Use of Bladder Sparing Surgery for Muscle Invasive Bladder Cancer by Life Expectancy at Diagnosis

Patients who are older and sicker are ideal candidates for bladder sparing therapy for muscle invasive bladder cancer given risks of treatment related morbidity with radical cystectomy and cancer mortality with observation. However, little is known about the independent impact of age, comorbidity and life expectancy on utilization of bladder sparing therapy.

We sampled 19,228 patients with muscle invasive bladder cancer diagnosed between 2004 and 2013 from the National Cancer Database. We used multivariable multinomial logistic regression to determine relative risk ratios and predicted probabilities of receipt of bladder sparing therapy by estimates of life expectancy, and by age and comorbidity at diagnosis.

On multivariable analysis decreasing life expectancy was significantly associated with higher use of bladder sparing compared with cystectomy (relative RR 1.08, 95% CI 1.07-1.08). However, absolute changes were modest with predicted probability of bladder sparing increasing from 8%, 10%, 12%, 14% and 17% among patients with 25-year, 20-year, 15-year, 10-year and 5-year life expectancies, respectively. By comparison, rates of cystectomy decreased from 54%, 47%, 39%, 32% and 26% and rates of observation increased from 22%, 26%, 31%, 36% and 40% across the same life expectancy subgroups, respectively. Age had a stronger effect on relative risk of bladder sparing than comorbidity. Predicted probabilities of bladder sparing therapy increased from 8%, 12%, 16% and 19% among 60-year-old, 70-year-old, 80-year-old and 90-year-old patients, respectively, while the probability was 13%, 13% and 15% among patients with Charlson scores of 0, 1, and 2+, respectively.

Bladder sparing therapy is underused in patients who are older and sicker with limited life expectancy who currently primarily receive observation or, less often, radical cystectomy.