Adjuvant chemotherapy for bladder cancer: A detailed characterization of factors precluding utilization.

Abstract

Background: Adjuvant chemotherapy (AChT) can improve survival in select patients after radical cystectomy (RC), though it remains underutilized. We detail the factors that preclude candidate patients from receiving AChT. Methods: We analyzed the records of patients who underwent RC for urothelial carcinoma of the bladder (2003-2013) using our IRB approved database. Patients with ≥ pT3, pN+, and/or positive surgical margins were considered candidates for AChT. Patients who received neoadjuvant chemotherapy were excluded. A systematic review of medical records detailed the cited reasons for patients not undergoing AChT. Cases with low concern based upon pathologic staging were classified as ''surgeon discretion.'' Results: A total of 1379 patients underwent RC during this period and 249 (18%) received neoadjuvant chemotherapy. There were 528 (38%) patients who were eligible for AChT. Of these patients, 296 (56%) did not receive AChT, 177 (34%) received AChT, and 55 (10%) had insufficient records for determination of adjuvant treatments. Of the 296 eligible patients who did not receive AChT, there was no documented reason precluding AChT in 83 (28%). In 56 patients (19%) there was more than one reason for not undergoing AChT. The breakdown of cited factors precluding AChT is shown in the Table. The most commonly documented reasons were surgeon discretion based upon pathology, medical co-morbidities, advanced age, poor performance status, and patient preference. The most common medical co-morbidities precluding AChT were renal insufficiency and cardiovascular disease. Conclusions: Over half of eligible patients did not undergo AChT after RC with a wide range of cited reasons as justification. These variables should be considered when planning the optimal treatment regimen (e.g. neoadjuvant chemotherapy) for patients with advanced bladder cancer. (Table presented).