Discerning Patterns and Quality of Neoadjuvant Chemotherapy Use Among Patients with Muscle-invasive Bladder Cancer

It is well known that there is a significantly decreased use of neoadjuvant chemotherapy in patients who undergo radical cystectomy for bladder cancer. However, there remains a paucity of data in regards to the quality of chemotherapy administered in large population-based analyses. We sought to determine utilization treatment patterns and survival outcomes according to regimens administered. Using the Surveillance, Epidemiology and End Results (SEER)-Medicare linked the database to identify patients diagnosed with clinical stage TII-IV bladder cancer from 2001 to 2011, we assessed trends in use and multivariable logistic regression models to determine predictors for use. Cox proportional hazards models were used to compare overall survival according to regimens administered.

We found only 344 (12.6%) radical cystectomy patients received neoadjuvant chemotherapy. The agents most commonly used were gemcitabine (72.3%), cisplatin (55.2%), and carboplatin (31.1%). The regimens most commonly used were gemcitabine-cisplatin (45.3%), gemcitabine-carboplatin (24.1%), and methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC; 6.7%). Use of neoadjuvant chemotherapy more than tripled during the study period, from 5.7% in 2001 to 17.3% in 2011 (p<0.001). 6.7%). Importantly, there was no significant difference in NAC use or type according to chronic renal disease status.

The quality of the regimen administered impacted survival outcomes, as M-VAC use was significantly associated with better overall survival among patients diagnosed with stage II bladder cancer (hazard ratio 0.24, 95% confidence interval 0.07-0.86; p=0.030]. However, as noted above, M-MVAC was the least commonly used regimen observed in only 6.7% of patients.

In conclusion, we observed significant underuse of neoadjuvant chemotherapy. We also noted significant quality concerns as <50% of patients who received chemotherapy were cisplatin-based and <1% of all patients who underwent radical cystectomy received M-VAC. The findings are not important regarding data interpretation specially in large population-based studies, but highlight the need for targeted interventions to improve the use and quality of chemotherapy use in bladder cancer patients.

Written by: Stephen B. Williams, MD, Medical Director for High Value Care; Chief of Urology, Associate Professor, Director of Urologic Oncology, Director Urologic Research, The University of Texas Medical Branch at Galveston, TX

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