Receipt of aggressive therapies for muscle-invasive bladder cancer: Results from the National Cancer Data Base.

Abstract

272 Background: Over 17,000 patients are diagnosed with muscle-invasive bladder cancer (MIBC) in the United States each year. Despite its lethal potential, emerging data has suggested that many patients do not receive aggressive therapy consistent with established practice standards. Using data from American College of Surgeons Commission on Cancer accredited facilities, we seek to characterize treatment patterns for patients with MIBC according to demographic, clinical, pathologic and facility variables. Methods: 28,691 adult patients diagnosed with MIBC (stages II-IV), excluding those with T4b tumors or distant metastases between 2004 and 2008 were selected for analyses from the National Cancer Database. Treatments included radical or partial cystectomy +/− chemotherapy (CT), chemoradiotherapy (CRT), radiotherapy (RT) or CT alone and surveillance. Aggressive therapy (AT) was defined as any open surgery or RT with a total dose ≥50 Gy. Determinants of AT were assessed by multivariate generalized estimating equations accounting for facility clustering. Results: 52.5% of patients received AT (45% were treated surgically while 7.5% received CRT or RT), 11.7% received palliative CT or RT, and 25.9% received surveillance only. Receipt of AT decreased significantly with advancing age (OR 0.29 for age >80 vs. 18-59, p<.001). AT was also received less frequently by minorities (OR 0.72 for blacks p<.001), the uninsured (OR 0.72, p<.001), Medicaid-insured patients (OR 0.81, p=.006) and by those patients treated at low-volume centers (OR 0.63 vs. high-volume, p<.001). Receipt of AT increased with more advanced stage (OR 2.33 for stage III vs. stage II, p<.001) and in patients with non-urothelial histology (OR 1.32 and 1.50 for squamous and adenocarcinoma histology respectively, p<.001). Hydronephrosis was associated with decreased use of AT (OR 0.70, p<.001). Conclusions: Aggressive therapies for MIBC are received less frequently by the elderly and those with historically poorer socioeconomic status. These data indicate a significant unmet clinical need for physician education regarding appropriate selection of patients for cystectomy and RT-based bladder sparing therapy.