Clinicopathological factors in bladder cancer for cancer-specific survival outcomes following radical cystectomy: a systematic review and meta-analysis

Background Assessing the prognostic significance of specific clinicopathological features plays an important role in surgical management after radical cystectomy. This study investigated the association between ten clinicopathological characteristics and cancer-specific survival (CSS) in patients with bladder cancer. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a literature search was conducted through the PubMed, EMBASE and Web of Science databases using appropriate search terms from the dates of inception until November 2018. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated to evaluate the CSS. Fixed- or random-effects models were constructed according to existence of heterogeneity. Results Thirty-three articles met the eligibility criteria for this systematic review, which included 19,702 patients. The overall results revealed that CSS was associated with advanced age (old vs. young: pooled HR = 1.01; 95% CI:1.00–1.01; P < 0.001), higher tumor grade (3 vs. 1/2: pooled HR = 1.29; 95% CI:1.15–1.45; P < 0.001), higher pathological stage (3/4 vs. 1/2: pooled HR = 1.60; 95% CI:1.37–1.86; P < 0.001), lymph node metastasis (positive vs. negative: pooled HR = 1.51; 95% CI:1.37–1.67; P < 0.001), lymphovascular invasion (positive vs. negative: pooled HR = 1.36; 95% CI:1.28–1.45; P < 0.001), and soft tissue surgical margin (positive vs. negative: pooled HR = 1.42; 95% CI:1.30–1.56; P < 0.001). However, gender (male vs. female: pooled HR = 0.98; 95% CI: 0.96–1.01; P = 0.278), carcinoma in situ (positive vs. negative: pooled HR = 0.98; 95% CI: 0.88–1.10; P = 0.753), histology (transitional cell cancer vs variant: pooled HR = 0.90; 95% CI: 0.79–1.02; P = 0.089) and adjuvant chemotherapy (yes vs. no: pooled HR = 1.16; 95% CI: 1.00–1.34; P = 0.054) did not affect CSS after radical resection of bladder cancer. Conclusions Our results revealed that several clinicopathological characteristics can predict CSS risk after radical cystectomy. Prospective studies are needed to further confirm the predictive value of these variables for the prognosis of bladder cancer patients after radical cystectomy. Electronic supplementary material The online version of this article (10.1186/s12885-019-5924-6) contains supplementary material, which is available to authorized users.


Background
Bladder cancer (BCa) is the most common malignancy of the urinary tract and occurs with a relatively high incidence in developing countries [1], with annual mortality rates ranging from approximately 1-5 deaths per 100,000 men and 0.5-1.5 deaths per 100,000 women [2]. Radical cystectomy (RC) with bilateral pelvic lymph node dissection is the gold standard for patients with localized muscle-invasive tumors. Despite a better understanding of BCa biology and the use of adjuvant therapies, BCa continues to have high mortality rates, and the oncological outcomes following RC have not changed in the last 30 years [3].
BCa prognoses vary widely. Many factors have been investigated as potential predictors of clinical outcome in BCa. Positive soft tissue surgical margins (STSM) [4], lymphovascular invasion (LVI) [5], lymph node metastasis (LNM) [6], concomitant carcinoma in situ (CIS) [7], and failure to receive adjuvant chemotherapy (ACT) [8] have been reported to be associated with poor prognoses for BCa after RC. Although these predictive variables have contributed to estimating the BCa recurrence risk and survival outcomes, additional variables that can integrate with well-established prognostic models and provide accurate risk grading for BCa patients after RC are critical.
A major problem for urologists is identifying prognostic factors that can predict cancer progression. The ability to determine cancer-specific survival (CSS) and provide integrated patient survivorship and better estimates of survival probability at each follow-up may lead to more informative prognostic information in patient monitoring [9].Therefore, we aimed to provide a comprehensive systematic review and metaanalysis of previous studies to investigate the prognostic roles of pathological status and clinical variables for CSS in patients following RC. We identified ten common clinicopathological characteristics that should be systematically assessed to guide postoperative decision-making after RC.

