Oncology - Bladder, Renal, Test
Introduction & Objective : Neoadjuvant chemotherapy (NAC) with cisplatin-based regimens followed by radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer (MIBC). However, NAC is used in less than 20% of patients with MIBC. Our goal is to investigate factors that contribute to the current underutilization of cisplatin-based NAC prior to RC and identify areas that can increase its incorporation into clinical practice.
Methods : We identified 5915patients diagnosed with cT2-T3N0M0 MIBC who underwent RC between 2004 and 2014 from the National Cancer Database. 1113 (18.8%) received NAC prior to RC while 4802 (81.2%) were treated with RC alone. We used univariate and multivariable models to predict NAC administration, and estimated 5-year overall survival (OS) between patients treated with NAC vs RC alone.
Results : Overall rate of NAC increased over time, but its use remains low (cT2 36%; cT3 28%). On univariateanalyses, NAC followed by RC was more likely at academic vs community (p < 0.0001) and in the Midwest vs West region (p = 0.002). Also, lower education level education (p = 0.012) and lower median income (p = 0.017) were associated with treatment with RC alone. On multivariate analysis, higher education (HR=1.32, 95% CI: 1.05-1.65) and treatment in the Midwest area (HR=1.34, 95% CI: 1.10-1.63) was independently associated with NAC utilization, while older age (65-74 years old, HR=0.62, 95% CI: 0.38-0.99) and treatment at comprehensive community cancer programs (HR=0.66, 95% CI: 0.52-0.84) were less likely to receive NAC. OS was significantly higher (48.5% vs 42.6%, p < 0.001) in patients treated with NAC followed by RC vs RC alone, consistent with prior level one data.
Conclusions : AlthoughNAC is associated with improved OS for patients with MIBC, we found that utilizing a nationwide population-based database most patients are not treated with NAC prior to radical cystectomy. We found that decreased utilization of NAC was associated with older patient age, lower education level, and regional variations. Our results suggest specific settings for intervention and education to increase use of NAC in patients with MIBC.