title: Delivery of perioperative chemotherapy for bladder cancer in routine clinical practice.
abstract: BACKGROUND
  Few articles have documented regimens and timing of perioperative chemotherapy for bladder cancer in routine practice. Here, we describe practice patterns in the general population of Ontario, Canada.
  
  
  METHODS
  In this retrospective cohort study, treatment and physician billing records were linked to the Ontario Cancer Registry to describe use of neoadjuvant (NACT) and adjuvant (ACT) chemotherapy among all patients with muscle-invasive bladder cancer treated with cystectomy in Ontario 1994-2008. Time to initiation of ACT (TTAC) was measured from cystectomy. Multivariate Cox regression was used to identify factors associated with overall (OS) and cancer-specific survival (CSS).
  
  
  RESULTS
  Of 2944 patients undergoing cystectomy, 4% (129/2944) and 19% (571/2944) were treated with NACT and ACT, respectively. Five-year OS was 25% [95% confidence interval (CI) 17% to 34%] for NACT, 29% (95% CI 25% to 33%) for ACT cases. Among patients with identifiable drug regimens, cisplatin was used in 82% (253/308) and carboplatin in 14% (43/308). The most common regimens were gemcitabine-cisplatin (54%, 166/308) and methotrexate, vinblastine, doxorubicin, cisplatin (MVAC) (21%, 66/308). Mean TTAC was 10 weeks; 23% of patients had TTAC >12 weeks. TTAC >12 weeks was associated with inferior OS [hazard ratio (HR) 1.28, 95% CI 1.00-1.62] and CSS (HR 1.30, 95% CI 1.00-1.69). In adjusted analyses, OS and CSS were lower among patients treated with carboplatin compared with those treated with cisplatin; OS HR 2.14 (95% CI 1.40-3.29) and CSS HR 2.06 (95% CI 1.26-3.37).
  
  
  CONCLUSIONS
  Most patients in the general population receive cisplatin, and this may be associated with superior outcomes to carboplatin. Initiation of ACT beyond 12 weeks is associated with inferior survival. Patients should start ACT as soon as they are medically fit to do so.
authors.affiliation: Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston; Department of Oncology; Department of Public Health Sciences. Electronic address: boothc@kgh.kari.net.
authors.forename: C M
authors.initials: CM
authors.lastname: Booth
authors.affiliation: Department of Oncology; Department of Urology, Queen's University, Kingston.
authors.forename: D R
authors.initials: DR
authors.lastname: Siemens
authors.affiliation: Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston; Department of Public Health Sciences.
authors.forename: Y
authors.initials: Y
authors.lastname: Peng
authors.affiliation: Princess Margaret Cancer Centre, Toronto, Canada.
authors.forename: I F
authors.initials: IF
authors.lastname: Tannock
authors.affiliation: Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston; Department of Oncology; Department of Public Health Sciences.
authors.forename: W J
authors.initials: WJ
authors.lastname: Mackillop
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D002170:Canada; D016190:Carboplatin / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant; D002945:Cisplatin / Q000627:therapeutic use; D015331:Cohort Studies; D015653:Cystectomy; D003841:Deoxycytidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D004317:Doxorubicin / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008297:Male; D008727:Methotrexate / Q000627:therapeutic use; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D012189:Retrospective Studies; D016896:Treatment Outcome; D001743:Urinary Bladder / Q000473:pathology / Q000601:surgery; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy* / Q000601:surgery*; D014747:Vinblastine / Q000627:therapeutic use; D055815:Young Adult; D000093542:Gemcitabine
chemical_list: D003841:Deoxycytidine; D014747:Vinblastine; D004317:Doxorubicin; D016190:Carboplatin; D002945:Cisplatin; D008727:Methotrexate; D000093542:Gemcitabine
keywords: bladder cancer; chemotherapy; outcomes; quality of care; surgery