Use of Palliative Chemotherapy for Advanced Bladder Cancer: Patterns of Care in Routine Clinical Practice

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Background: Palliative chemotherapy for advanced bladder cancer is recommended in clinical practice guidelines. Patterns of care in routine clinical practice have not been well described. This article describes use rates of chemotherapy and referral rates to medical oncology in the last year of life among patients who have died of bladder cancer. Methods: A population-based cohort of patients with bladder cancer was identified from the Ontario Cancer Registry; the study population included patients who died of bladder cancer between 1995 and 2009. Electronic records of treatment and physician billing records were used to identify treatment patterns and referral to medical oncology. Log-binomial and modified Poisson regression were used to examine factors associated with chemotherapy use and medical oncology consultation. Results: A total of 8,005 patients died of bladder cancer, 25% (n=1,964) of whom received chemotherapy in the last year of life. Use was independently associated with patient age, comorbidities, socioeconomic status, sex, time period, and treatment region. A total of 68% (n=5,426) of patients were seen by a medical oncologist. Referral to medical oncology was associated with age, comorbidities, year of death. Geographic variation was seen with chemotherapy use—from 18% to 30%—that persisted on adjusted analysis. Conclusions: The efficacy of palliative chemotherapy demonstrated in clinical trials and recommended in guidelines has not translated into widespread use in practice. Understanding the extent to which patient preferences and health system factors influence use is needed. Access to acceptable palliative systemic treatments remains an unmet need for most patients dying of bladder cancer.

Correspondence: Andrew G. Robinson, MD, Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, 10 Stuart Street, Kingston, ON, K7L 3N6, Canada. E-mail: robinsa4@kgh.kari.net
  • 1.

    Cancer Facts & Figures 2014. American Cancer Society Web site. Available at: http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2014/. Accessed July 31, 2014.

    • Search Google Scholar
    • Export Citation
  • 2.

    Bamias A, Dafni U, Karadimou A. Prospective, open-label, randomized, phase III study of two dose-dense regimens MVAC versus gemcitabine/cisplatin in patients with inoperable, metastatic or relapsed urothelial cancer: a Hellenic Cooperative Oncology Group study (HE 16/03). Ann Oncol 2013;24:10111017.

    • Search Google Scholar
    • Export Citation
  • 3.

    Roberts JT, von der Maase H, Sengeløv L. Long-term survival results of a randomized trial comparing gemcitabine/cisplatin and methotrexate/vinblastine/doxorubicin/cisplatin in patients with locally advanced and metastatic bladder cancer. Ann Oncol 2006;17(Suppl 5):v118122.

    • Search Google Scholar
    • Export Citation
  • 4.

    Saxman SB, Propert KJ, Einhorn LH. Long-term follow-up of a phase III intergroup study of cisplatin alone or in combination with methotrexate, vinblastine, and doxorubicin in patients with metastatic urothelial carcinoma: a cooperative group study. J Clin Oncol 1997;15:25642569.

    • Search Google Scholar
    • Export Citation
  • 5.

    Bellmunt J, Orsola A, Wiegel T. Bladder cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2011;22(Suppl 6):vi4549.

    • Search Google Scholar
    • Export Citation
  • 6.

    Clark PE, Agarwal N, Biagioli MC. Bladder cancer. J Natl Compr Canc Netw 2013;11:446475. To view the most recent version of these guidelines, visit NCCN.org.

    • Search Google Scholar
    • Export Citation
  • 7.

    Witjes JA, Compérat E, Cowan NC. EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines. Eur Urol 2014;65:778792.

    • Search Google Scholar
    • Export Citation
  • 8.

    Use of chemotherapy in advanced unresectable or metastatic transitional cell carcinoma of the bladder or urothelium. Available at: https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=14028. Accessed Fberuary 4, 2016.

    • Search Google Scholar
    • Export Citation
  • 9.

    Bremnes RM, Andersen K, Wist EA. Cancer patients, doctors and nurses vary in their willingness to undertake cancer chemotherapy. Eur J Cancer 1995;31a:19551959.

    • Search Google Scholar
    • Export Citation
  • 10.

    Kim MK, Lee JL, Hyun MS. Palliative chemotherapy preferences and factors that influence patient choice in incurable advanced cancer. Jpn J Clin Oncol 2008;38:6470.

    • Search Google Scholar
    • Export Citation
  • 11.

    Booth CM, Siemens DR, Peng Y, Mackillop WJ. Patterns of referral for perioperative chemotherapy among patients with muscle-invasive bladder cancer: a population-based study. Urol Oncol 2014;32:12001208.

    • Search Google Scholar
    • Export Citation
  • 12.

