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Neoadjuvant chemotherapy utilization in muscle-invasive bladder cancer: Increasing yet inappropriate use?

441 Background: Neoadjuvant cisplatin-based chemotherapy (NAC) is associated with improved overall survival in patients with muscle-invasive bladder cancer (MIBC); however, utilization nationally has been low. Over the past decade, the use of NAC has increased to approximately 20% of patients with MIBC. We investigate whether this increase in NAC is with appropriate cisplatin-based regimens using registry data. Methods: This is a population-based analysis of linked SEER-Medicare data from 2004-2011. We identified 4,534 patients with cT2-4N0-1 bladder cancer undergoing cystectomy. Specific chemotherapy drugs administered were identified using pharmacy records. The cohort was stratified into three groups, standard of care (SOC: i.e., appropriate cisplatin-based chemotherapy), non-SOC, and no NAC. Descriptive statistics were performed to compare each group and multivariate logistic regression performed to determine factors associated with receiving SOC NAC. Results: Over the study period, 694/4534 (15.3%) of patients in the study received NAC, increasing from 11.0% in 2004 to 24.8% in 2011. From 2004-2011, 345/694 (49.7%) of patients who were given NAC received a non-SOC regimen. Among patients that received non-SOC NAC, the most common regimens included gemcitabine-carboplatin in 170/345 (49.3%), gemcitabine monotherapy 73/345 (21.2%) carboplatin monotherapy in 51/345 (14.8%), cisplatin monotherapy 29/345 (8.4%), and MVA with carboplatin 3/345 (0.8%). On multivariate analysis, age (OR 0.91[95% CI 0.88-0.94]) and moderate/severe renal disease (OR 0.2[95% CI 0.08-0.51]) were negatively associated with SOC NAC. The year of diagnosis (OR 1.32[95% CI 1.23-1.42]) was positively associated with the receipt of SOC NAC in the cohort. Conclusions: Although NAC for MIBC has increased, nearly half of these patients are not receiving SOC cisplatin-based regimens. This underscores the importance of better identifying patients eligible for neoadjuvant therapy, the need for appropriate drug selection which may be facilitated through centers of excellence and multidisciplinary clinics, and the need for more clinical trials for cisplatin ineligible patients.