Treatment of muscle invasive bladder cancer: evidence from the National Cancer Database, 2003 to 2007.

PURPOSE: We describe nationwide treatment patterns of muscle invasive bladder cancer, investigated determinants of cystectomy and provide contemporary trends in process of care measures in patients undergoing cystectomy.
MATERIALS AND METHODS: We selected 40,388 patients 18 to 99 years old diagnosed with muscle invasive (stages II to IV) bladder cancer in 2003 to 2007 from the National Cancer Database. Treatment included cystectomy, neoadjuvant and adjuvant chemotherapy, chemotherapy without surgery and radiation therapy. In patients undergoing cystectomy we retrieved the procedure type (partial vs radical), lymphadenectomy extent and 30-day followup. Cystectomy determinants were assessed by Poisson regression with robust error variance. Perioperative mortality was analyzed by multilevel logistic regression.
RESULTS: The proportion of patients treated with cystectomy (42.9%) and radiation therapy (16.6%) remained stable with time while the incidence of those who received chemotherapy increased from 27.0% in 2003 to 34.5% in 2007 due to an increase in neoadjuvant chemotherapy and chemotherapy without surgery. The cystectomy rate decreased with age and was lower in racial/ethnic minorities (especially black patients), uninsured or Medicaid patients, patients residing in the South and Northeast, and those treated at nonteaching/research hospitals. The partial cystectomy rate decreased and lymphadenectomy extent increased with time. The perioperative mortality rate was 2.6% and it was higher at low vs very high volume hospitals (OR 1.71, 95% CI 1.26-2.32).
CONCLUSIONS: Recent nationwide data confirm ongoing improvements in process of care measures in patients who undergo cystectomy but also show marked differences in treatment patterns for muscle invasive bladder cancer by patient age, race, insurance status, geographic area and facility type.