Introduction:

Platinum-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is the gold standard treatment for muscle-invasive bladder cancer (MIBC). Utilization of NAC has slowly increased over the last two decades, and currently between 30-40% of patients receive some form of chemotherapy prior to cystectomy. Counseling and referral practices for NAC are poorly characterized, particularly for patients who are eligible yet do not receive it. The goal of this study was to describe reasons for NAC deferral in a cohort of patients with MIBC in order to inform interventions aimed at increasing appropriate NAC use.

Methods:

We performed a retrospective review of an institutional cystectomy case registry.  All patients undergoing partial or radical cystectomy for muscle-invasive urothelial cancer between June 2014 and July 2017 were identified. 466 patients were identified, of which 231 (49.6%) received NAC and were excluded. We also excluded patients with non-MIBC (108, 23.2%), pure squamous or adenocarcinoma histology (19, 4.1%), and those who underwent cystectomy for cancers of non-bladder origin or benign disease (19, 4.1%). Patient demographics, comorbidities, functional status, estimated glomerular filtration rate (GFR), and clinical encounters regarding NAC administration and surgical planning were recorded. Descriptive statistics were calculated to compare documented reasons for NAC deferral between patients referred and not referred to medical oncology for counseling. Documented deferral reasons were categorized into absolute and relative contraindication, patient preference, and not documented groups. Absolute contraindications included renal insufficiency and pathologic variant known to be unresponsive to chemotherapy.

Results:

89 patients with MIBC did not receive NAC (Table 1). 70 patients (78.7%) were not referred to medical oncology; among whom NAC deferral was categorized as relative (25.7%) or absolute (24.3%) contraindications, patient preference (21.4%), and not documented (24.3%) (Figure 1).  NAC was most commonly deferred due to renal insufficiency (24.3%), prior receipt of systemic therapy (10%), and variant histology (5.7%).19 patients (21.3%) were referred to medical oncology and NAC deferral was classified as relative (26.3%) or absolute (21.1%) contraindications, patient preference (47.4%), and not documented in (5.3%). Among these patients, NAC was most commonly deferred due to symptoms (10.5%), prior receipt of systemic therapy (10.5%), and renal insufficiency (10.5%). Referral to medical oncology by surgeons ranged from 10.0%-28.6%. In-depth chart review of patients without a documented reason for NAC deferral identified 8 absolute and 2 relative contraindications. Justification for NAC deferral was ultimately not identified in 9 (12.9%) patients.

Conclusion:

21.3% of patients who did not receive NAC were evaluated by a medical oncologist at a tertiary care center with high utilization of NAC for MIBC. Of those not referred to medical oncology, identified and/or documented reasons were evenly distributed between absolute contraindication, relative contraindication and patient preference categories. Documented reasons for NAC deferral were not identified in approximately a quarter of the patient subgroup evaluated by surgeons but not referred to medical oncology. More in-depth study of physician counseling and referral practices, as well as patient preference and involvement in the decision-making will better characterize this issue.

Funding: N/A