Trends in the Use of Perioperative Chemotherapy for Localized and Locally Advanced Muscle-invasive Bladder Cancer: A Sign of Changing Tides

Abstract

Background Despite the documented survival benefit conferred by neoadjuvant (NAC) and adjuvant chemotherapy (AC), there has been a slow adoption of guideline recommendations for the use of perioperative chemotherapy (POC) in patients with muscle-invasive bladder cancer (MIBC). Objective To evaluate temporal trends in POC utilization and identify factors influencing POC delivery in a representative cohort of patients with MIBC. Design, setting, and participants Retrospective cohort study identifying factors associated with receipt of POC and evaluating temporal changes in NAC and AC utilization. We included patients from the National Cancer Data Base (NCDB) with no prior malignancy who ultimately underwent radical cystectomy for ≥cT2/cN0/cM0 MIBC between 2006 and 2010. Outcome measurements and statistical analysis Relationships between demographic and hospital factors and the likelihood of receiving POC were evaluated using Pearson chi-square and Wilcoxon rank-sum tests, and multivariable logistic regression. Temporal changes in NAC and AC use were detected using a linear test of trend. Results and limitations A total of 5692 patients met our inclusion criteria. POC use increased from 29.5% in 2006 to 39.8% in 2010 (p < 0.001). NAC use increased from 10.1% in 2006 to 20.8% in 2010 (p = 0.005); AC remained stable between 18.1% and 21.3% (p = 0.68). Multivariable modeling revealed advanced age, increasing comorbidity, lack of insurance, increased travel distance, geographic location outside the northeastern United States, and lower income as negatively associated with POC receipt (all p < 0.05). Limitations include retrospective design and potential sampling bias, excluding patients treated at non-NCDB facilities. Conclusions POC use for MIBC increased from 2006 to 2010, with this increase disproportionately due to rising NAC utilization. Nonetheless, there is persistent variation in the likelihood of receiving POC secondary to nonclinical factors. Patient summary When retrospectively analyzing a representative cohort of patients undergoing radical cystectomy for muscle-invasive bladder cancer between 2006 and 2010, we noted that preoperative chemotherapy rates increased steadily while use of chemotherapy after surgery remained stable. Factors related to access to care significantly influenced receipt of chemotherapy.

Predictors of referral for neoadjuvant chemotherapy prior to radical cystectomy for muscle-invasive bladder cancer and changes in practice over time

“…24 Regional differences within the province were evident, and in Calgary in 2011 the referral rate was still only 25.0% in spite of the development of provincial guidelines. Possible reasons for poor uptake in Calgary include skepticism on the part of some surgeons regarding the benefits of NACT, lack Neoadjuvant chemotherapy in muscle-invasive bladder cancer of a formal referral pathway to medical oncology for patients with MIBC being considered for cystectomy, and anecdotal evidence of an imbalance in surgeon volumes (i.e., more surgeons are performing cystectomies in Calgary than in Edmonton), leading to greater variability in practice.…”

Trends and disparities in the use of neoadjuvant chemotherapy for muscle-invasive urothelial carcinoma

“…It has been over a decade 9,10 . Similarly, our study noted elderly age and increased comorbidity to be associated with decreased NAC utilization.…”

“…Although several observational studies identified a significant increase in the utilization of NAC up until 2010, contemporary national cancer registry data beyond this is lacking 4,9,10 . As such, in this study, we examine trend of the utilization of NAC and explore factors associated with its delivery.…”

Treatment of muscle-invasive bladder cancer in Canada: A survey of genitourinary medical oncologists and urologists

“…8 Similarly, an Australian study showed an uptake of 17% increasing over time. 9 Nonetheless, in the context of Level 1 evidence, these rates are low, and these retrospective studies do not help us understand why.…”