Introduction:

Non-muscle-invasive bladder cancer (NMIBC) is a uniquely burdensome chronic condition due to its high recurrence rate. Depending on AUA risk level, NMIBC management may require 19 or more urology visits per year for surgery, surveillance cystoscopies, intravesical treatment, and imaging. Bladder cancer disproportionately affects older adults (median age at diagnosis 73 years), and older NMIBC patients juggle additional burdens due to co-existing chronic conditions and geriatric conditions. Treatment burden, defined as the work of being a patient, is emerging as an important patient-centered measure in other burdensome chronic conditions such as diabetes. However, little is known about treatment burden in the context of cancer and aging. Our objective was to evaluate the association between geriatric conditions using a geriatric assessment-derived deficit accumulation index (DAI) and patient-reported treatment burden in older adults with NMIBC.

Methods:

We conducted a cross-sectional survey of 119 older adults with NMIBC (age >=65 years at diagnosis, AJCC Stage <2) from 2019-2021. Using established methods, we calculated Deficit Accumulation Index (DAI) using the Cancer and Aging Research Group’s survey-based geriatric assessment, cognitive screening, Timed Up and Go (TUG), and labs. DAI categories were: robust (<0.2), pre-frail (0.2<0.35), and frail (>=0.35). Urogenital Distress Inventory-6 (UDI-6) was administered to measure urinary symptoms. The primary outcome was patient-reported treatment burden measured by the Treatment Burden Questionnaire (TBQ, range 0-150). Following multiple imputation for missing data, a negative binomial regression with LASSO penalty was used to model TBQ. In a convergent mixed methods design, we conducted template analysis of responses to an open-ended survey question: “Please share with us what has been your Greatest Challenge in managing medical care for your bladder cancer.” Responses were coded and integrated with DAI category in a joint display.

Results:

Mean age was 78.9 years, 77.3% were male, 57.1% high school educated, 45.4% were rural, 87.4% had multimorbidity, 24.4% had polypharmacy, and 33.1% intermediate/slow TUG. By DAI category, 56.3% were robust, 30.3% were pre-frail, and 13.4% were frail. Mean TBQ scores were low (15.8, SD 15.5). Financial burden, appointment frequency, and lab tests/exams were the most frequent treatment burdens (Figure 1). In the multivariable model, DAI and UDI-6 were most significantly associated with TBQ. Patients with DAI above the median (>0.21) had TBQ scores 1.94 times greater than those below (IRR 1.94, 95% CI 1.33-2.82). Similarly, individuals with UDI-6 greater than the median (25) had TBQ scores 1.7 times greater than those below (IRR 1.70, 95% CI 1.16-2.49). The top 5 most frequent themes identified in responses to the Greatest Challenge question were cancer treatments (22.2%), cancer worry (19.2%), urination bother (18.2%), self-management (18.2%), and appointment time (11.1%, Table 1).

Conclusion:

In this cross-sectional survey study of older adults with NMIBC, we found that a geriatric assessment-based Deficit Accumulation Index and urinary symptoms were associated with patient-reported treatment burden. Older adults with NMIBC shared that their greatest challenges centered around burdens from managing cancer treatments, cancer-related worry about recurrence and progression, bother from urinary side effects of NMIBC treatment, self-management of urinary catheters, and time spent in appointments. These data suggest that urologists should consider a holistic approach to NMIBC management in older adults that accounts for the additive burdens of aging as well as the impact of urinary side effects from intravesical therapy.

Funding: This work was supported by the National Institute on Aging at the National Institutes of Health (grant number R03AG064382), Yale Claude D. Pepper Older Americans Independence Center (grant number P30AG021342), and the Duke Claude D. Pepper Older Americans Independence Center (grant number P30AG028716).