Trends of Perioperative Chemotherapy for Muscle-Invasive Bladder Cancer - Expert Commentary

Perioperative chemotherapy is frequently underutilized. Understanding the trends in the utilization of neoadjuvant or adjuvant cisplatin-based chemotherapy in muscle-invasive bladder cancer (MIBC) undergoing cystectomy is critical.

A new article published by Macleod et al. in Urologic Oncology evaluated the trends and factors associated with perioperative chemotherapy use in MIBC patients. Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the researchers identified 3,826 patients with MIBC between 2004 and 2013 who underwent radical cystectomy. They categorized the patients into three groups: radical cystectomy only, neoadjuvant chemotherapy and adjuvant chemotherapy. A multinomial multivariable logistic regression model was used to study the association of patients' characteristics with the treatment received.

In this study, 80% of the patients were ≥70 years old, 71% male, 88% white, and 64% married. 65% of the patients (2,484) received cystectomy alone, and 18% (676) received neoadjuvant chemotherapy of which 69% was cisplatin-based. 17% (666) received adjuvant chemotherapy, of which 55% was cisplatin-based. During the study period, the investigators found increased odds of getting neoadjuvant chemotherapy by 27.5% (P < 0.001) and an increase (35% to 72%, P < 0.001) in the number of people getting cisplatin-based neoadjuvant chemotherapy. On the other hand, there was a decrease in adjuvant chemotherapy by 7.5% (P < 0.001) throughout the study with no significant increase in the number of people getting a cisplatin-based regimen (P=0.167). The increased odds of getting neoadjuvant chemotherapy was associated with being female (P < 0.05), being married (P < 0.05), having lower comorbidity (P < 0.05) and lower stage disease (P < 0.05).

The researchers concluded that the use of neoadjuvant chemotherapy for MIBC increased during the study period. While it is encouraging to see the increase in neoadjuvant chemotherapy, the overall rates remain low. The reasons behind the decrease in adjuvant chemotherapy deserve further study. Understanding the barriers to increasing perioperative chemotherapy use are critical to increase utilization. As immunotherapy makes inroads into the perioperative space, it will be important to study its patterns of utilization in real-world settings.

Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine

Read the Abstract

1. Macleod LC, Yabes JG, Yu M, Fam MM, Hale NE, Turner RM 2nd, Lopa SH, Gingrich JR, Borza T, Skolarus TA, Davies BJ, Jacobs BL. Trends and appropriateness of perioperative chemotherapy for muscle-invasive bladder cancer. Urol Oncol. 2019 Apr 30. upii: S1078-1439(19)30139-5. ddoi: 10.1016/j.urolonc.2019.04.006.