title: Neoadjuvant chemotherapy administration and time to cystectomy for muscle-invasive bladder cancer: An evaluation of transitions between academic and community settings.
abstract: OBJECTIVE
  Neoadjuvant chemotherapy (NAC) before radical cystectomy is the standard of care for muscle-invasive bladder cancer (MIBC). Many patients are referred to an academic medical center (AMC) for cystectomy but receive NAC in the community setting. This study examines if administration of NAC in the community is associated with differences in type of NAC received, pathologic response rate (pT0), and time to cystectomy as compared to NAC administered at an AMC.
  
  
  METHODS
  We performed a retrospective study of patients with MIBC (cT2a-T4-Nx-M0) referred to a single AMC between 1/2012 and 1/2014 who received NAC. We analyzed chemotherapy received, time to cystectomy, pT0, and survival in patients who received NAC in our AMC compared to those treated in the community.
  
  
  RESULTS
  In all, 47 patients were analyzed. A similar total dose of cisplatin (median: 280 mg/m(2) for both groups, P = 0.82) and pT0 rate (25% vs. 29%, P = 0.72) were seen in patients treated in our AMC and the community. However, administration of NAC in the community was associated with a prolonged time to cystectomy compared with that in our AMC (median number of days 162 vs. 128, P<0.01). This remained significant after adjusting for stage, comorbidity status, and distance to the AMC (P = 0.02). Disease-free survival and overall survival did not differ.
  
  
  CONCLUSIONS
  Patients with MIBC treated with NAC in the community as compared to an AMC received similar chemotherapy and achieved comparable pT0 rates, indicating effective implementation of NAC in the community. However, NAC in the community was associated with longer time to cystectomy, suggesting a delay in the transition of care between settings.
authors.affiliation: Department of Medicine, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Tracy L
authors.initials: TL
authors.lastname: Rose
authors.affiliation: Biostatistics and Clinical Data Management Core, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Allison M
authors.initials: AM
authors.lastname: Deal
authors.affiliation: Department of Medicine, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Ethan
authors.initials: E
authors.lastname: Basch
authors.affiliation: Department of Medicine, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Godley
authors.affiliation: Department of Medicine, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: W Kimryn
authors.initials: WK
authors.lastname: Rathmell
authors.affiliation: Department of Medicine, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: William Y
authors.initials: WY
authors.lastname: Kim
authors.affiliation: Department of Medicine, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Young E
authors.initials: YE
authors.lastname: Whang
authors.affiliation: Urologic Oncology Program, Department of Urology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Mary W
authors.initials: MW
authors.lastname: Dunn
authors.affiliation: Department of Radiation Oncology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Andrew
authors.initials: A
authors.lastname: Wang
authors.affiliation: Department of Radiation Oncology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Ronald C
authors.initials: RC
authors.lastname: Chen
authors.affiliation: Urologic Oncology Program, Department of Urology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Nielsen
authors.affiliation: Urologic Oncology Program, Department of Urology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Raj S
authors.initials: RS
authors.lastname: Pruthi
authors.affiliation: Urologic Oncology Program, Department of Urology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Wallen
authors.affiliation: Urologic Oncology Program, Department of Urology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Woods
authors.affiliation: Urologic Oncology Program, Department of Urology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
authors.forename: Angela B
authors.initials: AB
authors.lastname: Smith
authors.affiliation: Department of Medicine, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC. Electronic address: matt_milowsky@med.unc.edu.
authors.forename: Matthew I
authors.initials: MI
authors.lastname: Milowsky
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000008:administration & dosage*; D002295:Carcinoma, Transitional Cell / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D003154:Community Medicine; D015653:Cystectomy; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D010360:Patient Transfer; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*
chemical_list: D000970:Antineoplastic Agents
keywords: Cystectomy; Neoadjuvant therapy; Quality indicators; Time factors; Urinary bladder neoplasms