    Porter MP, Kerrigan MC, Donato BM, Ramsey SD. Patterns of use of systemic chemotherapy for Medicare beneficiaries with urothelial bladder cancer. Urol Oncol 2011;29:252258.

    • Search Google Scholar
    • Export Citation
  • 13.

    Robles SC, Marrett LD, Clarke EA, Risch HA. An application of capture-recapture methods to the estimation of completeness of cancer registration. J Clin Epidemiol 1988;41:495501.

    • Search Google Scholar
    • Export Citation
  • 14.

    Reynolds DL, Nguyen VC, Clarke EA. Reliability of cancer mortality statistics in Ontario: a comparison of incident and death diagnoses, 1979-1983. Can J Public Health 1991;82:120126.

    • Search Google Scholar
    • Export Citation
  • 15.

    Williams J, Young W. Appendix – A summary of studies on the quality of health care administrative databases in Canada. In: Goel V, Williams JI, Anderson GM, eds. Patterns of Health Care in Ontario: The ICES Practice Atlas, 2nd ed. Ottawa, Ontario: Canadian Medical Association; 1996:339345.

    • Search Google Scholar
    • Export Citation
  • 16.

    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373383.

    • Search Google Scholar
    • Export Citation
  • 17.

    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613619.

    • Search Google Scholar
    • Export Citation
  • 18.

    Mackillop WJ, Zhang-Salomons J, Groome PA. Socioeconomic status and cancer survival in Ontario. J Clin Oncol 1997;15:16801689.

  • 19.

    Booth CM, Shepherd FA, Peng Y. Adjuvant chemotherapy for non-small cell lung cancer: practice patterns and outcomes in the general population of Ontario, Canada. J Thorac Oncol 2012;7:559566.

    • Search Google Scholar
    • Export Citation
  • 20.

    Huang J, Zhou S, Groome P. Factors affecting the use of palliative radiotherapy in Ontario. J Clin Oncol 2001;19:137144.

  • 21.

    Logothetis CJ, Dexeus FH, Finn L. A prospective randomized trial comparing MVAC and CISCA chemotherapy for patients with metastatic urothelial tumors. J Clin Oncol 1990;8:10501055.

    • Search Google Scholar
    • Export Citation
  • 22.

    von der Maase H, Hansen SW, Roberts JT. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: results of a large, randomized, multinational, multicenter, phase III study. J Clin Oncol 2000;18:30683077.

    • Search Google Scholar
    • Export Citation
  • 23.

    De Santis M, Bellmunt J, Mead G. Randomized phase II/III trial assessing gemcitabine/carboplatin and methotrexate/carboplatin/vinblastine in patients with advanced urothelial cancer who are unfit for cisplatin-based chemotherapy: EORTC study 30986. J Clin Oncol 2012;30:191199.

    • Search Google Scholar
    • Export Citation
  • 24.

    Oberstein PE, Hershman DL, Khanna LG. Uptake and patterns of use of gemcitabine for metastatic pancreatic cancer: a population-based study. Cancer Invest 2013;31:316322.

    • Search Google Scholar
    • Export Citation
  • 25.

    Ritzwoller DP, Carroll NM, Delate T. Patterns and predictors of first-line chemotherapy use among adults with advanced non-small cell lung cancer in the cancer research network. Lung Cancer 2012;78:245252.

    • Search Google Scholar
    • Export Citation
  • 26.

    Rasco DW, Yan J, Xie Y. Looking beyond surveillance, epidemiology, and end results: patterns of chemotherapy administration for advanced non-small cell lung cancer in a contemporary, diverse population. J Thorac Oncol 2010;5:15291535.

    • Search Google Scholar
    • Export Citation
  • 27.

    Baunemann Ott CL, Ratna N, Prayag R. Survival and treatment patterns in elderly patients with advanced non-small-cell lung cancer in Manitoba. Curr Oncol 2011;18:e238242.

    • Search Google Scholar
    • Export Citation
  • 28.

    Population aging and growth main contributors to increasing cancer burden (May 2010). Cancer Care Ontario Web site. Available at: https://www.cancercare.on.ca/cms/one.aspx?portalId=1377&pageId=73110. Accessed July 31, 2014.

    • Search Google Scholar
    • Export Citation
  • 29.

    Brenner DR, Tammemägi MC, Bull SB. Using cancer registry data: agreement in cause-of-death data between the Ontario Cancer Registry and a longitudinal study of breast cancer patients. Chronic Dis Can 2009;30:1619.

    • Search Google Scholar
    • Export Citation
  • 30.

    Hall S, Schulze K, Groome P. Using cancer registry data for survival studies: the example of the Ontario Cancer Registry. J Clin Epidemiol 2006;59:6776.w

    • Search Google Scholar
    • Export Citation
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