National Practice Patterns and Outcomes for T4b Urothelial Cancer of the Bladder.

Objective: Management of cT4b bladder cancer is poorly defined; national guidelines recommend chemotherapy (CT) alone or chemoradiation (CRT). Using a large, contemporary dataset, we evaluated national practice patterns as well as associated outcomes, especially with respect to radical cystectomy (RC) and CRT versus CT alone.

Methods: The National Cancer Data Base was queried (2004-2013) for patients diagnosed with cT4bN0-3M0 bladder cancer. Patients were divided into 5 treatment groups: CT alone, CRT, RC (with/without CT/radiotherapy [RT]), other treatment (subtherapeutic RT with/without CT), or no treatment. Statistics included multivariable logistic regression to determine factors predictive of observation, Kaplan-Meier analysis to evaluate overall survival (OS), and Cox proportional hazards modeling to determine variables associated with OS.

Results: Of 896 total patients, 185 (20.6%) underwent CT alone, 80 (8.9%) CRT, 161 (18.9%) RC, 221 (24.7%) other treatments, and 249 (27.8%) observation. Differences in treatment paradigms were appreciated based on age, gender, nodal status, insurance, and facility-related parameters. Observation yielded a median OS of 3.7 months, lower than CT alone (P < .001). As compared with the latter, CRT was associated with higher OS (10.5 vs. 12.1 months, P = .004). RC-based treatment displayed the numerically highest OS (14.2 months) and was statistically similar to CRT (P = .676). Treatment with any modality independently predicted for superior OS over observation.

Conclusions: In the largest study of its kind, a surprisingly high proportion of patients underwent observation. CRT is associated with higher survival over CT alone, and carefully selected patients undergoing RC may experience prolonged survival.