No abstract

Our study assessed whether rising age, socioeconomic status (SES) and the presence of serious comorbidity affected treatment choice and survival in a population-based series of patients with muscle-invasive bladder cancer (MIBC) in The Netherlands. Therefore, a consecutive series was studied, including all patients diagnosed with MIBC between 1995 and 2009 in the Eindhoven Cancer Registry, preceding centralization of cystectomy. The independent effects of age, SES and serious comorbidity on therapy choice and their effects on overall survival were estimated by multivariate logistic regression and multivariate Cox proportional hazard analyses, respectively. Out of the 2,445 patients, 38% were aged 75 years at diagnosis and 63% had at least one serious comorbid condition. Higher age and serious comorbidity were independent predictors for abstaining from cystectomy, where SES was not (61-74 vs. 60: odds ratio [OR], 0.8; 95% confidence interval [CI], 0.6-1.0; 75 vs.60: OR, 0.1; 95% CI,0.1-0.2; one comorbid condition vs. none: OR, 0.7; 95% CI, 0.5-0.9; two vs. none: OR, 0.6; 95% CI, 0.5-0.8). Patients undergoing cystectomy, external beam radiotherapy or interstitial radiotherapy survived longer independent of age, SES and serious comorbidity (hazard ratio [HR]: 0.4; 95% CI: 0.4-0.5; HR: 0.8; 95% CI: 0.7-0.9; HR: 0.4; 95% CI: 0.3-0.5, respectively). Consequently, preceding centralization of cystectomy, higher age and serious comorbidity were independent predictors for abstaining from cystectomy owing to an expected high rate of short-term medical problems. As cystectomy is associated with a better survival, independently of age, SES and serious comorbidity, it can be questioned whether cystectomy has been underutilised in elderly and in patients with serious comorbidity. Centralization might be a solution for this suggested underutilisation.In the Netherlands, patients aged 65 years represent more than 80% of all cases of mortality. 1 In 2008, the most important cause of death was cancer, which accounted for 30% of all deaths. As expected, the prevalence of registered comorbidity in newly diagnosed cancer patients increased with age: 48% for patients aged 50-64 years and up to 80% for those 80 years. 2 In the Netherlands, bladder cancer was the seventh most common cancer in 2010 (www.cijfersoverkanker. nl) and has a peak incidence in the seventh decade of life. 3

Treatment policies for muscle-invasive bladder cancer in the Netherlands showed regional preferences and a gradual increase of cystectomy. Cystectomy albeit considered as golden standard, was performed in a minority of the muscle-invasive cases. In high-volume institutions, lymph node dissection rates were higher and post-operative mortality rates were lower.

What ' s known on the subject? and What does the study add?The subject of mortality and survival rates after radical cystectomies in high-volume hospitals in comparison to low-volume hospitals has been extensively studied. Postoperative mortality is known to be signifi cantly lower with high-volume providers, but for survival rates there was only a trend forwards this fi nding. For this reason, we performed this Dutch population-based study on survival rates, to see if we had enough power to support this trend with signifi cant fi ndings. To our knowledge, this is the fi rst study of good quality showing a signifi cant benefi cial effect for survival in high-volume hospitals.