br Center for Surgery and Public Health Division of Urologic

1Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 2Faculty of Medicine, McGill University, Montreal, Quebec, Canada 3Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Address for correspondence: Quoc-Dien Trinh, MD, Assistant Professor Division of Urologic Surgery, Brigham and Women’s Hospital, 45 Francis St, Boston, MA 02115 E-mail contact: [email protected]
transurethral resection (TURBT), radiosensitizing chemotherapy, and local radiation treatment (RT) ( 50 Gy) are the standard-of-care options for muscle-invasive, localized disease with curative intent. In the setting of locally advanced or and metastatic CCK-8 cancer, palliative multi-agent chemotherapy is the standard of care; however, local therapy, such as TURBT, RT (< 50 Gy), or even RC may be offered for disease control. A recent observational study showed that RC may even be associated with a survival benefit in select cases.2 Importantly, patients who opt for RC or TMT face a lengthy course of treatment and recovery, significant morbidity, and adverse effects on quality of life.3-5 These adverse effects must be weighed against the treatment benefits. Unfortunately, despite the radical nature of treatment, overall survival (OS) in bladder cancer is modest at best; even in localized disease, it does not exceed 50% at 5 years.6 Therefore, patients may be reluctant to choose these
Table 1 Descriptive Characteristics of 42,144 Patients With Bladder Cancer, Stratified According to the Receipt of Definitive Versus Non-definitive Therapy, National Cancer Database 2004-2012
Localized Disease, n (%)
Advanced Disease, n (%)
Non-definitive
Non-definitive
Definitive Therapy, Therapy, N [ 19,381 P Value Definitive Therapy, Therapy, N [ 2620 P Value
Gender
Race
CCI
Educationa
Insurance
government
Year of diagnosis
Incomeb
Great circle distancec
Facility type
Facility location
Clinical Genitourinary Cancer June 2019 - e489
Survival Rates for Definitive and Non-Definitive Therapy of Muscle-Invasive Bladder Cancer
Table 1 Continued
Localized Disease, n (%)
Advanced Disease, n (%)
Non-definitive
Non-definitive
Definitive Therapy, Therapy, N [ 19,381 P Value Definitive Therapy, Therapy, N [ 2620 P Value
County type
Clinical T stage
NMIBC e e
cT4b e e
AJCC stage
e
e
e
Clinical N stage
cN0 e e
cNþ e e
Treatment
e
Abbreviations: AJCC ¼ American Joint Committee on Cancer; CCI ¼ Charlson Comorbidity Index; NMIBC ¼ nonemuscle-invasive bladder cancer; RC ¼ radical cystectomy; SD ¼ standard deviation; TMT ¼ trimodal therapy. aEducation: percentage of people in the patient’s Zip code without a high school degree. bMedian household income for patient’s zip code is based on 2000 United States Census data. cDistance from facility was calculated as distance in miles between the patient’s residence and the hospital that reported the case.
morbid interventions. For example, a number of studies have demonstrated that RC remains an underutilized treatment in stage
II disease.7,8 To help patients and clinicians weigh the risks and benefits, we sought to examine the stage-by-stage OS for definitive (DT) versus non-definitive therapy (nDT) for muscle-invasive bladder cancer within the National Cancer Database (2004-2012).
Materials and Methods
From a population of 391,214 patients diagnosed with bladder cancer between 2004 and 2012 (International Classification of Diseases for Oncology, Third Edition [ICD-0-3] codes C67.0-C67.9), we identified a cohort of 42,144 patients with localized muscle-invasive or locally advanced/systemic bladder can-cer who were presumably eligible for DT. Patients were stratified according to the documented American Joint Committee on Cancer (AJCC) stages II (cT2 N0 M0), III (cT3-4 N0 M0), and IV (cT4b N0 M0, any cTx N1-3 M0) (see Supplemental Figure 1 in the online version). The DT group included either RC with/without single-/multi-agent (neo-) adjuvant treatment, or TMT consisting of TURBT, single- or multi-agent radiosensitizing chemotherapy, and 60 to 65 Gy of RT.9 The nDT group included any other combination of single-/multi-agent chemotherapy, TURBT, RT 
(< 50 Gy), or no treatment at all. The Mann-Whitney U test and Pearson c2 test were used to compare differences in continuous and categorical variables, respectively. Kaplan-Meier curves were built, and the log-rank test was used to compare OS after stratifying pa-tients based on AJCC stages II to IV. A Cox regression model, adjusted for all available covariates, was used to compare the probability of OS between the groups and strata. Given that clinical