Early Mortality in Patients With Muscle-Invasive Bladder Cancer Undergoing Cystectomy in the United States

Abstract

Background: Although radical cystectomy (RC) is a standard treatment for muscle-invasive bladder cancer (MIBC), for many patients the risks versus benefits of RC may favor other approaches. We sought to define the landscape of early postcystectomy mortality in the United States and identify patients at high risk using pretreatment variables.

Methods: We identified patients with MIBC (cT2-T4aN0M0) who underwent RC without perioperative chemotherapy within the National Cancer Database (2003-2012). Using multistate multivariable modeling, we calculated time spent in three health states: hospitalized, discharged, and death more than 90 days postcystectomy. Cross-validation was performed by geographic region. Time spent in each state was weighted by utility to determine 90-day quality-adjusted life days (QALDs).

Results: Among 7922 patients, 90-day mortality was 7.6% (8.0% for lower and 6.7% for higher volume hospitals). Increasing age, clinical T stage, Charlson Comorbidity Index, and lower volume were associated with higher 90-day mortality and were included in the model. Cross-validation revealed appropriate performance (C-statistics of 0.53-0.74; calibration slopes of 0.50-1.67). The model predicted 25% of patients had a 90-day mortality risk higher than 10%, and observed 90-day mortality in this group was 14.0% (95% CI = 12.5% to 15.6%). Mean quality-adjusted life days (QALDs) was 63 (range = 44-68).

Conclusions: RC is associated with relatively high early mortality risk. Pretreatment variables may identify patients at particularly high risk, which may inform clinical trial design, facilitate shared decision making, and enhance quality improvement initiatives.

Figure 1.

Selection of study population with reasons for patient exclusions. NCDB = National Cancer Database; TCC = transitional cell carcinoma.

Figure 2.

State-transition diagram of the multistate model. Each bubble represents a possible state, with arrows representing possible transitions (A = discharge; B = inpatient death; C = postdischarge death) with each 1-day cycle. All patients started in the hospitalized state, with death being a terminal state.

Figure 3.

Proportion of cystectomies by volume category over time. The graph depicts the proportion of patients who underwent cystectomy in each of the volume categories separated by year of diagnosis. Volume categories were determined by the number of cystectomies performed by the institution in the year preceding the patient’s year of diagnosis.

Figure 4.

Proportional area diagram of predicted 90-day risk of mortality. The area of each circle is proportional to the number of patients in each labeled risk category (predicted 90-day mortality >5%, >10%, or >15%). The largest circle represents all patients in the study population.

Figure 5.

State-transition model-based predictions using individual patient risk profiles as examples: A) Patient with most common values: 69-year-old Caucasian male with clinical T (cT) stage 2 disease; Charlson/Deyo Comorbidity Index (CCI) = 0; cystectomy volume category = intermediate (5–14 cases per year). B) 60-year-old Caucasian male with cT2 disease; CCI = 0; cystectomy volume category = high (≥15 cases per year). C) 80-year-old Caucasian female with cT3 disease; CCI = 1; volume category = low (<5 cases per year). CCI = Charlson/Deyo Comorbidity Index; cT = clinical T stage; QALDs = quality-adjusted life days.