Introduction:

Delayed radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC) has been associated with decreased survival. However, the definition of delayed cystectomy (DC) varies. Utilizing a large population-based database, we sought to evaluate the temporal inflection point at which cystectomy delay leads to increased mortality as also to identify factors associated with DC.

Methods:

11,468 patients diagnosed with Stage II-IV bladder urothelial carcinoma who underwent RC from 2004 to 2013 were identified in the National Cancer Database. Those receiving neoadjuvant chemotherapy (NAC) (n=3,348) versus non-NAC (n=8,120) were identified and separated. Cox regression models were utilized to determine the temporal inflection point from date of diagnosis to date of cystectomy at which there was significantly increased risk of mortality in each group in order to define DC. Logistic regression models were then created to evaluate variables associated with DC as defined by our Cox model.

Results:

Cox regression analysis suggested increased mortality with DC beyond 60 (HR 1.06, 95% CI 1.00-1.13) and 210 days (HR 1.20, 95% CI 1.04-1.39) for non-NAC and NAC cohorts, respectively. Univariate analysis demonstrated distance to medical provider and insurance status were associated with DC regardless of NAC utilization (p<0.001). For non-NAC patients, increasing age, Hispanic race, non-private insurance, surgery at an academic center, and higher Charlson score were associated with DC, while female gender was associated with timely cystectomy (TC). For NAC patients, higher tumor stage and non-private insurance were associated with DC, while surgery at non-academic comprehensive community center and residence in areas with highest high-school graduation rates was associated with TC.

Conclusion:

Utilizing a large population-based dataset, we are able to suggest time-frames in which cystectomy should be performed in order to avoid unnecessary mortality due to delay. Inequities in health care delivery based on race, sex, insurance status, education, and treating hospital were identified as significant predictors of DC. While population-based data should not dictate changes in clinical management, future study is needed to address inequities in health care delivery to bladder cancer. Additionally, a more expedient referral system and timely transfer of medical services, particularly in academic centers, is needed to decrease latency to radical cystectomy. 

Funding: N/A