Does care fragmentation in patients with bladder cancer lead to worse outcomes?

• Published in: Urologic oncology 2023-03, Vol.41 (3), p.147.e7-147.e14
• Main Authors: Riveros, Carlos, Chalfant, Victor, Elshafei, Ahmed, Bandyk, Mark, Balaji, K.C.
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Bladder cancer; Carcinoma, Transitional Cell - pathology; Cystectomy; Humans; Neoadjuvant Therapy; outcomes; patient care; Retrospective Studies; Urinary Bladder - pathology; Urinary Bladder Neoplasms - pathology
• ISSN: 1078-1439; 1873-2496
• DOI: 10.1016/j.urolonc.2022.10.028

•Fragmentation of care has been previously associated with worse oncologic outcomes.•In the setting of muscle-invasive bladder cancer, it is unknown whether fragmented care impacts overall survival.•We found that fragmented care was not associated with worse oncologic outcomes, including overall survival. Care fragmentation may influence oncologic outcomes. The impact of care fragmentation on the outcomes of patients receiving neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC) is not well defined. We aimed to compare outcomes between patients who received fragmented care (FC) versus non-fragmented care (NFC). The National Cancer Database was queried for adult (≥18 years old) patients with cT2-T4aN0M0 urothelial carcinoma of the bladder receiving NAC followed by RC between 2004 and 2017. Patients were dichotomized based on whether they received FC (defined as receiving NAC at a different facility from where RC was performed) or NFC (defined as receiving NAC and RC at a single facility). The main outcome of interest was overall survival (OS). Secondary outcomes included time from diagnosis to treatment (NAC and RC) and perioperative outcomes. Kaplan-Meier survival estimates were calculated after stratifying by type of care received. Multivariable Cox regression analysis was performed to evaluate the association between FC and OS in the context of other clinically relevant covariates. A total of 2223 patients were included: 1035 (46.6%) received FC whereas 1188 (53.4%) received NFC. Factors associated with FC included greater travel distance, higher comorbidity burden, and surgical treatment at a high-volume facility. Patients who received FC had a slightly longer median time to RC (160 vs. 154 days, P = 0.001). However, on Kaplan-Meier analysis no differences in median OS were found between the two groups. On multivariable Cox regression analysis, factors associated with worse OS included age, advanced TNM stage, lymphovascular invasion, and positive surgical margins; yet FC was not associated with worse OS (hazard ratio [HR] 1.02; 95% confidence interval [CI] 0.88–1.17). On subgroup analysis, we found that FC received at academic facilities (HR 0.76; 95% CI 0.58–0.99), as well as NFC received at high-volume centers (HR 0.65; 95% CI 0.43–0.98), were associated with a decrease in overall mortality. Fragmented care is not associated with worse survival outcomes in patients with MIBC receiving NAC followed by RC