Concurrent chemoradiotherapy for bladder cancer: Practice patterns and outcomes in the general population

doi:10.1016/j.radonc.2017.12.009

Radiotherapy and Oncology

Volume 127, Issue 1, April 2018, Pages 136-142

https://doi.org/10.1016/j.radonc.2017.12.009 Get rights and content

Abstract

Background

Clinical trials have shown that chemoradiotherapy (CRT) improves survival compared to radiation therapy (RT) alone in muscle-invasive bladder cancer. We describe uptake of CRT and comparative effectiveness in routine practice.

Methods

Electronic treatment records were linked to the population-based Ontario Cancer Registry to identify all patients with bladder cancer treated with curative-intent RT in 1999–2013. Modified Poisson regression was used to analyze factors associated with use of CRT. Cox model and propensity score analyses were used to explore factors associated with cancer-specific (CSS) and overall survival (OS).

Results

1192 patients underwent RT during 1999–2013; median age was 79. Use of CRT increased over time: 36% (124/341) in 1999–2003, 38% (153/399) in 2004–2008, 48% (217/452) in 2009–2013 (p = 0.001). Drug details were available for 82% (402/493) of CRT cases; the most common regimens were single-agent Cisplatin (57%, 230/402), single-agent Carboplatin (31%, 125/402) and 5-FU/Mitomycin (4%, 17/402). Factors associated with CRT include younger age (p < 0.001), lower comorbidity (p = 0.001), and geographic region (range 14–89%, p < 0.001). Five year CSS and OS among CRT cases were 45% (95%CI 39–51%) and 35% (95%CI 30–40%). On adjusted analyses CRT was associated with superior survival compared to RT (CSS HR 0.70, 95%CI 0.59–0.84; OS HR 0.74, 95%CI 0.64–0.85); results were consistent on propensity score analysis. There was significant improvement in survival of all RT-treated cases (irrespective or chemotherapy delivery) in 2009–2013 compared to 1999–2003 (CSS HR 0.77, 95%CI 0.61–0.97; OS HR 0.82, 95%CI 0.69–0.98).

Conclusion

CRT is associated with superior survival compared to RT alone and its uptake corresponded to improved survival among all RT-treated cases in the general population. Uptake of CRT varies widely by geographic region.

Section snippets

Study design and population

This is a population-based, retrospective cohort study to describe management and outcome of muscle-invasive bladder cancer in the Canadian province of Ontario. Ontario has a population of approximately 13.5 million people and a single-payer universal health insurance program. All incident cases of bladder cancer in Ontario with urothelial carcinoma, adenocarcinoma, and squamous cell histology treated with RC or RT during 1999–2013 were included. The study population was classified into three

Study population

During 1999–2013, 1192 patients in Ontario with bladder cancer underwent curative-intent RT (Supplemental eFig. 1). As shown in Supplemental eFigs. 1 and 2, the vast majority (>75%) of patients treated with curative intent in Ontario undergo cystectomy and not radical RT. Moreover, substantially more patients with bladder cancer are treated with palliative-intent RT rather than curative-intent RT. Over the three study periods, the proportion of patients treated with radical RT and radical

Discussion

We describe the management and outcomes of all patients with bladder cancer treated with curative-intent RT in the general population of Ontario during 1999–2013. Several important findings have emerged. Second, while the proportion of patients treated with RT vs cystectomy has remained relatively stable, the proportion of those cases treated with CRT has increased significantly in the most recent years. Second, advanced age, and greater comorbidity are independently associated with decreased

Funding

Dr. Booth is supported as the Canada Research Chair in Population Cancer Care. This work was supported by grants from the Canada Foundation for Innovation and the Canadian Cancer Society Research Institute.

Conflict of interests statement

The authors have no conflict of interests to disclose.

Acknowledgments

Parts of this material are based on data and information provided by Cancer Care Ontario. However, the analysis, conclusions, opinions and statements expressed herein are those of the authors and not necessarily those of Cancer Care Ontario.

Parts of this material are based on data and information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI.

This study was supported by the

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Despite the reported acceptable tolerability and toxicity reported in the CRT trials, CRT in this non-trial population was only prescribed in just 40% of this UK cohort. A recent publication by Ghate et al. [32], detailing the penetrance of CRT between 1999 and 2013, using the Ontario Cancer Registry, describes increasing use with time, to a level of 48% of patients receiving CRT 2009–2013. This low-level uptake within the UK, despite unequivocal recommendations, reflects hesitancy in the treating clinicians and a reluctance to embrace evidence-based medicine.
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This is the largest multicentre prospective study to define contemporary management of MIBC in patients receiving radiotherapy within the UK. The population studied is the oldest described to date. Timelines to starting definitive treatment confirm an urgent need to streamline the pathway. An increasing use of NAC is described, although the penetrance of CRT is disappointingly low. Areas for improvement with regards to the delivery and quality of radiotherapy have been identified. The detail within this study can be used to inform practice and future trial design, ultimately with the aim of improving outcomes for patients with MIBC.
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Utilization of bladder cancer RTConcurrent chemoradiotherapy for bladder cancer: Practice patterns and outcomes in the general population

Abstract

Background

Methods

Results

Conclusion

Section snippets

Study design and population

Study population

Discussion

Funding

Conflict of interests statement

Acknowledgments

Eur Urol

Clin Oncol (R Coll Radiol)

Eur Urol

Int J Radiat Oncol Biol Phys

J Clin Epidemiol

Urology

Clin Oncol (R Coll Radiol)

Int J Radiat Oncol Biol Phys

Guideline on muscle-invasive and metastatic bladder cancer (European Association of Urology Guideline): American Society of Clinical Oncology Clinical Practice Guideline Endorsement

J Clin Oncol

Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1054 patients

J Clin Oncol

Combined-modality treatment and selective organ preservation in invasive bladder cancer: long-term results

J Clin Oncol

Improved local control of invasive bladder cancer by concurrent cisplatin and preoperative or definitive radiation. The National Cancer Institute of Canada Clinical Trials Group

J Clin Oncol

Radiotherapy with or without chemotherapy in muscle-invasive bladder cancer

N Engl J Med

Utilization of bladder cancer RT
Concurrent chemoradiotherapy for bladder cancer: Practice patterns and outcomes in the general population