Search strategy
In line with the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) [10], the electronic database of PubMed, EMBASE and Web of Science were searched for studies published prior to November 2018. The following search term combinations were used: 'urinary bladder neoplasms' , 'bladder and neoplasms' , 'radical cystectomy' , 'cancer-specific survival' , 'clinical' , and 'pathological'. The publication language was restricted to English. In addition, the reference lists of the identified studies were also searched manually.

Inclusion and exclusion criteria
The inclusion criteria were as follows: (1) all patients with BCa were pathologically confirmed; (2) the study included prognostic factors for CSS following radical cystectomy; (3) treatment was limited to RC in all studies; and (4) the authors provided the hazard ratios (HRs) and 95% confidence intervals(CIs). The exclusion criteria were: (1) duplicates; (2) lack of sufficient data (HRs and CIs) for further analysis; and (3) case reports, reviews, letters, author replies, expert opinions or meeting abstracts. If the data overlapped across several different articles, only the most recent and informative article was selected.

Data extraction and qualitative assessment
Two authors extracted the information from the selected studies. Any disagreement between the reviewers was resolved by discussion with a third author. The following information were collected from eligible studies: first author's name, publication date, country, recruitment period, follow-up time, sample size, patient's age, pathological stage, tumor grade, histopathological subtype in transitional cell cancer (TCC) and the HR and 95% CIs for CSS.
We evaluated the study quality using the 9-star Newcastle-Ottawa Scale (NOS) [11]. Scores of 7-9 indicated a high-quality study, and scores < 7 indicated a low-quality. The cohort study quality was assessed as follows: object selection, inter-group comparability, and outcome measurement. Dichotomous variables were presented as HRs with 95% CIs. If the data results were calculated by multivariate and univariate analysis simultaneously, the multivariate analyses were used.

Statistical analysis
All calculations were performed using STATA 12.0 software (Stata Corp LP, College Station, TX, USA). Heterogeneity was estimated using the Higgins Isquared statistic test, and P heterogeneity ≤ 0.1 or I 2 > 50%. indicated heterogeneity among studies. When significant heterogeneity was observed among the studies, a random-effect (RE) model was used; otherwise, we adopted a fixed-effect (FE) model. To explore the source of heterogeneity, subgroup analysis was performed for CSS. Sensitivity analysis was conducted by excluding single studies one by one to examine the stability and reliability of the pooled results. A funnel plot and Egger's test were used to statistically evaluate the publication bias between studies. Two-tailed P < 0.05 was considered statistically significant.

Literature search
From the search criteria, 887 articles were identified from the databases and the manual search. Of these articles, 664 studies were excluded based on their titles and/or abstracts, resulting in 223 studies for further analysis. The full texts were then screened, and 190 papers were excluded because of insufficient survival information or duplicated cohorts. Finally, 33 studies [3,5,6,8, containing 19,702 patients (range 51-2,944) were included as per the eligibility criteria. Figure 1 presents a flowchart of the study selection process.

Characteristics of eligible studies
Tables 1 and 2 summarize the main characteristics and clinicopathological outcomes of the 33 included studies. All studies were performed retrospectively, and all were published between 2007 and 2018. Of the included studies, 11 were conducted in Asia, 8 in Europe, 7 in North America, 4 at international multicenters, 3 in Turkey and 1 in Australia. Histopathological examinations were performed on resected tumor specimens. All studies used CSS as a common endpoint to evaluate the prognostic value of the clinicopathological indicators of survival. The quality scores of the studies ranged from 7 to 9.Therefore, all included studies were of high quality (studies with a score ≥ 7; Additional file 2: Table S1).

