Department of Urology, University of California Davis, Sacramento, CA.
Public Health Institute, Cancer Registry of Greater California, Sacramento, CA.
Urol Oncol. 2023 Oct;41(10):431.e7-431.e14. doi: 10.1016/j.urolonc.2023.05.019. Epub 2023 Jun 8.
Among patients diagnosed with non-muscle invasive bladder cancer (NMIBC), those with high risk disease have the greatest risk of recurrence and disease progression. The underutilization of intravesical immunotherapy with Bacillus Calmette-Guérin (BCG) has been a longstanding concern in clinical practice. This study aimed to determine the disparities present in receipt of adjuvant intravesical chemotherapy and immunotherapy in treatment of patients with high grade NMIBC following initial transurethral resection of a bladder tumor (TURBT).
The California Cancer Registry data was used to identify 19,237 patients diagnosed with high grade NMIBC who underwent TURBT. Treatment variables include re-TURBT, re-TURBT and intravesical chemotherapy (IVC) and/or BCG. Independent variables include age, sex, race/ethnicity, neighborhood socioeconomic status (nSES), primary insurance payer and marital status at diagnosis. Multiple logistic regression and multinomial regression models were used to examine variation in the treatments received following TURBT.
The proportion of patients receiving TURBT followed by BCG was similar across all racial and ethnic groups (28%-32%). BCG therapy was higher in patients belonging to the highest nSES quintile (37% for highest vs. 23%-26% for the 2 lowest quintiles). In multiple variable analyses, receipt of any intravesical therapy (IVT) was influenced by nSES, age, marital status, race/ethnicity, and insurance type. Patients in the lowest nSES quintile had a 45% less likelihood of receiving IVT compared to the highest nSES group (OR [95%CI]: 0.55[0.49, 0.61]). Race/ethnicity differences in receipt of any adjuvant therapy were noted in the middle to lowest nSES quintile for Hispanic and Asian/Pacific Islander patients when compared to non-Hispanic White patients. When comparing variation in treatment by insurance type at diagnosis, those with Medicare or other insurance were 24% and 30% less likely to receive BCG after TURBT compared to those with private insurance, (OR [95%CI]: 0.76 [0.70, 0.82] and 0.70[0.62, 0.79]) respectively.
In patients with a diagnosis of high risk NMIBC, disparities in utilization of BCG are seen based on SES, age, and insurance type.
在诊断为非肌肉浸润性膀胱癌（NMIBC）的患者中，高危疾病患者复发和疾病进展的风险最大。卡介苗（BCG）膀胱内免疫治疗的利用率低一直是临床实践中的一个长期关注问题。本研究旨在确定在初始经尿道膀胱肿瘤切除术（TURBT）后接受辅助膀胱内化疗和免疫治疗治疗高危 NMIBC 患者的治疗差异。
使用加利福尼亚癌症登记处的数据，确定了 19237 名诊断为高危 NMIBC 并接受 TURBT 的患者。治疗变量包括再次 TURBT、再次 TURBT 联合膀胱内化疗（IVC）和/或 BCG。独立变量包括年龄、性别、种族/族裔、社区社会经济地位（nSES）、主要保险支付者和诊断时的婚姻状况。多变量逻辑回归和多项回归模型用于检查 TURBT 后接受的治疗差异。
在所有种族和族裔群体中，接受 TURBT 后接受 BCG 的患者比例相似（28%-32%）。属于最高 nSES 五分位数的患者接受 BCG 治疗的比例更高（最高五分位数为 37%，而最低两个五分位数为 23%-26%）。在多变量分析中，任何膀胱内治疗（IVT）的接受程度受 nSES、年龄、婚姻状况、种族/族裔和保险类型的影响。最低 nSES 五分位数的患者接受 IVT 的可能性比最高 nSES 组低 45%（OR [95%CI]：0.55[0.49, 0.61]）。在中等到最低 nSES 五分位数的西班牙裔和亚太裔患者中，与非西班牙裔白人患者相比，在接受任何辅助治疗方面存在种族/族裔差异。在按诊断时的保险类型比较治疗差异时，与私人保险相比，拥有医疗保险或其他保险的患者在接受 TURBT 后接受 BCG 的可能性分别降低了 24%和 30%（OR [95%CI]：0.76 [0.70, 0.82] 和 0.70[0.62, 0.79]）。
在诊断为高危 NMIBC 的患者中，根据 SES、年龄和保险类型，BCG 的利用存在差异。
