Trends in the Use of Perioperative Chemotherapy for Localized and Locally Advanced Muscle-invasive Bladder Cancer: A Sign of Changing Tides
Reardon ZD1, Patel SG2, Zaid HB3, Stimson CJ3, Resnick MJ4, Keegan KA5, Barocas DA6, Chang SS3, Cookson MS7. Eur Urol. 2014 Jan 23. pii: S0302-2838(14)00021-9. doi: 10.1016/j.eururo.2014.01.009. [Epub ahead of print]

Author information

1Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address: zachary.d.reardon@vanderbilt.edu. 2Section of Urology, University of Chicago Medical Center, Chicago, IL, USA. 3Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. 4Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Surgical Quality and Outcomes Research, Vanderbilt University Medical Center, Nashville, TN, USA; The VA Tennessee Valley Health Care System, Nashville, TN, USA. 5Division of Urology, San Antonio Military Medical Center, San Antonio, TX, USA. 6Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Surgical Quality and Outcomes Research, Vanderbilt University Medical Center, Nashville, TN, USA. 7Department of Urology, University of Oklahoma College of Medicine, Norman, OK, USA.

Abstract

BACKGROUND: Despite the documented survival benefit conferred by neoadjuvant (NAC) and adjuvant chemotherapy (AC), there has been a slow adoption of guideline recommendations for the use of perioperative chemotherapy (POC) in patients with muscle-invasive bladder cancer (MIBC).

OBJECTIVE: To evaluate temporal trends in POC utilization and identify factors influencing POC delivery in a representative cohort of patients with MIBC.

DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study identifying factors associated with receipt of POC and evaluating temporal changes in NAC and AC utilization. We included patients from the National Cancer Data Base (NCDB) with no prior malignancy who ultimately underwent radical cystectomy for ≥cT2/cN0/cM0 MIBC between 2006 and 2010.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Relationships between demographic and hospital factors and the likelihood of receiving POC were evaluated using Pearson chi-square and Wilcoxon rank-sum tests, and multivariable logistic regression. Temporal changes in NAC and AC use were detected using a linear test of trend.

RESULTS AND LIMITATIONS: A total of 5692 patients met our inclusion criteria. POC use increased from 29.5% in 2006 to 39.8% in 2010 (p<0.001). NAC use increased from 10.1% in 2006 to 20.8% in 2010 (p=0.005); AC remained stable between 18.1% and 21.3% (p=0.68). Multivariable modeling revealed advanced age, increasing comorbidity, lack of insurance, increased travel distance, geographic location outside the northeastern United States, and lower income as negatively associated with POC receipt (all p<0.05). Limitations include retrospective design and potential sampling bias, excluding patients treated at non-NCDB facilities.

CONCLUSIONS: POC use for MIBC increased from 2006 to 2010, with this increase disproportionately due to rising NAC utilization. Nonetheless, there is persistent variation in the likelihood of receiving POC secondary to nonclinical factors.

PATIENT SUMMARY: When retrospectively analyzing a representative cohort of patients undergoing radical cystectomy for muscle-invasive bladder cancer between 2006 and 2010, we noted that preoperative chemotherapy rates increased steadily while use of chemotherapy after surgery remained stable. Factors related to access to care significantly influenced receipt of chemotherapy.