Trends and disparities in the use of neoadjuvant chemotherapy for muscle-invasive urothelial carcinoma

Abstract

Introduction: Neoadjuvant chemotherapy (NAC) prior to radical or partial cystectomy is considered the standard of care for eligible patients with muscle-invasive urothelial carcinoma. Despite guideline recommendations, adoption of NAC has historically been low, although prior studies have suggested that use is increasing. In this contemporary study, we examine trends in the use of NAC and explore factors associated with its receipt. Methods: We identified patients in the National Cancer Database who underwent radical or partial cystectomy for cT2-cT4N0M0 urothelial carcinoma from 2006-2014. The proportion of patients receiving NAC during each year was examined. Logistic regression models were used to evaluate clinical and socioeconomic factors associated with the receipt of NAC. Results: A total of 18 188 patients were identified who underwent radical or partial cystectomy for muscle-invasive bladder cancer. Overall, 3940 (21.7%) received NAC. We noted a significant increase in the use of NAC over time, from 9.7% in 2006 to 32.2% in 2014. Factors associated with lower use of NAC include older age, higher comorbidity score, lower cT stage, lower hospital radical cystectomy volume, treatment at a non-academic facility, lower patient income, and receipt of partial cystectomy (all p<0.001). Interestingly, neither sex nor race were associated with receipt of NAC. Conclusions: Use of NAC has increased significantly over time to a modest rate of 32%. However, disparities still exist in the receipt of NAC and future efforts aimed at mitigating these disparities are warranted.

Short‐ and long‐term survival has improved after radical cystectomy for bladder cancer in Québec during the years 2000‐2015

“…28 Indeed, a recently published manuscript found that neoadjuvant chemotherapy is used more frequently in patients with a higher clinical T-stage. 29 benefit would be several millions of dollars per year. However, we did observe a slightly higher readmission rate, which can offset the potential benefit of shorter stays.…”

“…Potentially, the introduction of neoadjuvant chemotherapy also resulted in patients with more advanced disease undergoing RC, reducing the survival benefit due to selection bias . Indeed, a recently published manuscript found that neoadjuvant chemotherapy is used more frequently in patients with a higher clinical T‐stage . It is possible that other variables than the ones analyzed may have contributed in part to the improved BC outcome as well.…”

Contemporary best practice in the use of neoadjuvant chemotherapy in muscle-invasive bladder cancer

“…Hopefully, many studies have reported an improvement in the use of NAC, and the low uptake worldwide seems to decrease over time but still remains too low. 39–44 The results of the last meta-analysis published confirmed the superiority of NAC and showed an 8% absolute improvement in survival at 5 years with a number needed to treat of 12.5. 45…”

Review of SWOG S1314: Lessons from a Randomized Phase II Study of Co-Expression Extrapolation (COXEN) with Neoadjuvant Chemotherapy for Localized, Muscle-Invasive Bladder Cancer

“…A notable aspect of contemporary and historical treatment of MIBC is the underutilization of neo-adjuvant chemotherapy [8][9][10]. This underutilization exists despite the support of two randomized, phase III clinical trials.…”