Cystectomy for muscle-invasive bladder cancer: Patterns and outcomes of care in the medicare population

doi:10.1016/j.urology.2004.12.029

Urology

Volume 65, Issue 6, June 2005, Pages 1118-1125

https://doi.org/10.1016/j.urology.2004.12.029 Get rights and content

Abstract

Objectives

To describe the population-based patterns of care among patients with muscle-invasive bladder cancer.

Methods

A retrospective cohort study using the Surveillance, Epidemiology and End Results (SEER)-Medicare database identified 4664 patients aged 65 years or older with muscle-invasive bladder cancer diagnosed between 1991 and 1999. The use of particular treatment modalities was evaluated according to the clinical and demographic characteristics available in the SEER-Medicare database.

Results

Considerable variation was found in the treatments delivered to the cohort members. Overall, 39% had undergone cystectomy; 30% of Stage II, 57% of Stage III, and 38% of Stage IV patients underwent this operation within 6 months of diagnosis. The frequency of resection declined with age, such that 55% of patients aged 65 to 69 years and 27% of those aged 80 to 84 years underwent cystectomy. For 36% of Stage II, 18% of Stage III, and 27% of Stage IV patients, no evidence was found of surgery, chemotherapy, or radiotherapy within 6 months of diagnosis. Other management strategies included chemotherapy alone (14% Stage II, 6% Stage III, and 12% Stage IV), radiotherapy alone (11% for each stage), or combined modality chemoradiotherapy (10% Stage II, 8% Stage III, and 12% Stage IV). Multivariate analyses suggested that cystectomy conferred a survival advantage.

Conclusions

A marked heterogeneity exists in the strategies used to treat muscle-invasive bladder cancer. The extent to which this variation can be attributed to the lack of informative clinical trials, the presence of comorbid illness, patient or physician preferences, or access to care warrants further evaluation.

Section snippets

Data sources

Linkage of the Surveillance, Epidemiology and End Results (SEER) population-based cancer registries with the Centers for Medicare Services’ Medicare database containing healthcare claims for its enrollees enabled us to identify a cohort of patients with muscle-invasive bladder cancer. The SEER registries, sponsored by the National Cancer Institute, ascertain all incident cancer cases diagnosed in five states and six U.S. metropolitan areas, representing approximately 14% of the U.S. population.

Results

We identified 4664 patients with muscle-invasive bladder cancer, 1991 (43%) with Stage II, 1096 (23%) with Stage III, and 1577 (34%) with Stage IV disease at diagnosis. The patients’ clinical and demographic attributes are shown in Table I, which underscored that our cohort was composed of elderly white men. The pie charts in Figure 1 characterized the patients according to the treatments received within 6 months of diagnosis and showed that the practice patterns for management of

Comment

Using the SEER-Medicare linked data, we found a marked heterogeneity in the management of muscle-invasive bladder cancer in the United States in the 1990s. This analysis represents a first step toward the benchmarking of practice patterns recommended by the National Cancer Institute’s Bladder Cancer Progress review group. ²³ Given that all cohort members were Medicare beneficiaries, the variation we found could not be attributed to insurance status.

Patients who underwent cystectomy achieved

Acknowledgment

To the staff of the Applied Research Program, National Cancer Institute for their efforts and Dr. Joan Warren, coordinator of the SEER-Medicare program; the Office of Information Services, and the Office of Strategic Planning, HCFA; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

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Cited by (83)

