CURATIVE TREATMENT OF PATIENTS WITH MUSCLE INVASIVE BLADDER CANCER

Nearly half of US patients with muscle-invasive bladder cancer (MIBC) are not being offered treatment with curative intent, say experts.

Because of this, survival rates at local centers have not improved in 3 decades and are about half of those seen in centers of excellence. Five-year survival rates for locoregional disease are now around 69% to 85% at centers of excellence but are only 35% to 40% at local centers.

Ralph de Vere White, MD, University of California, Davis, Comprehensive Cancer Center, Sacramento, and colleagues argue that this is because too few patients at local centers are receiving treatment with curative intent.

Such treatment includes cystectomy or trimodal therapy, which consists of transurethral resection of the bladder plus chemotherapy and radiotherapy.

A paradigm shift in care is needed, they say, so that such treatments can be delivered to patients who are being treated at local centers.

De Vere White and coauthors suggest that hospitals and health systems that are considered to be bladder cancer centers of excellence should partner with smaller centers, community practices, and individual providers to ensure their patients receive the most effective therapy possible.

This new approach, endorsed by the Society of Urological Oncology, should be led by an interdisciplinary team from various national urology, medical oncology, and radiation oncology professional organizations, they add.

The new plan, as well as the current problem, is outlined in an article published online January 17 in the Journal of Clinical Oncology.

The problem comes from a "perfect storm" of numerous factors that are contributing to the poor outcomes seen in local centers, says de Vere White.

These include the costly and complex nature of cystectomy, patients being unwilling or unable to afford to travel long distances to centers of excellence, and local hospitals or clinics not wanting to face postoperative complications.

In addition, "There may be considerable confusion among urologists, radiation therapists, and medical oncologists on how best to select patients" for the optimal treatment strategies, the authors suggest.

The result is that more than half of patients at local centers do not receive treatment with curative intent, which is not the case in centers of excellence.

A study that reported on 3205 Medicare patients with stage II (organ-confined, nonmetastatic) urothelial cancer in the Surveillance, Epidemiology, and End Results database showed that only 21% underwent radical cystectomy, with a resultant 42% 5-year overall survival rate, and that half (51%) of the patients underwent surveillance, resulting in a 14.5% 5-year survival rate (J Natl Cancer Inst. 2010:102;802-811).

"We need doctors and patients to understand that, at this time, many patients are not receiving treatment that could prolong their life, and we need to find out why," de Vere White commented in a statement.

"We should have addressed this much earlier.... So I do think it is incumbent on the leaders of urological oncology to recognize this problem and to put considerable effort and resources into helping us solve it."

"Why Did We Not Notice This?"

Speaking to Medscape Medical News, de Vere White said that it would be a "very fair question" to ask: "Why did all of you in leadership not notice this?"

He said that, unfortunately, there is no "absolute answer" to why it has taken 30 years for the problem to become apparent.

"I think I've written something like 76, 77 papers on bladder cancer, and I just never knew anything about this until 2 years ago," de Vere White said in an interview.

"I think it's because we were concentrated on what was happening in our own programs, in our own centers...and we somehow were unaware that there were so many patients not getting into those centers of excellence," he said.

So why has survival improved only in centers of excellence and not for the whole patient population?

"We think the real problem is that there are too many patients who are not being given access to or who have chosen not to take treatments with curative intent," de Vere White said.

He pointed out that the "really fascinating thing" is that "we thought that we were going to be told, 'Well, this is the American healthcare system,' because when you look at people in centers of excellence, they in general have better financial means."

He noted, however, that a study from Sweden, "which has a totally different healthcare system," showed that the proportion of patients who did not receive treatment with curative was 57% (J Urol. 2019;202:905-912). This is only a little higher than the 51% to 52% seen in US studies.

To increase the proportion of patients who receive treatment with curative intent, effort is needed on a number of fronts, de Vere believes.

The first is to tackle the huge financial commitment that is often required in traveling to a center of excellence to receive standard of care for the treatment of MIBC. The cost of the travel alone can be a barrier, nevermind out-of-pocket costs of treatment. A survey in 2018 found that "60% of Americans could not come up with $1000 from savings for a real genuine emergency," he commented.

In addition, most of these patients are past an age when they are earning. The mean patient age is around 70 years, "so you're in the Medicare age group," he noted.

Another issue is that one of the treatments with curative intent involves complex surgery, but at a local center, only a small number of these operations may be performed each year, and "you do not want people doing the occasional cystectomy," he commented.

He envisages centers of excellence working with local communities. This requires use of video conferencing and other tools to assess the best treatment that patients can receive at their local center.

There needs to be a paradigm shift in the way that care is delivered, he suggested. de Vere White cited the sea change that has occurred in prostate cancer following the realization that basing biopsy and treatment choices on the results of prostate-specific antigen tests was leading to overtreatment on a large scale.

"I think the same thing is going to happen here," he said.

"If we know that there are patients who are going to have to be treated locally, who maybe can't get a cystectomy or whole trimodal therapy, can we develop other treatment options and ask: Are they better than having the patients receive no treatment with curative intent?"

The researchers are going to test that concept in a pilot project in northern California. They will bring together the major healthcare systems to develop a registry of patients with MIBC and to work with physicians to offer the most suitable treatment.

In the meantime, they want to tackle the perception among some patients that they would be better off not being treated for their disease.

"If you're 70 years old and you're told about the rigors of cystecomy and trimodal therapies, not unreasonably, it doesn't sound very appealing," de Vere White said.

"I think a lot of people say, 'Gosh, I've lived a good life, I want to spare myself that,' and they think that they will have a better quality of life without undergoing those treatments while accepting that, 'Yes, I may die.' "

However, de Vere White said, "The truth of the matter is there is absolutely no evidence whatsoever that they have a better quality of life." The best evidence suggests that, without treatment with curative intent, the risk of dying from bladder cancer is 75%, with 40% of patients dying within a year.

"You must admit that's not a great outcome," he said. "And then you can look at what happens in that year.

"People get bleeding, they get obstruction, some have cystectomies anyway for palliation, some get palliative diversion, some get nephrostomy tubes, so I think a major problem is that patients are not being told what they can expect if they turn down treatment with curative intent."

However, delivering that treatment "leads to another potential problem...and that is if you've got someone 60 miles away in a small town. We have to come up with some way that it can be delivered to that patient in the best possible fashion," he said.

No information regarding funding for the study has been provided. The study authors' relevant financial relationships are listed in the original article. 

J Clin Oncol. Published online January 17, 2020. Full text