Underutilization of Radical Cystectomy Among Patients Diagnosed with Clinical Stage T2 Muscle-invasive Bladder Cancer

Background Radical cystectomy is the standard surgical treatment for muscle-invasive bladder cancer (MIBC). Objective We sought to identify population-based factors predicting the use of radical cystectomy. Design, setting, and patients Analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data for 3922 patients aged ≥66 yr diagnosed with clinical stage T2 MIBC from January 1, 2002 to December 31, 2011. Outcome measurements and statistical analysis We used univariate and multivariable regression analyses to identify factors predicting the use of radical cystectomy. Cox proportional hazards models were used to analyze survival outcomes. Results and limitations A total of 740 (18.9%) patients with MIBC underwent radical cystectomy. Older age at diagnosis (>80 vs 65–69 yr, odds ratio [OR] 0.15, 95% confidence interval [CI] 0.11–0.19; p < 0.001) and higher comorbidity (Charlson comorbidity index 3+ vs 0, OR 0.41, 95% CI 0.29–0.57; p < 0.001) were associated with lower use of radical cystectomy. Moreover, non-Hispanic black patients were less likely than white patients to undergo radical cystectomy (OR 0.62, 95% CI 0.40–0.96; p = 0.032) and pelvic lymph node dissection (OR 0.65, 95% CI 0.42–1.02; p = 0.058). Overall survival was better for patients who underwent radical cystectomy alone (hazard ratio [HR] 0.70, 95% CI 0.56–0.88; p = 0.002) and with lymph node dissection (HR 0.45, 95% CI 0.40–0.51; p < 0.001). Limitations include the limited ability of retrospective analysis to demonstrate causality. Conclusions There is significant underutilization of radical cystectomy among patients diagnosed with MIBC, especially among older patients with significant comorbidities and non-Hispanic black patients. Patient summary Despite guideline recommendations, there is significant underutilization of radical cystectomy among patients diagnosed with bladder cancer, especially for non-Hispanic black patients and older patients with significant comorbidities. There is significant underutilization of radical cystectomy among patients diagnosed with bladder cancer in the USA, especially among non-Hispanic black patients and older patients with significant comorbidities. Further research is needed to qualitatively describe the factors that drive the decision to undergo surgery and improve rates of radical cystectomy in patients with bladder cancer.