Overcoming the Chasm Between Evidence and Routine Practice for Bladder Cancer; Just a Quixotic Notion?
2021, Clinical Oncology
Citation Excerpt :
The introduction of operational delivery networks for radiotherapy across England should help to drive the implementation of bladder CRS as standard in the future using the available state of the art radiotherapy techniques [81]. It has repeatedly been shown that a marked heterogeneity exists in the strategies used to treat non-metastatic MIBC, and there is mounting evidence that the potentially curative treatments for non-metastatic bladder cancer are persistently underutilised [14,29,56,80,82]. There is also evidence of bladder cancer recommendations being influenced by patient age and geographic region [14,20,82] (Table 2).
There has been a failure to improve outcomes in bladder cancer over the last 30 years. This is despite clinical trial evidence showing a benefit of interventions such as neoadjuvant chemotherapy or concurrent radiosensitisation for non-metastatic muscle-invasive bladder cancer. The bladder cancer population is characteristically elderly, who typically suffer from multiple comorbidities. Historically, radical cystectomy has been heralded as the treatment of choice, with radiotherapy being reserved for those with inoperable tumours or those unfit for major pelvic surgery, despite a lack of robust comparative or quality of life data to support one treatment recommendation over the other. Although patients with non-metastatic muscle-invasive bladder cancer have potentially curable disease, a growing body of population-based analyses persistently highlights that most patients do not undergo curative-intent treatments – a trend that remains static. The causes for the disparity between evidence and routine practice is not clearly understood. Here, the facets of patient-centred evidence-based care, with respect to bladder conservation therapy, are examined, with proposals to reverse this unacceptable status quo.
Radical cystectomy in a cohort of octogenarians managed in the ERAS era
2021, Urologic Oncology: Seminars and Original Investigations
To describe contemporary perioperative outcomes for octogenarians managed under an Enhanced Recovery After Surgery (ERAS) protocol. ERAS protocols have improved outcomes in radical cystectomy (RC), though outcomes for octogenarian patients undergoing RC in the modern ERAS era are not well researched. ERAS components have been gradually implemented into our clinical care pathways over the past 10 years.
Octogenarians undergoing RC at our institution were retrospectively identified between 2009 and 2019. Cox proportional hazards models examined changes in time to hospital discharge and time to bowel movement over time, and logistic regression models examined differences in 90-day readmissions and discharge dispositions over time. Secondary analyses examined the effect of alvimopan on time to hospital discharge and time to bowel movement using log-rank tests, along with 90-day readmissions and discharge dispositions using Chi-squared tests.
Seventy octogenarian patients underwent RC during the study period. Median time to bowel movement was 6 days, while median time to hospital discharge was 9 days. Two-thirds of patients were discharged to home and 22% were readmitted within 90 days. There were no statistically significant associations between year of surgery and perioperative outcomes. Patients taking alvimopan had decreased time to hospital discharge (hazard ratio = 2.7, 95% confidence interval [1.5, 5.0], P = 0.002), but showed no difference in other perioperative outcomes.
Octogenarians treated with RC had no significant changes in perioperative outcomes during the implementation of ERAS components at our institution. However, octogenarians taking alvimopan were observed to have decreased time to hospital discharge.
The Feasibility and Impact of a Presurgical Exercise Intervention Program (Prehabilitation) for Patients Undergoing Cystectomy for Bladder Cancer
2020, Urology
To assess the feasibility of a prehabilitation program for cystectomy patients and to determine the effectiveness of the program in improving strength and functional capacity in the peri-operative period.
This phase I/II study accrued patients ≥60 years old from January 2013 to October 2017 with biopsy-proven bladder cancer, Karnofsky performance score ≥70 and a sedentary baseline lifestyle to participate in a 4-week supervised preoperative exercise training program. Primary outcomes were feasibility and safety; secondary outcomes included changes in fitness, patient-reported QOL, peri-operative complications and readmissions. Student's ttests and Wilcoxon signed-rank test were performed.
Fifty-four patients enrolled in the program. Successful completion, defined as patients who began the program and adhered to >70% of the sessions, was attained by 41 of 51 patients (80.4%, 90% CI [71%-90%]). There were no adverse events. Fitness and patient-reported QOL improved postintervention, with sustained improvements in general and mental health 90-days postsurgery. The primary limitation is no control group.
Prehabilitation prior to cystectomy is feasible, safe, and results in improvements in patient strength, endurance and sustained improvements in patient-reported QOL from baseline. Efforts to further evaluate the impact of prehabilitation in this population in an expanded and randomized fashion are warranted.
Longitudinal patterns of cost and utilization of medicare beneficiaries with bladder cancer
2020, Urologic Oncology: Seminars and Original Investigations
Bladder cancer (BC) is highly prevalent and costly. This study documented cost and use of services for BC care and for other (non-BC) care received over a 15-year follow-up period by a cohort of Medicare beneficiaries diagnosed with BC in 1998.
Data came from the Surveillance, Epidemiology and End Results Program linked to Medicare claims. Medicare claims provided data on diagnoses, services provided, and Medicare Parts A and B payments. Cost was actual Medicare payments to providers inflated to 2018 US$. Cost and utilization were BC-related if the claim contained a BC diagnosis code. Otherwise, costs were for “other care.” For utilization, we grouped Part B-covered services into 6 mutually-exclusive categories. Utilization rates were ratios of the count of claims in a particular category during a follow-up year divided by the number of beneficiaries with BC surviving to year-end.
