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UPJ INSIGHT Neoadjuvant Chemotherapy Before Radical Cystectomy for Muscle-Invasive Bladder Cancer
By: Hiten D. Patel, MD, MPH, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Ushasi Naha, MD, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Victor S. Chen, MD, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Caitlyn Ko, BS, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Rachel Yang, BS, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Aleksander Druck, MD, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Goran Rac, MD, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Jeffrey L. Ellis, MD, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Gopal N. Gupta, MD, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Michael E. Woods, MD, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Alex Gorbonos, MD, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Robert Flanigan, MD, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois; Marcus L. Quek, MD, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois | Posted on: 19 Jan 2024
Patel HD, Naha U, Chen VS, et al. Neoadjuvant chemotherapy before radical cystectomy for muscle-invasive bladder cancer: elective and eligibility factors impacting utilization. Urol Pract. 2024;11(1):136-144.
Study Need and Importance
Neoadjuvant chemotherapy (NAC) has emerged as the standard of care prior to radical cystectomy (RC), yet a significant proportion of muscle-invasive bladder cancer (MIBC) patients do not undergo NAC. It is difficult to assess why patients did not receive NAC through administrative or registry data sets, with scarce research delving into the topic. We evaluated the utilization of NAC in patients with MIBC who planned to undergo RC.
What We Found
Utilization of NAC for MIBC prior to RC has increased over time, but prior reports may underestimate true rates. A detailed assessment of eligibility factors and elective factors demonstrated up to 30% of patients may not be eligible to receive up-front NAC while 30% may not receive it due to elective factors. There was a dramatic increase over time when NAC utilization was assessed specifically among eligible patients (Table).
Table. Factors for Lack of Candidacy or Utilization of Neoadjuvant Chemotherapy
| Early (2005-2016) |
Recent (2016-2021) |
Total | P value | ||||
|---|---|---|---|---|---|---|---|
| No. | (%) | No. | (%) | No. | (%) | ||
| Eligibility factors for NAC candidacy | .02 | ||||||
| Total cohort | 228 | - | 152 | - | 380 | - | |
| NAC candidates | 152 | (66.7) | 119 | (78.3) | 271 | (71.3) | |
| Renal dysfunction | 43 | (18.9) | 20 | (13.1) | 63 | (16.6) | |
| Salvage cystectomy | 3 | (1.3) | 5 | (3.3) | 8 | (2.1) | |
| Histology | 17 | (7.4) | 3 | (2.0) | 20 | (5.3) | |
| Clinical justification | 13 | (5.7) | 5 | (3.3) | 18 | (4.7) | |
| Elective factors for lack of NAC utilization among candidates | < .001 | ||||||
| NAC candidates | 152 | - | 119 | - | 271 | - | |
| Received NAC | 52 | (34.2) | 102 | (85.7) | 154 | (56.8) | |
| Symptoms | 12 | (7.9) | 9 | (7.6) | 21 | (7.8) | |
| Disease progression concern | 15 | (9.9) | 4 | (3.3) | 19 | (7.0) | |
| Patient preference/refusal | 51 | (33.6) | 4 | (3.4) | 55 | (20.3) | |
| Provider discretion/other | 22 | (14.4) | 0 | 0.0 | 22 | (8.1) | |
| Abbreviations: NAC, neoadjuvant chemotherapy. | |||||||
Limitations
The cohort was derived from a single tertiary referral center with NAC rates that may not be representative of all practice settings. Eligibility and elective factors were determined retrospectively based on clinical notes and documentation by urologists and medical oncology providers. Follow-up was relatively short with a mean of 3 years, with only 20% followed > 5 years.
Interpretation for Patient Care
The study provides a contemporary estimate of improvements in NAC utilization when accounting for eligibility, as well as an evaluation of potential barriers to NAC utilization due to elective factors. The findings are important given the detriment to overall survival associated with lack of eligibility but also implications for prognosis for forgoing NAC for elective reasons. The potential ceiling for NAC utilization is higher than suggested in prior reports with > 80% among eligible patients representing a modern benchmark. Quality improvement initiatives related to NAC for MIBC should quantify both eligibility and elective factors.
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