Patterns of care and associated social determinants of health in the definitive treatment of localized muscle-invasive bladder cancer patients

Background Neoadjuvant chemotherapy followed by radical cystectomy (NACT-RC) is the prevailing standard of care for muscle-invasive bladder cancer (MIBC), but trimodality treatment (TMT) using chemoradiation after transurethral resection of bladder tumor (TURBT) is an effective alternative in select patients. Objective This study examined patterns of care and impact of social determinants of health on the overall survival (OS) using the National Cancer Database (NCDB). Methods Data on patients aged ≥18 years with stage II-IIIA MIBC treated with TMT or NACT-RC during 2014–2021 were analyzed with propensity score matching. Logistic and Cox regression were used to evaluate the association of social determinants of health with patterns of care and OS. Results Among 18,072 cases (mean age 68.3 years), 77.1% received NACT-RC. TMT use increased from 18.4% in 2014 to 27.1% in 2021 (p < 0.001). The odds for receiving NACT-RC were higher for patients with stage IIIA (odds ratio (OR) = 1.21, 95% confidence interval (CI) 1.09-1.34). However, older patients (OR 0.86, 95% CI 0.87-0.88), those treated at comprehensive community cancer programs (OR 0.51, 95% CI: 0.46-0.55), or used Medicaid (OR = 0.48, 95% CI 0.39-0.61) had lower odds for receiving NACT-RC. In propensity score matching analysis, NACT-RC was associated with lower mortality compared to TMT (Hazard ratio (HR) = 0.66, 95% CI:0.59-0.73). Medicaid users receiving NACT-RC had the highest mortality risk (HR = 1.47, 95% CI:1.28-1.68, p interaction =0.001). Conclusion TMT for MIBC has increased in recent years. Selection between NACT-RC and TMT was influenced by age, stage, diagnosis year, comorbidities, travel distance, facility, and insurance type, highlighting disparities in MIBC treatment. Categories Radiation Oncology, Oncology