Real-World Effectiveness of Chemotherapy in Elderly Patients With Metastatic Bladder Cancer in the United States

Abstract

Background: Outcomes for patients with metastatic bladder cancer (mBC) are generally poor and progressively worse following first-line (1L) chemotherapy.

Objective: To evaluate treatment patterns, survival outcomes, and characteristics of a large, real-world US population of elderly patients with advanced mBC receiving 1L and second-line (2L) treatment retrospectively.

Methods: We identified patients with advanced mBC (aged ≥66 years)-newly diagnosed between January 1, 2004, and December 31, 2011-in the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program-Medicare linked database and assessed their palliative systemic chemotherapy treatments and survival outcomes.

Results: Of 1703 eligible patients, 42% received 1L chemotherapy; 1L-treated patients tended to be younger and healthier than nontreated patients. Only 27% of 1L-treated patients received cisplatin-based chemotherapy, most commonly cisplatin-gemcitabine. Cisplatin-treated patients were younger and had fewer comorbidities than non-cisplatin-treated patients. Thirty-five percent of 1L-treated patients subsequently received 2L chemotherapy. Patients received a variety of 2L agents as combination chemotherapy (52%) or single-agent chemotherapy (39%). Median overall survival durations in 1L-treated and 2L-treated patients were 8.5 and 7.9 months, respectively.

Conclusions: Results from this retrospective SEER-Medicare database analysis underscore the historical inadequacies of 1L and 2L treatments in elderly patients with advanced mBC. Few patients were treated with 1L chemotherapy, a minority of whom received 1L cisplatin-based chemotherapy, and even fewer received 2L chemotherapy. These findings highlight the disconnect between 1L treatment in clinical trials and treatment in the real-world setting and the lack of standard approaches to 2L treatment in the United States.

Keywords: Aged; delivery of health care; drug therapy; urinary bladder neoplasms.

Fig.1

Treatment patterns in patients with metastatic bladder cancer. (A) 1L systemic chemotherapy regimens used. ^aIncludes 60 patients who had evidence of systematic chemotherapy, but the agent was not specified. (B) Flow from 1L to 2L treatment. ^bPatients with “Unknown” 2L treatments may include those who died before 2L treatment, who refused treatment or had no need for 2L treatment, or who were still being treated with 1L treatment. (C) 2L systemic chemotherapy regimens used. ^cIncludes 23 patients who had evidence of systematic chemotherapy, but the agent was not specified. 1L, first line; 2L, second line; Cis, cisplatin; Tax, taxane.

Fig.2

Kaplan-Meier plots of overall survival in patients with metastatic bladder cancer. (A) Any 1L treatment and no 1L treatment. Survival was measured from the index date. (B) 1L cisplatin-based and non-cisplatin–based treatments. Survival was measured from the start of 1L treatment. (C) 1L treatment with combination agents and with single agents. Survival was measured from the start of 1L treatment. (D) 2L single-agent treatment: non-taxane and taxane based. Survival was measured from the start of 2L treatment. (E) 2L combination treatment: non-taxane and taxane based. Survival was measured from the start of 2L treatment. 1L, first line; 2L, second line. **Includes <11 patients.