title: Clinical-pathologic stage discrepancy in bladder cancer patients treated with radical cystectomy: results from the national cancer data base.
abstract: OBJECTIVE
  To examine the accuracy of clinical staging and its effects on outcome in bladder cancer (BC) patients treated with radical cystectomy (RC), using a large national database.
  
  
  METHODS
  A total of 16,953 patients with BC without distant metastases treated with RC from 1998 to 2009 were analyzed. Factors associated with clinical-pathologic stage discrepancy were assessed by multivariate generalized estimating equation models. Survival analysis was conducted for patients treated between 1998 and 2004 (n=7270) using the Kaplan-Meier method and Cox proportional hazards models.
  
  
  RESULTS
  At RC 41.9% of patients were upstaged, whereas 5.9% were downstaged. Upstaging was more common in females, the elderly, and in patients who underwent a more extensive lymphadenectomy. Downstaging was less common in patients treated at community centers, in the elderly, and in Hispanics. Receipt of preoperative chemotherapy was highly associated with downstaging. Five-year overall survival rates for patients with clinical stages 0, I, II, III, and IV were 67.2%, 62.9%, 50.4%, 36.9%, and 27.2%, respectively, whereas those for the same pathologic stages were 70.8%, 75.8%, 63.7%, 41.5%, and 24.7%, respectively. On multivariate analysis, upstaging was associated with increased 5-year mortality (hazard ratio [HR] 1.80, P<.001), but downstaging was not associated with survival (HR 0.88, P=.160). In contrast, more extensive lymphadenectomy was associated with decreased 5-year mortality (HR 0.76 for ≥10 lymph nodes examined, P<.001), as was treatment at an National Cancer Institute-designated cancer center (HR 0.90, P=.042).
  
  
  CONCLUSIONS
  Clinical-pathologic stage discrepancy in BC patients is remarkably common across the United States. These findings should be considered when selecting patients for preoperative or nonoperative management strategies and when comparing the outcomes of bladder sparing approaches to RC.
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Radiation Oncology Program, Boston, Massachusetts.
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Gray
authors.affiliation: Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia.
authors.forename: Chun Chieh
authors.initials: CC
authors.lastname: Lin
authors.affiliation: Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia.
authors.forename: Ahmedin
authors.initials: A
authors.lastname: Jemal
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: William U
authors.initials: WU
authors.lastname: Shipley
authors.affiliation: Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia.
authors.forename: Stacey A
authors.initials: SA
authors.lastname: Fedewa
authors.affiliation: Division of Urology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts.
authors.forename: Adam S
authors.initials: AS
authors.lastname: Kibel
authors.affiliation: Genitourinary Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York.
authors.forename: Jonathan E
authors.initials: JE
authors.lastname: Rosenberg
authors.affiliation: Division of Surgery, Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Ashish M
authors.initials: AM
authors.lastname: Kamat
authors.affiliation: Department of Health Policy and Management, Emory University, Atlanta, Georgia.
authors.forename: Katherine S
authors.initials: KS
authors.lastname: Virgo
authors.affiliation: Department of Urology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Blute
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Zietman
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts. Electronic address: jefstathiou@partners.org.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Efstathiou
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor; D015653:Cystectomy / Q000379:methods*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging / Q000379:methods*; D011379:Prognosis; D016016:Proportional Hazards Models; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D001749:Urinary Bladder Neoplasms / Q000453:epidemiology / Q000532:radiotherapy* / Q000601:surgery*
chemical_list: D014408:Biomarkers, Tumor