Discussion
Despite modern advancements in surgical techniques, the oncological outcomes of BCa remains poor. The 5-yr overall survival rates were only 60% according to a multicenter database [41]. Determining the probability of CSS after RC is difficult because it can vary according to the different clinical features and various tumor characteristics. The traditional clinicopathological features, such as sex [34], pathological tumor stage or grade [25] and LNM [6], have been identified as important parameters with prognostic predictive value and contribute to postoperative clinical decision making based on some nomograms. Currently, the TNM staging system, which is based on pathological tumor stage and grade, tumor histological subtype, and lymph node status [42] is the most commonly used preoperative model for predicting CSS in BCa patients. Another predictive model is the European Organisation for the Research and Treatment of Cancer (EORTC) risk stratification scheme [43], which uses grade (World Health Organization [WHO] 1973), stage, CIS, multiplicity, size and previous recurrence rate to determine the risk of CSS after RC. Although these two traditional prognostic models have been externally validated, significant variations were founded in some studies. Variations in tumor outcomes may have been related to the heterogeneity of BCa biology and different clinicopathological features in patients with BCa.
Tumor markers that can accurately predict the oncological outcomes in BCa patients when applied with other pathological parameters are essential for clinical decision making. Some published studies on molecular biomarkers, such as luminal and basal subtypes [44], the gene alterations nuclear matrix protein number 22 [45], and the bladder tumor antigen (BTA) stat test [46], have been  adopted in recent years to improve diagnosing and managing patients receiving RC. However, none of these biomarkers have been shown to be sufficiently sensitive or specific in predicting survival outcomes. Therefore, in this study, we exploited more validated prognostic factors, including clinical variables (age, gender), pathological information (tumor stage and grade, LNM and STSM, LVI, CIS, and histology), and whether adjuvant therapy (ACT) was received for predicting CSS in BCa patients. This is the first study to systematically assess the association between ten clinicopathological features and CSS of BCa in a single study. To improve the statistical power and provide more credible results, 33 cohort studies with a large combined sample size of 19,702 BCa patients who underwent RC were pooled in our study. Strictly adhering to the inclusion and exclusion criteria, we extracted the raw data from the relevant studies. The results revealed that advanced age, higher tumor grade, LNM, LVI, and positive STSM significantly predicted the CSS of BCa patients (all P ≤ 0.05). Hence, these clinicopathological findings were independent risk factors in this meta-analysis. Besieds, all the results were reliable and robust via the subgroup and sensitivity analyses.
Interestingly, our results indicated that gender, CIS, histology and ACT may not be associated with CSS. Studies on gender, histology and CIS as prognostic factors for BCa patients have stimulated considerable interest, but the results remain controversial and ambiguous for managing BCa. Some investigators reported that gender and CIS had independent prognostic significance [14,34,47], while others considered that gender and CIS may not be significant factors in determining terminal prognosis compared with other widely used prognostic indicators [18,48,49]. Additionally, administering ACT after RC in patients with high-risk BCa remains a challenge for clinical urologists. Despite numerous studies being published, no level 1 evidence has demonstrated that ATC confers a significant survival benefit to BCa patients after RC [50]. In the present study, rigorous data analysis indicated that these three factors may not affect the CSS prognosis of patients with BCa.
Although this was a comprehensive meta-analysis, the present study had several limitations. First, most included studies were retrospective cohort studies, and data extracted from those studies may have led to inherent bias. Thus, a prospective multicenter trial providing more definite answers is needed. Second, substantial heterogeneity was observed in some studies. Although we found no possible source of heterogeneity after several subgroup analyses, the conclusions drawn from this meta-analysis should be approached with caution. However, the pooled results in most of the subgroup analyses were consistent with the overall findings. Third, the studies retrieved for our analysis were limited to those published in English, which may result in a language bias. Studies with negative results are not often published in English-language journals [51]; thus, our research may contain some publication bias.

Conclusions
In summary, the data from this meta-analysis indicate that BCa patients with advanced age, higher tumor grade, LNM, LVI, and positive STSM are likely to have poorer CSS, suggesting that these parameters may be independent indicators of BCa in patients following RC. In Table 3 Summary and subgroup results of the association between common clinicopathological characteristics and BCa (Continued)  contrast with what is seen clinical practice, gender, CIS, histology and postoperative ACT were not predictors of CSS in patients with BCa. We identified significant patient-specific (age) and tumor-specific (higher tumor grade, LNM, LVI, and positive STSM) predictors of CSS to propose a risk-based strategy for choosing surveillance and postoperative treatment options. Despite our rigorous systematic approach, further large, prospective studies are needed to confirm our findings considering the inherent limitations of the included studies.

Funding
No funding was received for this study.
Availability of data and materials All data generated or analyzed during the present study are included in this published article (and its supplementary information files).
Ethics approval and consent to participate Not applicable.

Consent for publication
Not applicable.