Use of radical cystectomy for patients with invasive bladder cancer.
BACKGROUND
Evidence-based guidelines recommend radical cystectomy for patients with muscle-invasive bladder cancer. However, many patients receive alternate therapies, such as chemotherapy or radiation. We examined factors that are associated with the use of radical cystectomy for invasive bladder cancer and compared the survival outcomes of patients with invasive bladder cancer by the treatment they received.


METHODS
From linked Surveillance, Epidemiology, and End Results-Medicare data, we identified a cohort of 3262 Medicare beneficiaries aged 66 years or older at diagnosis with stage II muscle-invasive bladder cancer from January 1, 1992, through December 31, 2002. We examined the use of radical cystectomy with multilevel multivariable models and survival after diagnosis with the use of instrumental variable analyses. All statistical tests were two-sided.


RESULTS
A total of 21% of the study subjects underwent radical cystectomy. Older age at diagnosis and higher comorbidity were associated with decreased odds of receiving cystectomy (for those > or = 80 vs 66-69 years old, odds ratio [OR] = 0.10, 95% confidence interval [CI] = 0.07 to 0.14; for Charlson comorbidity index of 3 vs 0-1, OR = 0.25, 95% CI = 0.14 to 0.45). Long travel distance to an available surgeon was associated with decreased odds of receiving cystectomy (for >50 vs 0-4 miles travel distance to an available surgeon, OR = 0.60, 95% CI = 0.37 to 0.98). Overall survival was better for those who underwent cystectomy compared with those who underwent alternative treatments (for chemotherapy and/or radiation vs cystectomy, hazard ratio of death = 1.5, 95% CI = 1.3 to 1.8; for surveillance vs cystectomy, hazard ratio of death = 1.9, 95% CI = 1.6 to 2.3; 5-year adjusted survival: 42.2% [95% CI = 39.1% to 45.4%] for cystectomy; 20.7% [95% CI = 18.7% to 22.8%] for chemotherapy and/or radiation; 14.5% [95% CI = 13.0% to 16.2%] for surveillance).


CONCLUSIONS
Guideline-recommended care with radical cystectomy is underused for patients with muscle-invasive bladder cancer. Many bladder cancer patients whose survival outcomes might benefit with surgery are receiving alternative less salubrious treatments.
Gore
John L
JL
Department of Urology, University of Washington School of Medicine, 1959 NE Pacific St, Box 356510, Seattle, WA 98195, USA. jlgore@u.washington.edu
Litwin
Mark S
MS
Lai
Julie
J
Yano
Elizabeth M
EM
Madison
Rodger
R
Setodji
Claude
C
Adams
John L
JL
Saigal
Christopher S
CS
D000368:Aged; D000369:Aged, 80 and over; D015653:Cystectomy / Q000379:methods / Q000706:statistics & numerical data; D018572:Disease-Free Survival; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008498:Medical Record Linkage; D006278:Medicare; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D012107:Research Design; D018426:SEER Program; D016896:Treatment Outcome; D014481:United States; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery* / Q000628:therapy
Urology. 2004 Aug;64(2):292-7
15302481
Med Care. 1999 Feb;37(2):204-9
10024124
J Clin Epidemiol. 1992 Jun;45(6):613-9
1607900
Am J Public Health. 1992 May;82(5):703-10
1566949
J Urol. 2004 Nov;172(5 Pt 1):1958-62
15540765
J Urol. 2005 Oct;174(4 Pt 1):1385-9; discussion 1389
16145443
J Med Syst. 1999 Jun;23(3):175-81
10554733
J Urol. 2005 May;173(5):1695-700
15821560
CA Cancer J Clin. 2008 Mar-Apr;58(2):71-96
18287387
J Am Geriatr Soc. 2004 May;52(5):731-5
15086653
Annu Rev Public Health. 1998;19:17-34
9611610
Cancer. 2000 Jul 1;89(1):142-51
10897011
Cancer. 2005 Feb 1;103(3):546-52
15630702
Int J Health Geogr. 2006 Sep 19;5:40
16984650
Health Serv Res. 2008 Jun;43(3):1102--20
18546544
Cancer. 2008 Apr 15;112(8):1708-17
18330868
Int J Radiat Oncol Biol Phys. 2001 Sep 1;51(1):23-30
11516847
Med Care. 1993 Aug;31(8):732-48
8336512
Int J Radiat Oncol Biol Phys. 2010 May 1;77(1):119-24
19665319
Health Serv Res. 2000 Feb;34(6):1351-62
10654835
J Rural Health. 2008 Fall;24(4):390-9
19007394
J Natl Compr Canc Netw. 2006 Nov;4(10):984-1014
17112448
Cancer. 2008 Feb 15;112(4):909-18
18189295
J Chronic Dis. 1987;40(5):373-83
3558716
Science. 1973 Dec 14;182(4117):1102-8
4750608
Cancer. 2007 May 1;109(9):1756-62
17366596
J Urol. 2003 Nov;170(5):1765-71
14532772
J Natl Compr Canc Netw. 2009 Jan;7(1):8-39
19176203
Eur Urol. 2003 Mar;43(3):246-57
12600427
Annu Rev Public Health. 1997;18:341-78
9143723
CA Cancer J Clin. 2005 Jan-Feb;55(1):10-30
15661684
Public Health Rep. 2004 May-Jun;119(3):263-70
15158105
Am J Med. 2008 Feb;121(2):142-8
18261503
Urology. 2007 May;69(5):871-5
17482924
J Clin Oncol. 2005 Oct 1;23(28):7074-80
16192590
JAMA. 2007 Jan 17;297(3):278-85
17227979
Oncology (Williston Park). 1998 Jul;12(7A):225-71
9699218
J Health Econ. 2008 May;27(3):531-43
18192044
Eur J Cancer. 2008 May;44(7):992-9
18375117
N Engl J Med. 2002 Apr 11;346(15):1128-37
11948273
Breast Cancer Res Treat. 1999 Jul;56(1):59-66
10517343