Riveros Carlos, Chalfant Victor, Elshafei Ahmed, Bandyk Mark, Balaji K C
Department of Urology, University of Florida, Jacksonville, FL.
Department of Urology, University of Florida, Jacksonville, FL.
Urol Oncol. 2023 Mar;41(3):147.e7-147.e14. doi: 10.1016/j.urolonc.2022.10.028. Epub 2023 Jan 9.
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.
医疗服务碎片化可能会影响肿瘤治疗结果。目前，医疗服务碎片化对接受新辅助化疗（NAC）和根治性膀胱切除术（RC）的肌层浸润性膀胱癌（MIBC）患者治疗结果的影响尚不明确。我们旨在比较接受碎片化医疗服务（FC）与非碎片化医疗服务（NFC）的患者之间的治疗结果。
查询国家癌症数据库，纳入2004年至2017年间年龄≥18岁、接受NAC后行RC的cT2-T4aN0M0膀胱尿路上皮癌成年患者。根据患者接受的是FC（定义为在与进行RC的机构不同的机构接受NAC）还是NFC（定义为在单一机构接受NAC和RC）进行二分法分类。主要关注的结果是总生存期（OS）。次要结果包括从诊断到治疗（NAC和RC）的时间以及围手术期结果。在按接受的医疗服务类型分层后计算Kaplan-Meier生存估计值。进行多变量Cox回归分析，以评估在其他临床相关协变量背景下FC与OS之间的关联。
共纳入2223例患者：1035例（46.6%）接受FC，1188例（53.4%）接受NFC。与FC相关的因素包括出行距离更远、合并症负担更高以及在大容量机构接受手术治疗。接受FC的患者至RC的中位时间略长（160天对154天，P = 0.001）。然而，根据Kaplan-Meier分析，两组之间的中位OS无差异。在多变量Cox回归分析中，与较差OS相关的因素包括年龄、晚期TNM分期、淋巴血管侵犯和手术切缘阳性；但FC与较差OS无关（风险比[HR] 1.02；95%置信区间[CI] 0.88-1.17）。在亚组分析中，我们发现学术机构接受的FC（HR 0.76；95% CI 0.58-0.99）以及大容量中心接受的NFC（HR 0.65；95% CI 0.43-0.98）与总体死亡率降低相关。
对于接受NAC后行RC的MIBC患者，碎片化医疗服务与较差的生存结果无关。
