Abstract
BACKGROUND: Traditional statistical models often fail to capture the complex dynamics influencing survival outcomes in patients with bladder cancer after radical cystectomy, a procedure where approximately 50% of patients develop metastases within 2 years. The integration of artificial intelligence (AI) offers a promising avenue for enhancing prognostic accuracy and personalizing treatment strategies. OBJECTIVE: This study aimed to develop and evaluate a machine learning algorithm for predicting disease-free survival (DFS), overall survival (OS), and the cause of death in patients with bladder cancer undergoing cystectomy, using a comprehensive dataset of clinical and pathological variables. METHODS: Retrospective data of 370 patients with bladder cancer who underwent radical cystectomy at Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy, were collected. The dataset comprised 20 input variables, encompassing demographics, tumor characteristics, treatment variables, and inflammatory markers. For specific analyses and models, we used patient subcohorts. The CatBoost algorithm was used for regression tasks (DFS in 346 patients, OS in 347 patients) and a binary classification task (tumor-related death in 312 patients). Model performance was assessed using mean absolute error (MAE) for regression and F1-score for classification, prioritizing a minimum recall of 75% for tumor-related deaths. Five-fold cross-validation and Shapley additive explanations (SHAP) values were used to ensure robustness and interpretability. RESULTS: For DFS prediction, the CatBoost model achieved an MAE of 18.68 months, with clinical tumor stage and pathological tumor classification identified as the most influential predictors. OS prediction yielded an MAE of 17.2 months, which improved to 14.6 months after feature filtering, where tumor classification and the systemic immune-inflammation index (SII) were most impactful. For tumor-related death classification, the model achieved a recall of 78.6% and an F1-score of 0.44 for the positive class (tumor-related deaths), correctly identifying 11 of 14 cases. Bladder tumor position was the most influential feature for cause-of-death prediction. CONCLUSIONS: The developed machine learning algorithm demonstrates promising accuracy in predicting survival and the cause of death in patients with bladder cancer after cystectomy. The key predictors include clinical and pathological tumor staging, systemic inflammation (SII), and bladder tumor position. These findings highlight the potential of AI in providing clinicians with an objective, data-driven tool to improve personalized prognostic assessment and guide clinical decision-making.