AUA 2018: Racial Disparities in Quality of Care and Overall Survival among Muscle-Invasive Bladder Cancer Patients treated with Radical Cystectomy

San Francisco, CA (UroToday.com)  Across the oncologic spectrum, patients of African-American (AA) race generally have inferior short and long-term outcomes compared to Caucasian patients. Specific to bladder cancer, previous studies have demonstrated that AA patients are more likely to present with metastatic bladder cancer [1]. Despite socioeconomic differences and presentation at advanced disease stages, these disparities may be due to lower utilization of radical cystectomy among AA patients [2]. However, studies assessing survival disparities explicitly in patients undergoing radical cystectomy for muscle invasive bladder cancer (MIBC) are limited. As such, Dr. Gild and colleagues at the invasive bladder cancer session at the 2018 AUA discussed findings of their population-based analysis examining the impact of race on quality of care and overall survival (OS) among patients with MIBC treated with radical cystectomy. 

For this study, the authors used the National Cancer Database (NCDB) from 2004 to 2012 to identify 12,652 patients who received a radical cystectomy for MIBC. Patients were stratified by race (AA vs. Caucasian), and imbalances in patient characteristics mitigated using propensity score weighting. Logistic and Cox regression models were used to examine the impact of race on quality of care metrics, which included:  

  • Receipt of pelvic lymph node dissection (PLND) 
  • Lymph node count 
  • Hospital volume 
  • Length of stay 
  • Delay of treatment  
  • Overall survival  
The difference in OS was expressed as Delta, and stratified by facility-type, hospital volume, and region. 
The authors found that AA patients were less likely to receive PLND (OR 0.70, 95%CI 0.55-0.91), or have a high number of lymph nodes removed (OR 0.76, 95%CI 0.64-0.90). AA patients also had a longer length of stay (OR 1.34, 95%CI 1.13-1.59), and delay of RC among recipients of neoadjuvant chemotherapy (OR 2.59, 95%CI 1.77-3.85). Furthermore, AA race was associated with inferior OS (HR 0.87, 95%CI 0.79-0.97). Disparities in OS varied based on facility type and geographical region, but not hospital volume. Specifically, AA patients had worse OS when treated in a community cancer program (Delta 0.42, 95%CI 0.28-0.57), or within New England/Middle Atlantic region (Delta 0.16, 95%CI 0.07-0.24). 

The strengths of this study include the population-level analysis to generate a large enough sample size allowing appropriate analysis for providing meaningful conclusions. Furthermore, this approach allows important geographical and facility level analyses to be performed. Limitations include the NCDB’s lack of disease-specific survival outcomes, and inability to assess the specific reasons for the underlying poor outcomes among AA patients. One can surmise, as has been suggested in many previous studies, that AA patients have less access to care (timely referral, treatment at tertiary centers of excellence, etc), appropriate insurance, etc. As a medical community, it is our responsibility to work as a team with our social workers, case managers, nurse navigators, etc to improve outcomes in these patients to the level of all patients with MIBC.  

Presented By: Philipp Gild, University Medical Center Hamburg-Eppendorf, Hamburg, Germany 
Co-Authors: Stephanie A. Wankowicz, Boston, MA, Akshay Sood, Detroit, MI, Nicolas von Landenberg, Herne, Germany, David F. Friedlander, Boston, MA, Shaheen Alanee, Detroit, MI, Felix K.H. Chun, Frankfurt, Germany, Margit Fisch, Hamburg, Germany, Mani Menon, Detroit, MI, Quoc-Dien Trinh, Joaquim Bellmunt, Boston, MA, Firas Abdollah, Detroit, MI  

References: 
1. Klaassen Z, DiBianco JM, Jen RP, et al. Female, black and unmarried patients are more likely to present with metastatic bladder urothelial carcinoma. Clin Genitourin Cancer. 2016;14(5):e489-e492. 
2. Schinkel JK, Shao S, Zahm SH, et al. Overall and recurrence-free survival among black and white bladder cancer patients in an equal-access health system. Cancer Epidemiol 2016;42:154-158. 

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre Twitter: @zklaassen_md  at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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