Although guidelines for the management of muscle-invasive bladder cancer recommend cisplatin-based neoadjuvant chemotherapy based on level 1 evidence showing a survival advantage, only a small percentage of patients undergoing radical cystectomy who were eligible for this treatment received it in a recent study, which was presented at the 2011 Genitourinary Cancers Symposium.¹ Surprisingly, these findings emerged from a survey of academic centers, where one would expect state-of-the-art treatment to be implemented.

“Our study showed that practice patterns varied considerably among the 15 academic institutions we surveyed in this first phase of our study. Among all patients treated with perioperative chemotherapy, only 9% received neoadjuvant cisplatin-based chemotherapy; 31% of those treated with neoadjuvant chemotherapy did not receive cisplatin,” stated Andrew Feifer, MD, Memorial Sloan-Kettering Cancer Center, New York. The overwhelming majority of patients included in the study received pelvic lymph node dissection as per recommendations.

Study Details

The survey was conducted among 15 academic centers and included 4,972 patients who underwent radical cystectomy for nonmetastatic muscle-invasive bladder cancer from 2003 to 2008. The retrospective study sought to determine current baseline practice patterns regarding four quality care indicators at academic centers. A second part of the study will explore the reasons for practice variations found during the first phase, Dr. Feifer explained.

The four quality indicators were: referral to medical oncology for multimodality therapy; if neoadjuvant therapy was recommended, use of cisplatin for at least three cycles; if adjuvant therapy was recommended, use of adjuvant cisplatin for at least three cycles; and bilateral pelvic lymphadenectomy of at least the iliac, hypogastric, and obturator lymph nodes.

Results showed that 33.6% of patients received any perioperative chemotherapy: 12.4% received any neoadjuvant therapy and 21.7% received any adjuvant chemotherapy. An analysis of time trends during 2003 to 2008 showed that the use of neoadjuvant therapy increased while the use of adjuvant therapy was slightly reduced. In a subset of 3,298 patients, among those who received any neoadjuvant chemotherapy, 69.4% received cisplatin; among those who received any perioperative chemotherapy, 63.5% received cisplatin. Overall, 80% of patients treated with perioperative chemotherapy received three cycles. Almost 95% of patients underwent bilateral lymph node dissection. The reasons for which patients were treated with or without systemic therapy are speculative. ■

Financial Disclosure: Dr. Feifer reported no potential conflicts of interest.

Reference

1. Feifer A, Taylor JM, Shouery M, et al: Multi-institutional quality-of-care initiative for nonmetastatic, muscle invasive, transitional cell carcinoma of the bladder: Phase I. Genitourinary Cancers Symposium. Abstract 240. Presented February 18, 2011.