Access to care for stage 2 transitional cell carcinoma of the bladder

Abstract

17568 Background: Receipt of aggressive therapy for invasive bladder cancer is influenced by clinical factors and patient sociodemographic characteristics. We assessed correlates of access to care for stage 2 transitional cell carcinoma (TCC) of the bladder where care algorithms are less equivocal and radical cystectomy (RC) remains the standard of care. We further stratified survival outcomes by treatment modality. Methods: SEER-Medicare subjects diagnosed with stage 2 TCC of the bladder from 1992–2000 were divided into 3 cohorts: those who underwent RC within 1 year, those who received chemotherapy or radiation therapy (Ch-XRT), and those who received no care (NC). We incorporated patient and provider characteristics into multivariate models comparing Ch-XRT and NC to RC. Multivariate Cox models compared survival stratified by treatment group adjusting for clinical determinants. Results: 21% of subjects with stage 2 TCC underwent RC; they were younger and had fewer comorbid conditions than Ch-XRT and NC subjects (p<0.001). Covariates associated with poor access to RC included age (OR 0.91, p<0.001), greater comorbidity (OR 0.32, p<0.001 for Charlson index ≥ 3 vs. Charlson 0), and cancer grade (OR 4.4, p<0.001 for grade 4 vs. grade 1). Use of RC did not vary by race, income, provider, or region. Subsetting a healthy cohort (age < 80 years, Charlson 0), death was associated with age (HR 1.03, p<0.001), being married (HR 0.68, p=0.007), cancer grade (HR 0.68, p=0.010 for grade 2 vs. 4), and treatment modality (HR 1.6, p<0.001 for Ch-XRT; HR 1.3, p=0.005 for NC vs. RC). Results were similar for the entire cohort (see Table). Conclusions: Few subjects with stage 2 TCC of the bladder undergo standard treatment. Although extirpative therapy appears to be determined by clinical parameters, we identified a large cohort of patients who would’ve benefited from more aggressive intervention. More detailed access models with incorporation of contextual variables may explain the differential care in these subjects. Cox model of mortality for SEER-Medicare subjects with stage 2 TCC of the bladder HR p-value Age (yrs) 1.05 <0.001 Female sex 1.40 <0.001 Ethnicity (vs. white) Black 1.17 0.30 Hispanic 1.00 0.99 Other 0.88 0.63 Married 0.82 0.14 Cancer grade (vs. 4) 2 9.68 0.005 3 1.08 0.43 Unknown 0.86 0.56 Region (vs. West) Northeast 1.03 0.80 Midwest 1.08 0.38 South 1.09 0.61 Treatment (vs. Ch-XRT) RC 1.17 0.45 NC 1.36 0.030 Interaction terms RC*Charlson 0 0.65 0.073 NC*Charlson 0 0.65 0.017 No significant financial relationships to disclose.