title: Increased Use of Cystectomy in Patients 75 and Older: A Contemporary Analysis of Survival and Perioperative Outcomes From the National Cancer Database.
abstract: OBJECTIVE
  To assess national utilization patterns for cystectomy and nonsurgical treatments for elderly patients with muscle-invasive bladder cancer.
  
  
  METHODS
  From the National Cancer Database, we identified patients ≥75 years old with T2-T4, non-metastatic urothelial carcinoma between 2003 and 2012. Patients were grouped by treatment: cystectomy, chemoradiation, or nonstandard treatment. Cochran-Armitage trend test was used to evaluate time trends for treatments and perioperative outcomes. Kaplan-Meier and Cox regression tests were used for overall survival analyses.
  
  
  RESULTS
  Of 18,945 patients with muscle-invasive bladder cancer, 3898 (21%) underwent cystectomy. Cystectomy use increased from 14% in 2003 to 24% in 2012 (P <.01 for overall trend). Inpatient length of stay after cystectomy decreased over time (P = .02), whereas 30-day readmission and mortality rates remained stable (P = .86 and P = .73, respectively). Median overall survival (95% confidence interval [CI]) was 26.5 (23.1-28.9) months for cystectomy, 22.1 (20.1-24.2) months for chemoradiation, and 12.0 (11.3-12.7) months for nonstandard treatment (P <.01). The survival benefit of cystectomy compared with nonstandard treatment was seen regardless of comorbidity burden. In the Cox analysis, the hazard of death was 0.69 (95% CI 0.63-0.75, P <.01) for cystectomy and 0.75 (95% CI 0.70-0.82, P <.01) for chemoradiation, compared with nonstandard treatment.
  
  
  CONCLUSIONS
  Cystectomy use is increasing in elderly patients, with stable or improved perioperative outcomes and improved survival compared with nonstandard treatment. These findings support continued use of cystectomy in appropriately selected elderly patients.
authors.affiliation: Urology Institute, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Bream
authors.affiliation: Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Maurice
authors.affiliation: Urology Institute, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH.
authors.forename: Joshua
authors.initials: J
authors.lastname: Altschuler
authors.affiliation: Louis Stokes Veterans Affairs Medical Center, Cleveland, OH.
authors.forename: Hui
authors.initials: H
authors.lastname: Zhu
authors.affiliation: Urology Institute, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH. Electronic address: robert.abouassaly@uhhospitals.org.
authors.forename: Robert
authors.initials: R
authors.lastname: Abouassaly
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000401:mortality* / Q000601:surgery*; D015653:Cystectomy / Q000706:statistics & numerical data*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D009361:Neoplasm Invasiveness; D018579:Patient Selection; D016019:Survival Analysis; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States; D001749:Urinary Bladder Neoplasms / Q000401:mortality* / Q000601:surgery*