SESAUA 2023: A Contemporary Analysis of Treatment of Muscle Invasive Bladder Cancer Using the National Cancer Database: Factors Associated With Receipt of Non-aggressive Therapy

( The 2023 SESAUA annual meeting included a bladder cancer session, featuring a presentation by Dr. Sol Moon discussing factors associated with receipt of non-aggressive therapy for the treatment of muscle invasive bladder cancer. Patients with muscle-invasive bladder cancer face a potentially lethal disease, yet often do not receive potentially curative therapies.

The goal of this study was to characterize the treatments received by patients with muscle-invasive bladder cancer, analyze their use according to sociodemographic, clinical, pathologic, and facility measures, and to identify possibilities for improvement in care for patients with muscle-invasive bladder cancer.

 Using the NCDB, Dr. Moon and colleagues analyzed 102,119 patients with stage II-IV muscle invasive bladder cancer who were diagnosed between 2009-2018, excluding patients with cT4b or distant metastases. Treatments included:

  • Cystectomy, with or without perioperative chemotherapy
  • Chemoradiation
  • Radiation alone
  • Chemotherapy
  • Observation

Aggressive therapy was defined as cystectomy or radiotherapy >50 Gy. A multivariable generalized estimating equation model was used to assess the relationship of independent variables with receiving aggressive therapy.

 The median age was 73 years, with 72.9% male, 84.3% White, and 7.1% Black. Stage distribution included 59.4% stage II, 23.0% stage III, and 17.6% stage IV. Overall, 55.2% of patients received aggressive therapy, 41.1% received non-aggressive therapy, and 26.6% observation alone. Furthermore, 45.4% of patients received cystectomy, 9.8% underwent definitive radiotherapy, and 12.8% underwent chemotherapy as primary treatment. Notably, over 30% of patients between ages of 50 and 70 did not receive aggressive therapy:

age graphs

On multivariable analysis, factors associated with lack of aggressive therapy included age >70 (OR 0.79, p<0.0001), Black race (OR 0.70, p<0.0001), Medicaid and underinsured status (OR 0.62-0.75, p<0.0001), Charlson Comorbidity score >/= 2 (OR 0.88-0.74, p<0.0001), and low volume (OR 0.72 p<0.0001), non-academic cancer programs (OR 0.54-0.71 p<0.0001). Trends over time included increased utilization of perioperative chemotherapy (15.5% in 2009 to 24.7% in 2018), and chemoradiotherapy (5.4% in 2009 to 8.8% in 2018).

Dr. Moon concluded this presentation discussing factors associated with receipt of non-aggressive therapy for the treatment of muscle invasive bladder cancer with the following take-home messages:

  • Over a third of patients do not receive aggressive therapy for muscle-invasive bladder cancer, with many of these patients seemingly eligible by age and comorbidity status
  • While increased utilization of perioperative chemotherapy and chemoradiotherapy over time are favorable indicators, more granular research is needed to determine exactly why these patients do not receive aggressive therapy
  • A better understanding of patient vs access to care vs provider factors would help to focus efforts to improve care for patients with muscle-invasive bladder cancer 

Presented by: Sol Moon, MD, University of Alabama Birmingham, Birmingham, AL

Co-Authors: Vishruti Pandya2, Andrew McDonald3, Arnab Basu4, Sejong Bae2, James Ferguson5

Affiliations: 2Department of Medicine, Division of Preventative Medicine, University of Alabama Birmingham, 3Department of Radiation Oncology, University of Alabama Birmigham4Department of Medicine, Division of Hematology-Oncology, University of Alabama Birmingham, 5Department of Urology, University of Alabama Birmingham, Birmingham Veterans Affairs Medical Center

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2023 Southeastern Section of the American Urological Association (SESAUA) Annual Meeting, Amelia Island, FL, Wed, Mar 15 – Sat, Mar 18, 2023.