Underutilization of Radical Cystectomy Among Patients Diagnosed with Clinical Stage T2 Muscle-invasive Bladder Cancer

Abstract

Background: Radical cystectomy is the standard surgical treatment for muscle-invasive bladder cancer (MIBC).

Objective: We sought to identify population-based factors predicting the use of radical cystectomy.

Design, setting, and patients: Analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data for 3922 patients aged ≥66 yr diagnosed with clinical stage T2 MIBC from January 1, 2002 to December 31, 2011.

Outcome measurements and statistical analysis: We used univariate and multivariable regression analyses to identify factors predicting the use of radical cystectomy. Cox proportional hazards models were used to analyze survival outcomes.

Results and limitations: A total of 740 (18.9%) patients with MIBC underwent radical cystectomy. Older age at diagnosis (>80 vs 65-69 yr, odds ratio [OR] 0.15, 95% confidence interval [CI] 0.11-0.19; p<0.001) and higher comorbidity (Charlson comorbidity index 3+ vs 0, OR 0.41, 95% CI 0.29-0.57; p<0.001) were associated with lower use of radical cystectomy. Moreover, non-Hispanic black patients were less likely than white patients to undergo radical cystectomy (OR 0.62, 95% CI 0.40-0.96; p=0.032) and pelvic lymph node dissection (OR 0.65, 95% CI 0.42-1.02; p=0.058). Overall survival was better for patients who underwent radical cystectomy alone (hazard ratio [HR] 0.70, 95% CI 0.56-0.88; p=0.002) and with lymph node dissection (HR 0.45, 95% CI 0.40-0.51; p<0.001). Limitations include the limited ability of retrospective analysis to demonstrate causality.

Conclusions: There is significant underutilization of radical cystectomy among patients diagnosed with MIBC, especially among older patients with significant comorbidities and non-Hispanic black patients.

Patient summary: Despite guideline recommendations, there is significant underutilization of radical cystectomy among patients diagnosed with bladder cancer, especially for non-Hispanic black patients and older patients with significant comorbidities.

Keywords: Bladder cancer; Disparities; Radical cystectomy; Utilization.