10.1371/journal.pone.0216255. eCollection 2019.

Systematic review and meta-analysis on trimodal therapy versus radical cystectomy for muscle-invasive bladder cancer: Does the current quality of evidence justify definitive conclusions?

Marian S Wettstein  1   2 , Jasjit K Rooprai  1 , Clinsy Pazhepurackel  2 , Christopher J D Wallis  1 , Zachary Klaassen  1 , Elizabeth M Uleryk  3 , Thomas Hermanns  2 , Neil E Fleshner  1 , Alexandre R Zlotta  1   4 , Girish S Kulkarni  1
Affiliations
Meta-Analysis

Systematic review and meta-analysis on trimodal therapy versus radical cystectomy for muscle-invasive bladder cancer: Does the current quality of evidence justify definitive conclusions?

Marian S Wettstein et al. PLoS One. .

Abstract

Objectives: To systematically review and meta-analyze the current literature in a methodologically rigorous and transparent manner for quantitative evidence on survival outcomes among patients diagnosed with muscle-invasive bladder cancer that were treated by either trimodal therapy or radical cystectomy.

Materials and methods: MEDLINE, EMBASE, CENTRAL were systematically searched for comparative observational studies reporting disease-specific survival and/or overall survival on adult patients diagnosed with localized muscle-invasive bladder cancer that were exposed to either trimodal therapy or radical cystectomy. Studies qualified for meta-analysis (random effects model) if they were not at critical risk of bias (RoB).

Results: The literature search identified 12 eligible studies. Three (all rated as "moderate RoB") out of 6 studies reporting on disease-specific survival qualified for quantitative analysis and yielded a pooled hazard ratio (trimodal therapy versus radical cystectomy) of 1.39 (95% confidence interval: 1.03-1.88). Four (mainly rated as "serious RoB") out of 12 studies were included in the meta-analysis of overall survival and estimated a hazard ratio of 1.39 (1.20-1.59).

Conclusion: Pooled results were significant in favor of radical cystectomy. The conclusion is mainly driven by large population-based studies that are at high RoB. Hence, the certainty of these treatment estimates can be considered very low and further research will likely have an important impact on these estimates. At present, the ultimate decision between trimodal therapy and radical cystectomy should be left to the patient based on individual preferences and on the recommendation of a multidisciplinary provider team experienced with both approaches.

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Conflict of interest statement

The commercial affiliation of Elizabeth M. Uleryk with E.M. Uleryk Consulting does not alter our adherence to PLOS ONE policies on sharing data and materials. All other authors declare that they have no competing interests related to this study.

Figures

Fig 1
Fig 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) flow diagram illustrating the study selection process.
Fig 2
Fig 2
Individual study results of studies reporting on disease-specific survival (A, N = 6) and the corresponding meta-analysis (B, N = 3). The numbers in brackets next to the study names correspond to the numbers in Table 2 and represent different analytic strategies. CIs in this figure might differ to the reported CIs in Table 2 at the 2nd decimal place due to imprecisions associated with log transformations. CI: confidence interval; HR: hazard ratio; RC: radical cystectomy; TMT: trimodal therapy.
Fig 3
Fig 3
Individual study results of studies reporting on overall survival (A, N = 12) and the corresponding meta-analysis (B, N = 4). The numbers in brackets next to the study names correspond to the numbers in Table 2 and represent different analytic strategies. CIs in this figure might differ to the reported CIs in Table 2 at the 2nd decimal place due to imprecisions associated with log transformations. CI: confidence interval; HR: hazard ratio; RC: radical cystectomy; TMT: trimodal therapy.
See this image and copyright information in PMC

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