Variability observed in muscle-invasive bladder cancer treatment

ORLANDO — Perioperative chemotherapy regimens administered to patients with muscle-invasive bladder cancer varied significantly at several institutions in the US, according to findings presented here.

Andrew Feifer, MD, of the Memorial Sloan-Kettering Cancer Center, said muscle-invasive bladder cancer is ideal for quality-of-care initiatives because it is expensive to treat, has variety in practice times and is an optimal model for multidisciplinary care with strong level-one data to support changes. The current findings are retrospective data of a two-phase study.

“Level-one evidence supports platinum neoadjuvant therapy for the treatment of muscle-invasive bladder cancer,” Feifer said. “However, we wanted to evaluate variation in practice patterns using data from multiple academic centers.”

There were 4,541 eligible participants who had undergone radical cystectomy for clinical T2-T4 N0M0 muscle-invasive bladder cancer from 2003 to 2008. Endpoints included rates of neoadjuvant and adjuvant therapy, cisplatin use, number of cycles and rates of pelvic lymphadenectomy.

“The rate of perioperative chemotherapy was 33.6%,” Feifer said. “More importantly, there was tremendous inter-institutional variability among academic institutions from 11.9% to 56.4% of those participating who gave perioperative chemotherapy.”

There was also variability regarding the type of chemotherapy administered. “Only 12.4% of all patients received neoadjuvant therapy, and 21.7% received adjuvant therapy. The ranges were also statistically significant,” he said.

A statistically significant increasing trend in neoadjuvant therapy was observed.

“There was a slight increase in cisplatin use from 2007 to 2008,” Feifer said. “However, for the 63.5% of patients who received any cisplatin within perioperative chemotherapy, the rate was relatively stable throughout the study duration.”

Practice patterns vary considerably for muscle-invasive bladder cancer.

“Only 9% of patients out of nearly 5,000 received neoadjuvant cisplatin-based therapy,” he said. “Approximately 31% of patients did not receive cisplatin. Pelvic lymph node dissection is used in overwhelming majority of cases.”

Feifer said the reasons for variation in practice patterns require clarification.

“This is why phase 2 of our study is under way,” he said. “We will be conducting a Web-based study evaluating patterns of decision-making among surgeons and medical oncologists.”

Among patients receiving perioperative chemotherapy, 80% received at least three cycles. Bilateral pelvic lymph node dissection was used in 95% of patients at radical cystectomy.

For more information:

• Feifer A. #240. Presented at: 2011 Genitourinary Cancers Symposium; Feb. 15-19, 2011; Orlando, Fla.

Disclosure: Dr. Feifer reports no relevant financial disclosures.

The use of perioperative and, particularly, neoadjuvant chemotherapy continues to be less than ideal, even in academic institutions, as this study illustrated. However, what is not clear at this time is what are the driving factors for this finding, which is the subject of phase 2 of this project. There has been accumulating evidence based on large randomized trials, including one that was conducted in the US by the Southwest Oncology Group, demonstrating feasibility of this approach and an overall survival advantage in favor of neoadjuvant chemotherapy. Although patients with bladder cancer tend to be elderly and with comorbidities and to offer cisplatin-based treatment, one must select patients carefully; this, in my experience, still does not explain the low rate of use of neoadjuvant chemotherapy.

I congratulate the investigators on their effort and look forward to the results of phase 2 of their study, which will hopefully provide insights as to why an approach supported by scientific evidence is not widely adopted. This kind of work is very important to better understand what issues and obstacles need to be addressed so that we can improve care for our patients by implementing evidence-based care.

– Maha Hussain, MD

Hemonc Today Editorial Board member

Disclosure: Dr. Hussain reports no relevant financial disclosures.