Impact of care fragmentation in patients receiving neoadjuvant chemotherapy and radical cystectomy for bladder cancer.

Abstract

468 Background: Neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is the standard of care for muscle-invasive bladder cancer (MIBC). However, the impact of care fragmentation on the outcomes of patients receiving NAC and RC for MIBC is not well defined. Methods: The National Cancer Database was queried for adult (≥18 years old) patients with cT2-T4aN0M0 urothelial carcinoma of the bladder receiving NAC followed by RC between 2004 and 2017. Patients were dichotomized based on whether they received fragmented care (FC, defined as receiving NAC at a different facility from RC) or integrated care (IC, defined as receiving NAC and RC at a single facility). Descriptive statistics were used to characterize the two groups based on demographic and therapeutic profiles. Overall survival was compared between patients who received FC versus IC. Statistical analyses include Chi-squared tests, t-tests, Kaplan-Meier with log-rank test, and Cox regression analysis. Results: A total of 5054 patients received NAC followed by RC: 1848 (36.6%) received FC and 3206 (63.4%) received IC. Greater travel distance, private insurance, and treatment at a community cancer program were associated with FC whereas age, sex, race, median income, education level, rurality, and comorbidity burden were not. While patients who received FC had a longer time to initiation of NAC (40 vs. 37 days, p< 0.001), there was no significant difference in median overall survival (OS) (84.3 vs. 92.8 months, p= 0.37). On multivariable Cox regression analysis, age, comorbidity burden, stage, lymphovascular invasion, and surgical margins were associated with OS, while FC was not (hazard ratio: 1.03; 95% confidence interval 0.94-1.13; p= 0.51). Conclusions: Although care fragmentation was associated with a slight delay in the initiation of NAC, long-term survival rates were similar between the FC and IC groups.[Table: see text]