Impact of smoking status at diagnosis on disease recurrence and death in upper tract urothelial carcinoma.
Cigarette smoking is the leading cause of urothelial carcinoma; however, the impact of smoking on outcomes after surgery for upper tract urothelial carcinoma is unknown. One study suggests that patients with a smoking history have an increased risk of recurrence in the bladder compared with never smokers but these patients did not differ with respect to time to pelvic recurrence or distant metastasis. We subdivided smokers into current and former smokers and performed multivariate analyses that showed that smoking status was not an independent predictor of recurrence when traditional prognostic factors were taken into account. In addition, competing risks analyses showed that although current smoking did not increase the risk of recurrence, it imparted a significant risk of dying compared with former and never smoking.


OBJECTIVE
To evaluate the impact of smoking exposure on oncological outcomes in patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU).


METHODS
Patient and disease characteristics from 288 patients with UTUC treated with RNU between 1995 and 2008 were collected from a prospectively maintained database at the Memorial Sloan-Kettering Cancer Center. Disease recurrence was defined as distant metastases, or local failure in the operative site or regional nodes. Factors associated with recurrence and death were determined.


RESULTS
The prevalence of current, former and never smoking at diagnosis was 19.1%, 55.2%, and 25.7%, respectively. 71.0% of patients reported a ≥20 pack-year smoking history. With a median follow-up of 4.02 years, disease recurrence occurred in 27% (n = 79) of patients and 41% (n = 117) died during follow-up. While age at diagnosis, American Society of Anesthesiologists score, advanced stage, nodal involvement and high grade adversely affected recurrence-free survival, smoking status was not associated with risk of recurrence or death in multivariate analysis (P = 0.60). Multivariate competing risks regression showed that current smokers faced a significantly higher risk of death than never smokers (hazard ratio 3.64, 95% confidence interval 1.59-8.34).


CONCLUSIONS
While smoking status at diagnosis and cumulative smoking exposure were not associated with UTUC recurrence, our findings highlight the substantial risk of death in patients with UTUC who are active smokers. Treatment plans to promote smoking cessation are recommended for these patients.
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA. ehdaieb@mskcc.org
Behfar
B
Ehdaie
Helena
H
Furberg
Emily Craig
EC
Zabor
Jamie S
JS
Ostroff
Shahrokh F
SF
Shariat
Bernard H
BH
Bochner
Jonathan A
JA
Coleman
Guido
G
Dalbagni
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001707:Biopsy, Needle; D002295:Carcinoma, Transitional Cell / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D015331:Cohort Studies; D016208:Databases, Factual; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007150:Immunohistochemistry; D053208:Kaplan-Meier Estimate; D007680:Kidney Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local / Q000401:mortality* / Q000473:pathology; D009392:Nephrectomy / Q000379:methods; D009519:New York City; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012907:Smoking / Q000009:adverse effects*; D016540:Smoking Cessation / Q000706:statistics & numerical data; D016019:Survival Analysis; D014513:Ureter / Q000601:surgery; D014516:Ureteral Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D001749:Urinary Bladder Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D014571:Urologic Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*