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| Treatment trends of muscle invasive bladder cancer: Evidence from the Surveillance, Epidemiology, and End Results database, 1988 to 2013 |
Victor Chalfanta,*( ),Michael L. BluteJr.a,Peter Silbersteinb
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a Urology at CHI Health Creighton University Medical Center Omaha, NE, USA
b Hematology Oncology at CHI Health Creighton University Medical Center Omaha, NE, USA |
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Abstract Objective: Guidelines for muscle-invasive bladder cancer (MIBC) recommend that patients receive neoadjuvant chemotherapy with radical cystectomy as treatment over radical cystectomy alone. Though trends and practice patterns of MIBC have been defined using the National Cancer Database, data using the Surveillance, Epidemiology, and End Results (SEER) program have been poorly described. Methods: Using the SEER database, we collected data of MIBC according to the American Joint Commission on Cancer. We considered differences in patient demographics and tumor characteristics based on three treatment groups: chemotherapy (both adjuvant and neoadjuvant) with radical cystectomy, radical cystectomy, and chemoradiotherapy. Multinomial logistic regression was performed to compare likelihood ratios. Temporal trends were included for each treatment group. Kaplan-Meier curves were performed to compare cause-specific survival. A Cox proportional-hazards model was utilized to describe predictors of survival. Results: Of 16 728 patients, 10 468 patients received radical cystectomy alone, 3236 received chemotherapy with radical cystectomy, and 3024 received chemoradiotherapy. Patients who received chemoradiotherapy over radical cystectomy were older and more likely to be African American; stage III patients tended to be divorced. Patients who received chemotherapy with radical cystectomy tended to be males; stage II patients were less likely to be Asian than Caucasian. Stage III patients were less likely to receive chemoradiotherapy as a treatment option than stage II. Chemotherapy with radical cystectomy and chemoradiotherapy are both underutilized treatment options, though increasingly utilized. Kaplan-Meier survival curves showed significant differences between stage II and III tumors at each interval. A Cox proportional-hazards model showed differences in gender, tumor stage, treatment modality, age, and marital status. Conclusion: Radical cystectomy alone is still the most commonly used treatment for muscle-invasive bladder cancer based on temporal trends. Significant disparities exist in those who receive radical cystectomy over chemoradiotherapy for treatment.
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Received: 06 September 2020
Available online: 20 January 2023
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Corresponding Authors:
Victor Chalfant
E-mail: victorchalfant@creighton.edu
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Case flow diagram. SEER, the Surveillance, Epidemiology, and End Results.
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| Patient demographic | Treatment (n=9243) | p-Valuea | | Radical cystectomy; n=5185 (56.1%) | Radical cystectomy + chemotherapy; n=1615 (17.5%) | Chemotherapy + radiation; n=2443 (26.4%) | | Age at diagnosis | | | | <0.001 | | Population age, mean, year | 66.2 | 63.8 | 72.1 | | | 85+ years old, n (%) | 165 (3.2) | 15 (0.9) | 384 (15.7) | | | Sex, n (%) | | | | <0.001 | | Male | 3918 (75.6) | 1264 (78.3) | 1785 (73.1) | | | Female | 1267 (24.4) | 351 (21.7) | 658 (26.9) | | | Race, n (%) | | | | <0.001 | | Caucasian | 4663 (89.9) | 1482 (91.8) | 2179 (89.2) | | | Asian or Pacific Islander | 221 (4.3) | 48 (3.0) | 82 (3.4) | | | African American | 275 (5.3) | 74 (4.6) | 170 (7.0) | | | Unknown | 26 (0.5) | 11 (0.7) | 2 (0.5) | | | Marital status, n (%) | | | | <0.001 | | Married | 3382 (65.2) | 1108 (68.6) | 1383 (56.6) | | | Widowed | 613 (11.8) | 122 (7.6) | 532 (21.8) | | | Divorced | 460 (8.9) | 147 (9.1) | 211 (8.6) | | | Single | 510 (9.8) | 163 (10.1) | 209 (8.6) | | | Unknown | 220 (4.2) | 75 (4.6) | 108 (4.4) | | | Primary site, n (%) | | | | <0.05 | | Trigone of bladder | 329 (6.3) | 89 (5.5) | 177 (7.2) | | | Dome of bladder | 194 (3.7) | 63 (3.9) | 124 (5.1) | | | Bladder wall | 1607 (31.0) | 505 (31.3) | 847 (34.7) | | | Overlapping lesion of bladder | 881 (17.0) | 278 (17.2) | 375 (15.4) | | | Unknown | 2174 (41.9) | 680 (42.1) | 920 (37.7) | | | Grade, n (%) | | | | <0.001 | | Moderately differentiated | 387 (7.5) | 51 (3.2) | 94 (3.8) | | | Poorly differentiated or undifferentiated | 4553 (87.8) | 1450 (89.8) | 2187 (89.5) | | | Unknown | 245 (4.7) | 114 (7.1) | 162 (6.6) | |
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Patient demographics and tumor characteristics based on treatment groups for stage II.