Cumulatively over 15-years, for all stages combined, total BC-related cost per BC beneficiary was $42,011 (95% Confidence Interval (CI): $42,405–$43,417); other care cost was about twice this number. Cumulative total BC-related cost of 15-year BC survivors for all stages was $43,770 (CI: $39,068–$48,522), intensity of BC-related care was highest during the first year following BC diagnosis, falling substantially thereafter. After follow-up year 5, there were few statistically significant changes in BC-related utilization. Utilization of other care remained constant during follow-up or increased.
Substantial costs were incurred for non-BC care. While increasing BC survivorship is an important objective, non-BC care would remain a burden to Medicare.
Comparative Perioperative Outcomes in Septuagenarians and Octogenarians Undergoing Radical Cystectomy for Bladder Cancer—Do Outcomes Differ?
2018, European Urology Focus
Treatment choice for muscle invasive bladder cancer continues to be radical cystectomy. However, radical cystectomy carries a relatively high risk of morbidity and mortality compared with other urological procedures.
To compare surgical complications following radical cystectomy in septuagenarians and octogenarians.
The National Surgical Quality Improvement Program database (2009–2013) was used to identify patients who were 70 yr and older and underwent radical cystectomy.
The data were analyzed for demographics and comorbidities, and compared for complications, including pulmonary, thromboembolic, wound, and cardiac complications. Patients who were 70–79 yr of age were compared with those 80 yr and older. Univariate and multivariate analyses were completed.
A total of 1710 patients aged ≥70 yr met our inclusion criteria. Of them, 28.8% (n = 493) were 80 yr and older, while 71.2% (n = 1217) were between 70 and 79 yr old. Operative time (338.4 vs 307.2 min, p = 0.0001) and the length of stay (11.9 vs 10.4 d, p = 0.0016) were higher in the octogenarian group. The intra- and postoperative transfusion rates, reoperative rates, wound dehiscence rates, and pneumonia, sepsis, and myocardial infarction rates were similar between the two groups. The wound infection rate (7.3% vs 4.1%, p = 0.01) was higher in the septuagenarians and mortality rate (4.3% vs 2.3%, p = 0.04) was higher in the octogenarian group.
Radical cystectomy can safely be performed in octogenarians without increased cardiac, pulmonary, and thromboembolic complications when compared with septuagenarians. These patients need to be counseled that the mortality rate is slightly higher compared with that in septuagenarians. Chronological age alone should not be used to decide on offering radical cystectomy.
We looked at complications following radical cystectomy in patients aged 80 yr and older. We found that there was no significant difference for wound, cardiac, or pulmonary complications, but there was an increased risk of mortality in this age group.
The relationship of travel distance with cystectomy access and outcomes
2018, Urologic Oncology: Seminars and Original Investigations
Regionalization of care and travel distance may result in unintended consequences for complex surgery such as cystectomy. Our objective was to evaluate effect of differential distance on cystectomy receipt among patients with muscle-invasive bladder cancer (MIBC) and investigate the association between travel distance and cystectomy outcomes such as readmission.
Using a linked data resource combining the NC Central Cancer Registry with claims data from Medicare, Medicaid, and private insurance plans, we included 736 patients with MIBC and 1,082 who underwent cystectomy. To evaluate access, differential distance was calculated as the difference between the nearest urologist and nearest cystectomy provider. To assess outcomes, logistic regression was used to evaluate rehospitalization and major complications, and Cox proportional hazards model for survival analysis.
To evaluate access and outcomes, 736 patients with MIBC and 1,082 patients undergoing cystectomy were evaluated, respectively. Overall, 29% (211 of 736) with MIBC underwent cystectomy. Differential distance was not a predictor of cystectomy receipt (odds ratio = 1.0; 95% CI: 1.00, 1.01). Among patients undergoing cystectomy, travel distance from cystectomy provider was not a significant predictor of 30- or 31 to 90 day readmissions (odds ratio = 1.0; 95% CI: 1.00, 1.00) although patients who lived further from their cystectomy provider were more likely to be readmitted to a nonindex hospital (P<0.001) when controlling for other factors. Although travel distance did not have a significant effect on overall survival, patients readmitted between 31 to 90 days had worse overall survival (P<0.0001).
The additional distance needed to reach a cystectomy provider did not predict receipt of surgery for MIBC. Furthermore, travel distance from cystectomy provider was not a significant predictor for subsequent readmission after cystectomy and did not affect overall survival.

View all citing articles on Scopus

: D. Schrag supported by a career development award in preventive oncology (K07) from the National Cancer Institute.

: This study used the linked SEER-Medicare Database. The interpretation and reporting of these data are the sole responsibility of the authors.

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Adult urologyCystectomy for muscle-invasive bladder cancer: Patterns and outcomes of care in the medicare population

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Data sources

Results

Comment

Acknowledgment

J Urol

J Clin Epidemiol

J Chronic Dis

J Clin Epidemiol

Randomized trials of adjuvant and neoadjuvant chemotherapy in bladder cancer

Semin Urol Oncol

Bladder cancer, including upper tract tumors and transitional cell carcinoma of the prostate. National Comprehensive Cancer Network

Cancer of the bladder

International Classification of Diseases for Oncology

Potential for cancer related health services research using a linked Medicare-tumor registry database

Med Care

AJCC Cancer Staging Manual

International Classification of Diseases

Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group

Stat Med

Issues of study design and data analysis

Inflamm Bowel Dis

The effectiveness of adjustment by subclassification in removing bias in observational studies

Biometrics

Adult urology
Cystectomy for muscle-invasive bladder cancer: Patterns and outcomes of care in the medicare population