Abstract
BACKGROUND: Neoadjuvant chemotherapy followed by radical cystectomy (NACT-RC) is the prevailing standard of care for muscle-invasive bladder cancer (MIBC), but trimodality treatment (TMT) using chemoradiation after transurethral resection of bladder tumor (TURBT) is an effective alternative in select patients. OBJECTIVE: This study examined patterns of care and impact of social determinants of health on the overall survival (OS) using the National Cancer Database (NCDB). METHODS: Data on patients aged ≥18 years with stage II-IIIA MIBC treated with TMT or NACT-RC during 2014-2021 were analyzed with propensity score matching. Logistic and Cox regression were used to evaluate the association of social determinants of health with patterns of care and OS. RESULTS: Among 18,072 cases (mean age 68.3 years), 77.1% received NACT-RC. TMT use increased from 18.4% in 2014 to 27.1% in 2021 (p < 0.001). The odds for receiving NACT-RC were higher for patients with stage IIIA (odds ratio (OR) = 1.21, 95% confidence interval (CI) 1.09-1.34). However, older patients (OR 0.86, 95% CI 0.87-0.88), those treated at comprehensive community cancer programs (OR 0.51, 95% CI: 0.46-0.55), or used Medicaid (OR = 0.48, 95% CI 0.39-0.61) had lower odds for receiving NACT-RC. In propensity score matching analysis, NACT-RC was associated with lower mortality compared to TMT (Hazard ratio (HR) = 0.66, 95% CI:0.59-0.73). Medicaid users receiving NACT-RC had the highest mortality risk (HR = 1.47, 95% CI:1.28-1.68, p(interaction)=0.001). CONCLUSION: TMT for MIBC has increased in recent years. Selection between NACT-RC and TMT was influenced by age, stage, diagnosis year, comorbidities, travel distance, facility, and insurance type, highlighting disparities in MIBC treatment. CATEGORIES: Radiation Oncology, Oncology.