Trends in the use of perioperative chemotherapy for localized and locally advanced muscle-invasive bladder cancer: a sign of changing tides.
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.


METHODS
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.


METHODS
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.


CONCLUSIONS
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.


RESULTS
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.
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address: zachary.d.reardon@vanderbilt.edu.
Zachary D
ZD
Reardon
Section of Urology, University of Chicago Medical Center, Chicago, IL, USA.
Sanjay G
SG
Patel
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
Harras B
HB
Zaid
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
C J
CJ
Stimson
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Surgical Quality and Outcomes Research, Vanderbilt University Medical Center, Nashville, TN, USA; The VA Tennessee Valley Health Care System, Nashville, TN, USA.
Matthew J
MJ
Resnick
Division of Urology, San Antonio Military Medical Center, San Antonio, TX, USA.
Kirk A
KA
Keegan
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Surgical Quality and Outcomes Research, Vanderbilt University Medical Center, Nashville, TN, USA.
Daniel A
DA
Barocas
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
Sam S
SS
Chang
Department of Urology, University of Oklahoma College of Medicine, Norman, OK, USA.
Michael S
MS
Cookson
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D002277:Carcinoma / Q000188:drug therapy* / Q000473:pathology* / Q000601:surgery; D017024:Chemotherapy, Adjuvant / Q000706:statistics & numerical data / Q000639:trends; D015897:Comorbidity; D015653:Cystectomy; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007182:Income; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D009130:Muscle, Smooth / Q000473:pathology; D020360:Neoadjuvant Therapy / Q000706:statistics & numerical data / Q000639:trends*; D009361:Neoplasm Invasiveness; D019990:Perioperative Care / Q000639:trends*; D012189:Retrospective Studies; D014481:United States; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy* / Q000473:pathology* / Q000601:surgery
D000970:Antineoplastic Agents
Adjuvant therapy; Bladder cancer; Drug therapy; Neoadjuvant therapy; Review