title: Use of potentially curative therapies for muscle-invasive bladder cancer in the United States: results from the National Cancer Data Base.
abstract: BACKGROUND
  Despite its lethal potential, many patients with muscle-invasive bladder cancer (MIBC) do not receive aggressive, potentially curative therapy consistent with established practice standards.
  
  
  OBJECTIVE
  To characterize the treatments received by patients with MIBC and analyze their use according to sociodemographic, clinical, pathologic, and facility measures.
  
  
  METHODS
  Using the National Cancer Data Base, we analyzed 28 691 patients with MIBC (stages II-IV) treated between 2004 and 2008, excluding those with cT4b tumors or distant metastases. Treatments included radical or partial cystectomy with or without chemotherapy (CT), chemoradiotherapy (CRT), radiation therapy (RT), or CT alone and observation following biopsy. Aggressive therapy (AT) was defined as radical or partial cystectomy or definitive RT/CRT (total dose ≥ 50 Gy).
  
  
  METHODS
  AT use and correlating variables were assessed by multivariable, generalized estimating equation models adjusted for facility clustering.
  
  
  CONCLUSIONS
  According to the database, 52.5% of patients received AT; 44.9% were treated surgically, 7.6% received definitive CRT or RT, and 25.9% of patients received observation only. AT use decreased with advancing age (odds ratio [OR]: 0.34 for age 81-90 yr vs ≤ 50 yr; p<0.001). AT use was also lower in racial minorities (OR: 0.74 for black race; p<0.001), the uninsured (OR: 0.73; p<0.001), Medicaid-insured patients (OR: 0.81; p=0.01), and at low-volume centers (OR: 0.64 vs high-volume centers; p<0.001). Use of AT was higher with increasing tumor stage (OR: 2.23 for T3/T4a vs T2; p<0.001) and nonurothelial histology (OR: 1.25 and 1.43 for squamous and adenocarcinoma, respectively; p<0.001). Study limitations include retrospective design and lack of information about patient and provider motivations regarding therapy selection.
  
  
  CONCLUSIONS
  AT for MIBC appears underused, especially in the elderly and in groups with poor socioeconomic status. These data point to a significant unmet need to inform policy makers, payers, and physicians regarding appropriate therapies for MIBC.
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA.
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Gray
authors.forename: Stacey A
authors.initials: SA
authors.lastname: Fedewa
authors.forename: William U
authors.initials: WU
authors.lastname: Shipley
authors.forename: Jason A
authors.initials: JA
authors.lastname: Efstathiou
authors.forename: Chun Chieh
authors.initials: CC
authors.lastname: Lin
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Zietman
authors.forename: Katherine S
authors.initials: KS
authors.lastname: Virgo
mesh_terms: D000230:Adenocarcinoma / Q000208:ethnology / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D002294:Carcinoma, Squamous Cell / Q000208:ethnology / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D059186:Chemoradiotherapy, Adjuvant; D017024:Chemotherapy, Adjuvant; D015653:Cystectomy / Q000009:adverse effects / Q000401:mortality / Q000639:trends; D005260:Female; D019983:Guideline Adherence; D006297:Health Services Accessibility / Q000639:trends; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume; D006801:Humans; D008297:Male; D008484:Medicaid; D017057:Medically Uninsured; D008875:Middle Aged; D008913:Minority Groups; D015999:Multivariate Analysis; D020360:Neoadjuvant Therapy; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000639:trends; D011237:Predictive Value of Tests; D011879:Radiotherapy Dosage; D018714:Radiotherapy, Adjuvant; D012111:Residence Characteristics; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D001749:Urinary Bladder Neoplasms / Q000208:ethnology / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D055815:Young Adult