Investigators evaluate aggressive treatment rates for muscle-invasive bladder cancer

Opinion
Video

“We found that over 40% of patients with muscle-invasive bladder cancer are not receiving cystectomy or trimodal therapy,” says James Ferguson III, MD, PhD.

In this video, James Ferguson III, MD, PhD, discusses the background and notable findings from the recent Urologic Oncology paper, “Analysis of treatment of muscle invasive bladder cancer using the national cancer database: Factors associated with receipt of aggressive therapy.” Ferguson is an assistant professor of urology at the University of Alabama at Birmingham.

Transcription:

Please describe the background for this study.

I'm a urologic oncologist at the University of Alabama at Birmingham, and my research lab and clinical practice are focused on bladder cancer. Although radical cystectomy is the gold standard treatment for muscle-invasive bladder cancer, it's a morbid procedure with significant side effects and a pretty high mortality risk—about 3% in the first 30 to 90 days. Patients and physicians have long wondered if there could be a safe alternative to this while allowing patients to keep their bladders. I'm interested in studying biomarkers and noncystectomy therapies in the cystectomy-ineligible/refusal population, but wasn't sure how feasible this study would be, as these patients were anecdotally pretty rare in my experience at academic medical centers. But when I searched the literature, I found multiple older studies noting significant percentages of patients not receiving cystectomy for muscle-invasive bladder cancer. I wanted to confirm these studies with more contemporary data to see whether cystectomy use had improved over time.

What were some of the notable findings? Were any of them surprising to you and your coauthors?

We found that over 40% of patients with muscle-invasive bladder cancer are not receiving cystectomy or trimodal therapy. These can be grouped together to be considered aggressive therapies. I expected some patients in this category, but that percentage was surprisingly high to us. When we compared to historical studies, this percentage has not improved over time, even despite uptake in robotic surgery. So in order to determine what variables were associated with not receiving aggressive therapy, we performed a multivariable analysis and found that older age, Black race, underinsured status, high comorbidities, and treatment at low-volume, nonacademic centers were all associated with lack of aggressive therapy, so either cystectomy or radiation therapy. These are consistent with prior studies and unfortunately have not improved over the past few decades. Surprisingly, though, even in younger patients aged 50 to 70 and those with low comorbidity status, nonaggressive therapy rates were still around 30%. This was pretty surprising to us.

This transcript was edited for clarity.

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