3230 - Patterns of Care and Associated Socioeconomic Determinants of Health in the Definitive Treatment of Localized Muscle-Invasive Bladder Cancer Patients

M. Mai¹, V. Tran¹, A. Zhu², D. Appiah³, and Z. Shi⁴; ¹School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, ²Rice University, Houston, TX, ³Department of Public Health, School of Population and Public Health, Texas Tech University Health Sciences Center, Lubbock, TX, ⁴School of Medicine, Texas Tech University Health Sciences Center, Radiation Oncology Clinic, UMC Cancer Center, Lubbock, TX

Purpose/Objective(s): Radical cystectomy is the prevailing standard of care for muscle-invasive bladder cancer (MIBC) patients. However, emerging data has shown that a bladder preservation approach using concurrent chemoradiation after transurethral resection of bladder tumor (TURBT), i.e. combined modality treatment (CMT), is an effective alternative in select MIBC patients. The purpose of this study is to gain deeper understanding of patterns of care related to MIBC, to examine potential health socioeconomic disparities in relation to access to both treatments, and to investigate whether variances in treatment approaches impact the overall survival (OS) of patients using the National Cancer Database. Materials/

Methods: Patients aged 18 years and older diagnosed with primary transitional or urothelial cell carcinoma of the bladder between 2014 and 2021, who received CMT or neoadjuvant chemotherapy followed by radical cystectomy (NACT-RC) for stage II-IIIA bladder cancer were retrospectively analyzed. Logistic regression methods were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association between baseline characteristics and type of treatment. Cox regression was used to evaluate the risk of mortality.
Results: There were 18,248 cases of stage II-IIIA bladder cancer that received CMT (n=4,274) or NACT-RC (n=13,974). The mean age was 68.4 years old (standard deviation 9.9 years), with majority of them being males (76.3%) and Non-Hispanic White (87.3%). In multivariable adjusted models, the odds of NACT-RC were significantly increased for stage IIIA (OR 1.21, 95% CI 1.09-1.35) and traveling more than 30 miles to the treatment facility (OR 1.86, 95% CI 1.66-2.08) when compared to CMT. The odds of NACT-RC were significantly decreased with each additional year of age at diagnosis (OR 0.87, 95% CI 0.86-0.87), each additional year of diagnosis after 2014 (OR 0.93, 95% CI 0.91, 0.95), treatment at a comprehensive community cancer program (OR 0.52, 95% CI 0.47-0.57), having Charlson-Deyo score 2 or more (OR 0.66, 95% CI 0.59-0.74), and having Medicaid (OR 0.49, 95% CI 0.39-0.61). In time-to-event analysis, CMT was associated with a lower probability of OS compared to NACT-RC (p<0.001). There was significant difference in OS among different insurance groups when adjusting for age and type of treatment. Participants using Medicaid had a higher risk of mortality compared to those using private/managed care (Hazard ratio: 1.23, 95% CI: 1.12-1.35).
Conclusion: Our study reveals a discernible increase in the utilization of CMT among MIBC patients in recent years. Factors such as age, comorbidities, clinical stage, travel distance, year of diagnosis, treatment facility, and type of health insurance significantly influence the choice of treatment. Notably, NACT-RC demonstrates better unadjusted OS rates compared to CMT. These findings highlight the substantial impact of socioeconomic factors on treatment decisions and their potential implications for OS.