National Practice Patterns and Outcomes for T4b Urothelial Cancer of the Bladder

Management of cT4b bladder cancer is poorly defined; national guidelines recommend chemotherapy (CT) alone or chemoradiation (CRT). Using a large, contemporary dataset, we evaluated national practice patterns as well as associated outcomes, especially with respect to radical cystectomy (RC) and CRT versus CT alone.

The National Cancer Data Base was queried (2004-2013) for patients diagnosed with cT4bN0-3M0 bladder cancer. Patients were divided into 5 treatment groups: CT alone, CRT, RC (with/without CT/radiotherapy [RT]), other treatment (subtherapeutic RT with/without CT), or no treatment. Statistics included multivariable logistic regression to determine factors predictive of observation, Kaplan-Meier analysis to evaluate overall survival (OS), and Cox proportional hazards modeling to determine variables associated with OS.

Of 896 total patients, 185 (20.6%) underwent CT alone, 80 (8.9%) CRT, 161 (18.9%) RC, 221 (24.7%) other treatments, and 249 (27.8%) observation. Differences in treatment paradigms were appreciated based on age, gender, nodal status, insurance, and facility-related parameters. Observation yielded a median OS of 3.7 months, lower than CT alone (P < .001). As compared with the latter, CRT was associated with higher OS (10.5 vs. 12.1 months, P = .004). RC-based treatment displayed the numerically highest OS (14.2 months) and was statistically similar to CRT (P = .676). Treatment with any modality independently predicted for superior OS over observation.

In the largest study of its kind, a surprisingly high proportion of patients underwent observation. CRT is associated with higher survival over CT alone, and carefully selected patients undergoing RC may experience prolonged survival.