Urologic Oncology: Seminars and Original Investigations
Original articlePerioperative chemotherapy for bladder cancer in the general population: Are practice patterns finally changing?☆
Introduction
Muscle-invasive bladder cancer (MIBC) may be locally controlled by cystectomy or radiotherapy but more than 50% of patients ultimately die of distant metastases. International guidelines recommend neoadjuvant chemotherapy (NACT) on the basis of level I evidence [1], [2], [3]. Although less robust than NACT, there is growing evidence to suggest that adjuvant chemotherapy (ACT) might offer a comparable benefit to NACT [4]. In this context, practice recent guidelines are now shifting to recommend either NACT or ACT for MIBC [2].
Despite the pivotal randomized controlled trials in 1999 and 2003 [5], [6], multiple studies showed minimal uptake of NACT and a paradoxical greater uptake of ACT [7], [8], [9]. These initial studies reported practice in the 1990s and mid-2000s. We have previously reported practice patterns in the Canadian province of Ontario during 1994 to 2008 and showed that use of NACT was very low (mean utilization rate 4%) with no clear increase over time [10]. Despite multiple studies describing low use of perioperative chemotherapy, potential reasons for underutilization are not well described. Potential reasons include low referral rate from urology to medical oncology (MO), patient ineligibility owing to renal dysfunction, and patient/physician preference against chemotherapy [11]. Our data showed that during 1994 to 2008 only 10% of patients with MIBC were referred to MO before cystectomy [12]. Recent surveys suggest that physician attitude towards chemotherapy for bladder cancer may be changing [13], [14], and 2 population-based studies have described increasing use of chemotherapy [15], [16]. There remains a paucity of data to describe to what extent MO referral rates have changed over time. We undertook the following study to provide insight into delivery of perioperative chemotherapy and referral patterns to MO in the contemporary era.
Section snippets
Study design and population
This is a population-based, retrospective cohort study to describe use of perioperative chemotherapy and referral to MO among patients with MIBC in the Canadian province of Ontario. We have previously reported practice patterns during 1994 to 2008 [10], [12]; in this report we update this analysis to include patients treated in 2009 to 2013. Ontario has a population of approximately 13.5 million people and a single-payer universal health insurance program. All incident cases of bladder cancer
Study population
During 1994 to 2013, 5,582 patients in Ontario underwent cystectomy for bladder cancer of which 4,250 patients had muscle-invasive urothelial carcinoma (Supplemental eFigure). Most patients (59%) were 70+ years of age and 75% were males (Table 1). A total of 9% (372/4,250) of patients received NACT; 19% (827/4,250) of patients were treated with ACT. Furthermore, 70 patients (2%) were treated with NACT and ACT.
Use of perioperative chemotherapy
Use of NACT increased substantially during the study period from 5% (1994–1998) to 3%
Discussion
We have explored use of perioperative chemotherapy and referral to MO among patients with MIBC in the contemporary era. Several important findings have emerged. First, after many years of practice lagging behind evidence, there has been a substantial increase in use of NACT. Second, increased use of NACT appears to be driven by greater preoperative referral to MO as well as greater propensity of MOs to deliver NACT among referred patients. Third, chemotherapy use and referral patterns are
Acknowledgments
Parts of this material are based on data and information provided by Cancer Care Ontario and the Canadian Institute for Health Information. However, the analysis, conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of Cancer Care Ontario or the Canadian Institute for Health Information.
Dr. Booth had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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Dr. Booth is supported as a Canada Research Chair in Population Cancer Care. This work was also supported by the Canada Foundation for Innovation and the Canadian Cancer Society Research Institute. This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual Grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.