Comparison of Neoadjuvant and Adjuvant Chemotherapy in Muscle-invasive Bladder Cancer |
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| Affiliation: | 1. Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI;2. Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI;3. Division of Urology, William S. Middleton Memorial Veterans Hospital, Madison, WI;4. Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA;5. Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI;6. Department of Urology, H. Lee Moffitt Cancer Center, Tampa, FL;7. Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA;8. Department of Operations and Decision Technologies, Kelley School of Business, Indiana University, Bloomington, IN;9. VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI;1. Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada;2. Urology Unit, ASST Spedali Civili of Brescia. Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Italy;3. Department of Urology, European Institute of Oncology, Milan, Italy;4. Martini Klinik, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;5. Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy;6. Department of Urology, Medical University of Vienna, Vienna, Austria;7. Division of Urology, University of Montreal Hospital Center (CHUM), Montreal, Quebec, Canada;8. Division of Experimental Oncology/Unit of Urology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute, Milan, Italy;9. Vita-Salute San Raffaele University, Milan, Italy |
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| Abstract: | BackgroundWe use observational methods to compare impact of perioperative chemotherapy timing (ie, neoadjuvant and adjuvant) on overall survival (OS) in muscle-invasive bladder cancer because there is no head-to-head randomized trial, and patient factors may influence decision-making.Patients and MethodsUsing Surveillance, Epidemiology, and End Results-Medicare data, we identified patients receiving cystectomy for muscle-invasive bladder cancer diagnosed between 2004 and 2013. Patients were classified as receiving neoadjuvant or adjuvant chemotherapy. Propensity of receiving neoadjuvant chemotherapy was determined using gradient boosted models. Inverse probability of treatment weighted survival curves were adjusted for 13 demographic, socioeconomic, temporal, and oncologic covariates.ResultsWe identified 1342 patients who received neoadjuvant (n = 676) or adjuvant chemotherapy (n = 666) with a median follow-up of 23 months (interquartile range, 9-55 months). Inverse probability of treatment weighted adjustment allows comparison of the groups head-to-head as well as counterfactual scenarios (eg, effect if those getting one treatment were to receive the other). The average treatment effect (ie, “head-to-head” comparison) of adjuvant compared with neoadjuvant on OS was not significant (hazard ratio, 1.14; 95% confidence interval, 0.99-1.31). However, the average treatment effect of the treated (ie, the effect if the neoadjuvant patients were to receive adjuvant instead) was associated with a 33% increase in risk of mortality if they were given adjuvant therapy instead (hazard ratio, 1.33; 95% confidence interval, 1.12-1.57).ConclusionSignificant treatment selection bias was noted in peri-cystectomy timing, which limits the ability to discriminate differential efficacy of these 2 approaches with observational data. However, patients with higher propensity to receive neoadjuvant therapy were predicted to have increased OS with approach, in keeping with existing paradigms from trial data. |
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| Keywords: | Drug therapy Health services research Medicare SEER program Urinary bladder neoplasms |
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