The Impact of Travel Time on Trimodal Therapy Compared to Cystectomy for Bladder Cancer.

Abstract

Neoadjuvant chemotherapy followed by radical cystectomy (RC) and Transurethral Resection of Bladder Tumor (TURBT) followed by concurrent chemoradiation therapy (trimodal therapy, TMT) are both evidence-based approaches to the management of muscle-invasive bladder cancer, and no randomized evidence conclusively supports the use of one treatment over another. Literature suggests that increasing distance to radiation therapy (RT) facilities reduces the likelihood that patients will receive RT, though this has not been evaluated in bladder cancer. We hypothesize that greater travel time between a patient's home and their closest RT facility is associated with a lower likelihood of undergoing TMT. Clinical data and the locations of patient residences and surgical facilities performing RC were obtained from the California Cancer Registry. RT facility locations were compiled from state regulatory databases and dosimetric accrediting bodies. Travel time was identified using the Google Distance Matrix API. California patients diagnosed with T2-4N0 bladder cancer in 2018-2019 who underwent TMT (> = 55Gy) or RC were included in this analysis. Chi-square tests, Kruskal-Wallis tests, and univariate and multivariate logistic regressions were performed to assess factors associated with an increased likelihood of receipt of TMT, and to compare travel times for patients receiving TMT vs RC. A total of 536 patients met inclusion criteria, and 27.1% underwent TMT. Patients receiving TMT were more likely to be older, White, male, and live further from their nearest RT facility. After adjusting for age, sex, and race/ethnicity, patients undergoing TMT were more likely than RC patients to live more than 30 minutes away from the nearest RT facility (OR 1.53, p = 0.21, ref<15 minutes). On multivariate analysis, patients receiving TMT were less likely than surgical patients to live 30-60 minutes or >60 minutes from their treatment facility ((OR 0.5, p-value<0.01, and OR 0.23, p-value <.001), ref: <30 minutes). Only 26.2% of patients who received TMT were treated at their nearest RT facility, while 13.3% of patients undergoing RC were treated at their nearest surgical facility. In a modern cohort of bladder cancer patients in California, about a quarter of T2-4N0 patients are undergoing bladder preservation. Patients undergoing TMT lived further from their nearest RT facility than patients undergoing surgery. Surgical patients were more likely to live >30 minutes from their treating facility than TMT patients. A minority of patients underwent treatment at the facility nearest to them, regardless of treatment modality chosen. Taken together, this suggests that proximity to the nearest RT facility may not be associated with a higher likelihood of undergoing TMT. Examination of actual treatment facilities (as opposed to the closest facility) shows that patients are traveling further for surgical care than TMT.