Delays in radical cystectomy for muscle‐invasive bladder cancer

• Published in: Cancer Vol. 125; no. 12; pp. 2011 - 2017
• Main Authors: Chu, Alice T., Holt, Sarah K., Wright, Jonathan L., Ramos, Jorge D., Grivas, Petros, Yu, Evan Y., Gore, John L.
• Format: Journal Article
• Language: English
• Published: United States Wiley Subscription Services, Inc 15.06.2019
• Subjects: Aged; Bladder; Bladder cancer; Cancer; Chemotherapy; Confidence intervals; cystectomy; Cystectomy - mortality; Diagnosis; Epidemiology; Female; Follow-Up Studies; Government programs; Health care; Health risk assessment; Humans; Invasiveness; Male; Methyl isobutyl carbinol; Mortality; Muscle Neoplasms - mortality; Muscle Neoplasms - pathology; Muscle Neoplasms - surgery; Muscles; neoadjuvant therapy; Neoplasm Invasiveness; Oncology; Patients; Poverty; Prognosis; quality of health care; Regression analysis; Regression models; Retrospective Studies; Statistical analysis; Statistical models; Surgery; Survival; Survival Rate; Time-to-Treatment - statistics & numerical data; transitional carcinoma; urinary bladder neoplasms; Urinary Bladder Neoplasms - mortality; Urinary Bladder Neoplasms - pathology; Urinary Bladder Neoplasms - surgery; Urothelial cancer; Urothelial carcinoma; cystectomy; urinary bladder neoplasms; quality of health care; transitional carcinoma; neoadjuvant therapy
• ISSN: 0008-543X; 1097-0142; 1097-0142
• DOI: 10.1002/cncr.32048

Background Delays from the diagnosis of muscle‐invasive bladder cancer (MIBC) to radical cystectomy (RC) longer than 12 weeks result in higher mortality and shorter progression‐free survival. This study sought to identify factors associated with RC delays and to determine whether delays in care in the current treatment paradigm, which includes neoadjuvant chemotherapy (NAC), affect survival. Methods Subjects with American Joint Committee on Cancer stage II urothelial carcinoma of the bladder who underwent RC from 2004 to 2012 were identified from the linked Surveillance, Epidemiology, and End Results national cancer registry and the Medicare claims database and were stratified into RC groups with or without NAC. Cox multivariable proportional hazard models and multivariable logistic regression models assessed the significance of delays in RC for survival and identified independent characteristics associated with RC delays, respectively. Results This study identified 1509 patients with MIBC who underwent RC during the study period. In comparison with timely surgery, delays in RC increased overall mortality, regardless of the use of NAC (hazard ratio [HR] without NAC, 1.34; 95% confidence interval [CI], 1.03‐1.76; HR after NAC, 1.63; 95% CI, 1.06‐2.52). Patients proceeding to RC without NAC had higher odds of delayed care if they lived in a high‐poverty neighborhood (odds ratio [OR], 1.37; 95% CI, 1.01‐2.08) or nonmetropolitan area (OR, 1.61; 95% CI, 1.01‐2.55), were men (OR, 2.22; 95% CI, 1.25‐4.00), or required a provider transfer for bladder cancer care (OR, 1.82; 95% CI, 1.10‐3.03). Conclusions Delays in care from the time of either the initial diagnosis or the completion of NAC to RC are associated with worse overall survival among patients with MIBC. Timely surgery is fundamental in the treatment of MIBC, and this necessitates attention to disparities in access to complex surgical care and care coordination. Delays from either the initial diagnosis or the completion of neoadjuvant chemotherapy to definitive local treatment with radical cystectomy are associated with decreased survival among patients with muscle‐invasive bladder cancer. Timely surgery is a fundamental part of treatment, and this necessitates attention to disparities in access to complex surgical care.