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| Patient demographic | Treatment (n=7485) | p-Valuea | | Radical cystectomy; n=5283 (70.6%) | Radical cystectomy + chemotherapy; n=1621 (21.7%) | Chemotherapy + radiation; n=581 (7.8%) | | Age at diagnosis | | | | <0.001 | | Population age, mean, year | 68.9 | 65.5 | 71.9 | | | 85+ years old, n (%) | 229 (4.3) | 20 (1.2) | 78 (13.4) | | | Sex, n (%) | | | | <0.001 | | Male | 3707 (70.2) | 1216 (75.0) | 438 (75.4) | | | Female | 1576 (29.8) | 405 (25.0) | 143 (24.6) | | | Race, n (%) | | | | <0.05 | | Caucasian | 4728 (89.5) | 1462 (90.2) | 499 (85.9) | | | Asian or Pacific Islander | 214 (4.1) | 66 (4.1) | 27 (4.6) | | | African American | 317 (6.0) | 84 (5.2) | 53 (9.1) | | | Unknown | 24 (0.5) | 9 (0.6) | 2 (0.3) | | | Marital status, n (%) | | | | <0.001 | | Married | 3275 (62.0) | 1104 (68.1) | 325 (55.9) | | | Widowed | 870 (16.5) | 146 (9.0) | 122 (21.0) | | | Divorced | 471 (8.9) | 134 (8.3) | 64 (11.0) | | | Single | 487 (9.2) | 174 (10.7) | 49 (8.4) | | | Unknown | 180 (3.4) | 63 (3.9) | 21 (3.6) | | | Primary site, n (%) | | | | NS | | Trigone of bladder | 317 (6.0) | 263 (16.2) | 42 (7.2) | | | Dome of bladder | 263 (5.0) | 67 (4.1) | 16 (2.8) | | | Bladder wall | 1509 (28.6) | 459 (28.3) | 147 (25.3) | | | Overlapping lesion of bladder | 1146 (21.7) | 343 (21.2) | 111 (19.1) | | | Unknown | 2048 (38.8) | 489 (30.2) | 265 (45.6) | | | Grade, n (%) | | | | <0.001 | | Moderately differentiated | 418 (7.9) | 80 (4.9) | 30 (5.2) | | | Poorly differentiated or undifferentiated | 4700 (89.0) | 1479 (91.2) | 510 (87.8) | | | Unknown | 165 (3.1) | 62 (3.8) | 41 (7.1) | |
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Patient demographics and tumor characteristics based on treatment groups for stage III.
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| Stages | Treatment | Total | | Radical cystectomy | Radical cystectomy + chemotherapy | Chemotherapy + radiation | | II | 5185 (56.1) | 1615 (17.5) | 2443 (26.4) | 9243 | | III | 5283 (70.6) | 1621 (21.7) | 581 (7.8) | 7485 | | p-Valuea | NS | NS | <0.001 | |
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Treatment groups were separated into stage II and III.
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| Patient demographic | Likelihood ratio (95% CI) of stage II patients | Likelihood ratio (95% CI) of stage III patients | | Radical cystectomy + chemotherapy | Chemotherapy + radiation | p-Value | Radical cystectomy + chemotherapy | Chemotherapy + radiation | p-Value | | Sex | | | <0.001 | | | <0.001 | | Male | Reference | Reference | | Reference | Reference | | | Female | 0.9 (0.8-1.0) | 1.1 (1.0-1.2) | | 0.8 (0.7-0.9) | 0.8 (0.6-0.9) | | | Age, year | | | <0.001 | | | <0.001 | | 55-65 | Reference | Reference | | Reference | Reference | | | 65-75 | 1.1 (0.9-1.2) | 2.0 (1.6-2.4) | | 0.7 (0.6-0.9) | 1.1 (0.8-1.4) | | | 75-85 | 2.3 (1.9-2.7) | 8.7 (7.0-10.7) | | 0.4 (0.4-0.5) | 2.0 (1.5-2.6) | | | 85+ | Reference | Reference | | 1.0 (0.5-1.9) | 0.1 (0.1-0.2) | | | Race | | | <0.001 | | | <0.05 | | Caucasian | Reference | Reference | | Reference | Reference | | | Asian | 0.7 (0.5-0.9) | 0.8 (0.6-1.0) | | 1.0 (0.8-1.3) | 1.2 (0.8-1.8) | | | African American | 0.8 (0.7-1.1) | 1.3 (1.1-1.6) | | 0.9 (0.7-1.1) | 1.6 (1.2-2.2) | | | Marital status | | | <0.001 | | | <0.001 | | Married | Reference | Reference | | Reference | Reference | | | Divorced | 0.9 (0.7-1.2) | 1 (0.7-1.4) | | 0.84 (0.7-1.0) | 1.4 (1.0-1.8) | | | Grade | | | <0.001 | | | <0.001 | | Moderately differentiated | Reference | Reference | | Reference | Reference | | | Poorly or undifferentiated | 2.4 (1.8-3.3) | 2 (1.6-2.5) | | 1.6 (1.2-2.0) | 1.7 (1.1-2.6) | |
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Cox proportional hazards model indicating likelihood of group receiving either chemotherapy with radical cystectomy or chemotherapy plus radiation compared to reference radical cystectomy group.
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Percentage of patients by treatment group treated for stage II MIBC from 1988 to 2013 based on 5-year intervals. For 1988-1992, n=399; 1993-1997, n=597; 1998-2002, n=1186; 2003-2007, n=2848; 2008-2013, n=4213 (highly significant of p-values of <0.001).
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Percentage of patients by treatment treated for stage III MIBC from 1988 to 2013 based on 5-year intervals. For 1988-1992, n=478; 1993-1997, n=743; 1998-2002, n=1666; 2003-2007, n=2060; 2008-2013, n=2538 (highly significant of p-values of <0.001).
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5-year cause-specific survival curves of muscle-invasive bladder cancer for stage II versus stage III from 1988 to 2013 at 5-year intervals. Cases from (A) 1988-1992, n=877; (B) 1993-1997, n=1340; (C) 1998-2002, n=2852; (D) 2003-2007, n=4908; (E) 2008-2013, n=6751 (p-values <0.05).
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