The effect of centralization of care on overall survival in primary urethral cancer

Centralization of care to high-volume centers improves outcomes across urologic malignancies, but there exists a paucity of data for low-incidence cancers. Given the rarity of primary urethral cancer (UC) and the need for complex multidisciplinary treatment, we sought to evaluate differences in practice patterns and clinical outcomes across types of treating facilities.

We identified all patients diagnosed with UC from 2004 to 2016 in the National Cancer Database. The Kaplan-Meier method was used to evaluate overall survival (OS) and multivariable Cox regression analysis was used to investigate independent predictors of OS. The chi-square test was used to analyze differences in practice patterns.

We identified 6,445 patients with UC. Median overall survival was 40.5 months (interquartile range 38.4-42.6). There was a significant difference in OS based upon facility type, and this difference remained significant on subgroup analysis for squamous cell carcinoma and urothelial carcinoma. Academic centers had superior OS on pairwise comparisons (all P< 0.05) and were associated with decreased risk of death, hazard ratio 0.858 (95% confidence interval 0.749-0.983). Academic centers had a significantly greater frequency of neoadjuvant/adjuvant chemotherapy and radiation (P < 0.001). Academic centers performed radical surgery in 34.1% of patients compared to 14.5% in community programs (P < 0.001), and regional lymphadenectomy in 31.6% of patients compared to 13.2% in community programs (P < 0.001).

There exist significant differences in survival for patients with UC based upon treating facility. Variations in practice patterns including multimodal treatment, radical surgery, and regional lymphadenectomy may contribute to the observed differences in clinical outcomes.