Xia Leilei, Taylor Benjamin L, Mamtani Ronac, Christodouleas John P, Guzzo Thomas J
Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Urology. 2018 Apr;114:87-94. doi: 10.1016/j.urology.2017.12.014. Epub 2018 Jan 2.
To explore the associations between travel distance, hospital volume, and outcomes following radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC).
The 2006 to 2013 National Cancer Database was queried to identify patients with MIBC who underwent RC. Multivariable regressions alternately including travel distance, hospital volume, and both in the models were used. Travel distances and hospital volumes were categorized by quartiles. Outcomes of interest were overall survival and quality-of-care indicators.
A total of 6551 patients were included in the final cohort. When only travel distance or hospital volume was included in the multivariable regression model, fourth quartiles of both variables were associated with improved overall survival. When both travel distance and hospital volume were included in the model, only hospital volume was found to be associated with overall survival. Sensitivity analyses with both travel distance and hospital volume considered as continuous variables showed similar results. Patients who underwent RC in high-volume hospitals were more likely to receive neoadjuvant chemotherapy, have 10 or more lymph nodes removed, but also had higher odds of surgical delay (>3 months) in the full models adjusting for travel distance.
This National Cancer Database-based study suggests that the association between longer travel distance and improved overall survival (distance bias effect) after RC for MIBC is mainly mediated by higher hospital volume. The benefits of having RC at high-volume hospitals may outweigh the potential disadvantages of longer travel distance, which further supports the continued regionalization of RC and cancer care for MIBC.
探讨肌层浸润性膀胱癌（MIBC）根治性膀胱切除术（RC）后旅行距离、医院手术量与预后之间的关联。
查询2006年至2013年国家癌症数据库，以确定接受RC的MIBC患者。在模型中交替纳入旅行距离、医院手术量以及两者的多变量回归分析。旅行距离和医院手术量按四分位数分类。感兴趣的结局为总生存期和医疗质量指标。
最终队列共纳入6551例患者。当多变量回归模型仅纳入旅行距离或医院手术量时，这两个变量的第四四分位数均与总生存期改善相关。当模型中同时纳入旅行距离和医院手术量时，仅发现医院手术量与总生存期相关。将旅行距离和医院手术量视为连续变量的敏感性分析显示了相似结果。在高手术量医院接受RC的患者更有可能接受新辅助化疗、切除10个或更多淋巴结，但在调整旅行距离的完整模型中，手术延迟（>3个月）的几率也更高。
这项基于国家癌症数据库的研究表明，MIBC行RC后较长旅行距离与总生存期改善之间的关联（距离偏倚效应）主要由较高的医院手术量介导。在高手术量医院进行RC的益处可能超过旅行距离较长的潜在弊端，这进一步支持了MIBC的RC及癌症治疗持续区域化。
