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Meta-Analysis
. 2024;20(16):1123-1137.
doi: 10.2217/fon-2023-0298. Epub 2023 Aug 1.

Undertreatment in patients with advanced urothelial cancer: systematic literature review and meta-analysis

Mairead Kearney  1 , Liu Zhang  2 , Elizabeth Hubscher  2 , Mihaela Musat  2 , Sharada Harricharan  2 , Thomas Wilke  2   3
Affiliations
Meta-Analysis

Undertreatment in patients with advanced urothelial cancer: systematic literature review and meta-analysis

Mairead Kearney et al. Future Oncol. 2024.

Abstract

Aim: To assess rates of no systemic treatment (NST), attrition across lines of therapy, and factors influencing treatment selection in patients with locally advanced or metastatic urothelial cancer (la/mUC). Methods: Systematic literature review to identify real-world studies reporting NST or attrition rates in la/mUC from 2017-2022 (including data reported since 2015). Results: Of 2439 publications screened, 29 reported NST rates, ranging from 40-74% in eight European-based studies, 14-60% in 12 US-based studies, and 9-63% in nine studies in other locations (meta-analysis estimate, 39%). Factors associated with NST or no second-line therapy included older age, female sex, poor performance status, poor renal function and distant metastases. Conclusion: A substantial proportion of patients with la/mUC do not receive guideline-recommended treatment.

Keywords: attrition; best supportive care; chemotherapy; immunotherapy; palliative therapy; platinum-based chemotherapy; systemic therapy; treatment decisions; urothelial cancer.

Plain language summary

A review of how patients with bladder cancer are treated or not treated with anti-cancer drugsPeople with advanced bladder cancer have a short survival. Bladder cancer is called advanced when it has spread outside of the urinary tract. Several drug treatments are available for people with advanced bladder cancer. However, sometimes people do not receive any drug treatment. We looked at published studies to see how many people with advanced bladder cancer did not receive any drug treatment and the reasons why. We also looked at how long people lived with or without drug treatment. We found that many people with advanced bladder cancer did not receive drug treatment. The number of people who received no drug treatment varied in studies from different countries. People who were older, were female, had poor health or kidney problems, or had cancer that had spread to other parts of the body were less likely to receive drug treatment. People who did not receive drug treatment lived for an average of 2 to 7 months, compared with 9 to 35 months for people who received drug treatment. More studies are needed to investigate the reasons why drug treatment is sometimes not used in people with advanced bladder cancer who could receive treatment, so that more people can benefit from available treatments.

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Conflict of interest statement

This study was sponsored by Merck (CrossRef Funder ID: 10.13039/100009945), and was previously conducted under an alliance between Merck and Pfizer. M Kearney is an employee of Merck. L Zhang, E Hubscher, M Musat, S Harricharan, and T Wilke are employees of Cytel, Inc, which served as a consultant on the project. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Editorial support was provided by Katherine Quiroz-Figueroa of Clinical Thinking and was funded by Merck and Pfizer.

Figures

Figure 1.
Figure 1.
PRISMA diagram. *Includes duplicates with title and abstract review. †Includes duplicates between title and abstract review and manually added records from congress search* and bibliographic search.* ‡Records were not extracted unless they fulfilled the additional criteria for data extraction: 1. Reported NST rates, attrition rates, reasons for NST, or reasons for attrition. 2. Specification of the period when data were acquired. NST: No systemic treatment
Figure 2.
Figure 2.
Pooling and meta-analysis of no systemic treatment rates. NST: No systemic treatment.
Figure 3.
Figure 3.
Rates of NST by geography and time. (A) NST rates by geography. Circle size is relative to reported NST rate. (B) NST rates by relative temporal score. Circle size reflects the population size. Circles with a red outline come from the same study [12]. 1L: First line; BSC: Best supportive care; la/mUC: Metastatic urothelial cancer; NST: No systemic treatment.
Figure 4.
Figure 4.
Overall survival with no systemic treatment or systemic treatment. 1L: First line; aUC: Advanced urothelial cancer; BSC: Best supportive care; IO: Immunotherapy; mBC: Metastatic bladder cancer; mUTUC: Metastatic upper urinary tract urothelial cancer; NE: Not evaluable; NR: Not reported; NST: No systemic treatment; OS: Overall survival; SEER: Surveillance Epidemiology and End Results Program; ST: Systemic treatment; w/: With; w/o: Without.
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