title: Treatment and survival in patients with recurrent high-risk non-muscle-invasive bladder cancer.
abstract: BACKGROUND
  Multiple recurrences develop in patients with high-risk non-muscle-invasive bladder cancer. As neither the association of recurrences with survival nor the subsequent aggressive treatment in individuals with recurrent high-grade non-muscle-invasive bladder cancer has ever been quantified, we sought to determine whether the increasing number of recurrences is associated with higher subsequent treatment and mortality rates.
  
  
  METHODS
  Using linked Surveillance, Epidemiology, and End Results-Medicare data, we identified subjects with recurrent high-grade, non-muscle-invasive disease diagnosed in 1992 to 2002 and followed up until 2007. Using competing-risks regression analyses, we quantified the incidence of radical cystectomy, radiotherapy, and systemic chemotherapy after each recurrence. We then performed a propensity-score adjusted competing-risks regression analysis to determine whether the increasing recurrences portend worse survival.
  
  
  RESULTS
  Of 4,521 subjects, 2,694 (59.6%) had multiple recurrences within 2 years of diagnosis. Compared with patients who only had 1 recurrence, those with ≥ 4 recurrences were less likely to undergo radical cystectomy (hazard ratio [HR] = 0.73, 95% CI: 0.58-0.92), yet more likely to undergo radiotherapy (HR = 1.51, 95% CI: 1.23-1.85) and systemic chemotherapy (HR = 1.58, 95% CI: 1.15-2.18). For patients with ≥ 4 recurrences, only 25% were treated with curative intent. The 10-year cancer-specific mortality rates were 6.9%, 9.7%, 13.7%, and 15.7% for those with 1, 2, 3, and ≥ 4 recurrences, respectively.
  
  
  CONCLUSIONS
  Only 25% of patients with high-risk non-muscle-invasive bladder cancer who experienced recurrences at least 4 times underwent radical cystectomy or radiotherapy. Despite portending worse outcomes, increasing recurrences do not necessarily translate into higher treatment rates.
authors.affiliation: Health Services Research Group, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA. Electronic address: kchamie@mednet.ucla.edu.
authors.forename: Karim
authors.initials: K
authors.lastname: Chamie
authors.affiliation: Health Services Research Group, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA.
authors.forename: Eric
authors.initials: E
authors.lastname: Ballon-Landa
authors.affiliation: Health Services Research Group, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Daskivich
authors.affiliation: Health Services Research Group, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
authors.forename: Jeffrey C
authors.initials: JC
authors.lastname: Bassett
authors.affiliation: RAND Corporation, Santa Monica, CA.
authors.forename: Julie
authors.initials: J
authors.lastname: Lai
authors.affiliation: RAND Corporation, Santa Monica, CA.
authors.forename: Jan M
authors.initials: JM
authors.lastname: Hanley
authors.affiliation: Department of Urology, University of Minnesota, Minneapolis, MN.
authors.forename: Badrinath R
authors.initials: BR
authors.lastname: Konety
authors.affiliation: Health Services Research Group, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; RAND Corporation, Santa Monica, CA; Department of Health Services, University of California Los Angeles, School of Public Health, Los Angeles, CA.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Litwin
authors.affiliation: Health Services Research Group, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; RAND Corporation, Santa Monica, CA.
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Saigal
mesh_terms: D000368:Aged; D015331:Cohort Studies; D018450:Disease Progression; D005260:Female; D006801:Humans; D008297:Male; D009364:Neoplasm Recurrence, Local / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D012307:Risk Factors; D018426:SEER Program; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology; D001749:Urinary Bladder Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy*
keywords: Bladder cancer mortality; Progression; Quality of healthcare; Recurrence; Urinary bladder neoplasms