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Multi-institutional quality-of-care initiative for nonmetastatic, muscle-invasive, transitional cell carcinoma of the bladder: Phase I.

240 Background: Evidence supports multimodality treatment for muscle invasive bladder cancer [MIBC] with the strongest evidence (level 1) existing for cisplatin-based neoadjuvant chemotherapy. Although reflected in guidelines for the management of MIBC, little is known about the variation of actual practice patterns among academic institutions. We thus evaluated treatment variation among 14 academic centers in the management of patients with MIBC.


METHODS
Retrospective data were collected for centralized analysis. All patients who underwent radical cystectomy for clinical T2-4 N0M0 MIBC from 2003-2008 were eligible for inclusion. Specific endpoints for analysis included: rates of neoadjuvant and adjuvant therapy, cisplatin use, number of cycles and rates of pelvic lymphadenectomy.


RESULTS
14 institutions participated and data on 4,541 patients who met inclusion criteria were tabulated. Overall 34% of patients received perioperative chemotherapy. The overall use of neoadjuvant and adjuvant therapy was 12% and 22%, respectively. In a subset analysis of those patients with specific chemotherapy agent information provided (n=3,120), 59% of patients managed with perioperative chemotherapy received cisplatin. Of those who received treatment in the neoadjuvant setting, cisplatinum was received in 65% of cases (supported by level 1 evidence). 80% of patients who received perioperative chemotherapy received at least 3 cycles. At radical cystectomy 95% of patients received a bilateral PLND.


CONCLUSIONS
In this cohort of academic North American centers, 66% of potentially eligible bladder cancer patients undergoing radical cystectomy did not receive perioperative chemotherapy. Only 12% of patients received neoadjuvant chemotherapy, and 35% of those patients received a non-cisplatin based regimens. Despite level 1 evidence that cisplatin based neoadjuvant chemotherapy is associated with a survival advantage, only a small percentage of eligible patients undergoing radical cystectomy for muscle invasive, resectable disease receive combined treatment. Further study is needed clarify specific reasons for the treatment variation observed in academic centers. No significant financial relationships to disclose.