Abstract
BackgroundAlthough radical cystectomy (RC) is a standard treatment for muscle-invasive bladder cancer (MIBC), for many patients the risks versus benefits of RC may favor other approaches. We sought to define the landscape of early postcystectomy mortality in the United States and identify patients at high risk using pretreatment variables.MethodsWe identified patients with MIBC (cT2-T4aN0M0) who underwent RC without perioperative chemotherapy within the National Cancer Database (2003–2012). Using multistate multivariable modeling, we calculated time spent in three health states: hospitalized, discharged, and death more than 90 days postcystectomy. Cross-validation was performed by geographic region. Time spent in each state was weighted by utility to determine 90-day quality-adjusted life days (QALDs).ResultsAmong 7922 patients, 90-day mortality was 7.6% (8.0% for lower and 6.7% for higher volume hospitals). Increasing age, clinical T stage, Charlson Comorbidity Index, and lower volume were associated with higher 90-day mortality and were included in the model. Cross-validation revealed appropriate performance (C-statistics of 0.53–0.74; calibration slopes of 0.50–1.67). The model predicted 25% of patients had a 90-day mortality risk higher than 10%, and observed 90-day mortality in this group was 14.0% (95% CI = 12.5% to 15.6%). Mean quality-adjusted life days (QALDs) was 63 (range = 44–68).ConclusionsRC is associated with relatively high early mortality risk. Pretreatment variables may identify patients at particularly high risk, which may inform clinical trial design, facilitate shared decision making, and enhance quality improvement initiatives.
Highlights
Radical cystectomy (RC) is a standard treatment for muscle-invasive bladder cancer (MIBC), for many patients the risks versus benefits of radical cystectomy (RC) may favor other approaches
The proportion of cystectomies by volume category over time is shown in Figure 3, demonstrating that even in the most recent year of the analysis, approximately 20% of patients underwent cystectomy at lower volume hospitals
Further complicating treatment decisions is the availability of an alternative treatment modality, radiation therapy, that has never been fully embraced in the United States at least in large part because of a lack of definitive comparative effectiveness data
Summary
Radical cystectomy (RC) is a standard treatment for muscle-invasive bladder cancer (MIBC), for many patients the risks versus benefits of RC may favor other approaches. We sought to define the landscape of early postcystectomy mortality in the United States and identify patients at high risk using pretreatment variables. We calculated time spent in three health states: hospitalized, discharged, and death more than 90 days postcystectomy. Time spent in each state was weighted by utility to determine 90-day quality-adjusted life days (QALDs). Results: Among 7922 patients, 90-day mortality was 7.6% (8.0% for lower and 6.7% for higher volume hospitals). Increasing age, clinical T stage, Charlson Comorbidity Index, and lower volume were associated with higher 90-day mortality and were included in the model. Pretreatment variables may identify patients at high risk, which may inform clinical trial design, facilitate shared decision making, and enhance quality improvement initiatives
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