Income Disparities in Survival and Receipt of Neoadjuvant Chemotherapy and Pelvic Lymph Node Dissection for Muscle-Invasive Bladder Cancer
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Population
2.2. Statistical Analysis
3. Results
3.1. Patient Baseline Characteristics
3.2. Likelihood of Receipt of Neoadjuvant Chemotherapy
3.3. Likelihood of Any or Adequate Pelvic Lymph Node Dissection
3.4. Survival Analysis
4. Discussion
4.1. Summary of Key Findings
4.2. Temporal Trends
4.3. Factors Influencing the Use of NAC and PLND in RC
4.4. Policy Implications and Recommendations for Practice
4.5. Study Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Treatment Receipt | |||
---|---|---|---|
RC | RC + NAC + PLND | p-Value * | |
Count (%) | Count (%) | ||
Median Age | 70 | 66 | <0.001 |
Sex | 0.864 | ||
Male | 13,226, 75.9% | 6365, 75.8% | |
Female | 4200, 24.1% | 2032, 24.2% | |
Race | 0.909 | ||
White | 15,563, 89.3% | 7513, 89.5% | |
Black | 993, 5.7% | 468, 5.6% | |
Other | 870, 5.0% | 416, 5.0% | |
CCI | <0.001 | ||
0 | 11,597, 66.5% | 6069, 72.3% | |
1 | 3933, 22.6% | 1564, 18.6% | |
2 | 1304, 7.5% | 496, 5.9% | |
3+ | 592, 3.4% | 268, 3.2% | |
Insurance | <0.001 | ||
No Insurance | 391, 2.2% | 185, 2.2% | |
Private | 5133, 29.5% | 3232, 38.5% | |
Medicaid | 777, 4.5% | 470, 5.6% | |
Medicare | 11,125, 63.8% | 4510, 53.7% | |
Income | <0.001 | ||
Low Income | 7132, 40.9% | 2994, 35.7% | |
High Income | 10,294, 59.1% | 5403, 64.3% | |
Facility Type | <0.001 | ||
Non-Academic | 9117, 52.3% | 3720, 44.3% | |
Academic | 8309, 47.7% | 4677, 55.7% | |
Year of Diagnosis | <0.001 | ||
2004–2011 | 7246, 41.6% | 1544, 18.4% | |
20012–2019 | 10,180, 58.4% | 6853, 81.6% | |
cT Stage | 0.009 | ||
2 | 14,187, 81.4% | 6702, 79.8% | |
3 | 2011, 11.5% | 1045, 12.4% | |
4 | 1228, 7.0% | 650, 7.7% | |
cN Stage | <0.001 | ||
0 | 16,336, 93.7% | 7532, 89.7% | |
1 | 547, 3.1% | 457, 5.4% | |
2 | 463, 2.7% | 324, 3.9% | |
3 | 80, 00.5% | 84, 1.0% |
Income Status Split by Median Income | |||
---|---|---|---|
High Income | Low Income | p-Value * | |
Count (%) | Count (%) | ||
Median Age | 69 | 68 | <0.001 |
Sex | 0.572 | ||
Male | 11,928, 76.0% | 7663, 75.7% | |
Female | 3769, 24.0% | 2463, 24.3% | |
Race | <0.001 | ||
White | 14,397, 91.7% | 8679, 85.7% | |
Black | 495, 3.2% | 966, 9.5% | |
Other | 805, 5.1% | 481, 4.8% | |
CCI | <0.001 | ||
0 | 10,938, 69.7% | 6728, 66.4% | |
1 | 3185, 20.3% | 2312, 22.8% | |
2 | 1062, 6.8% | 738, 7.3% | |
3+ | 512, 3.3% | 348, 3.4% | |
Insurance | <0.001 | ||
No Insurance | 257, 1.6% | 319, 3.2% | |
Private | 5479, 34.9% | 2886, 28.5% | |
Medicaid | 578, 3.7% | 669, 6.6% | |
Medicare | 9383, 59.8% | 6252, 61.7% | |
Facility Type | <0.001 | ||
Non-Academic | 7671, 48.9% | 5166, 51.0% | |
Academic | 8026, 51.1% | 4960, 49.0% | |
Year of Diagnosis | <0.001 | ||
2004–2011 | 5220, 33.3% | 3570, 35.3% | |
20012–2019 | 10,477, 66.7% | 6556, 64.7% | |
cT Stage | 0.31 | ||
2 | 12,743, 81.2% | 8146, 80.4% | |
3 | 1837, 11.7% | 1219, 12.0% | |
4 | 1117, 7.1% | 761, 7.5% | |
cN Stage | 0.772 | ||
0 | 14,516, 92.5% | 9352, 92.4% | |
1 | 612, 3.9% | 392, 3.9% | |
2 | 466, 3.0% | 321, 3.2% | |
3 | 103, 0.7% | 61, 0.6% | |
Chemotherapy | <0.001 | ||
No NAC | 9900, 63.1% | 6869, 67.8% | |
NAC | 5797, 36.9% | 3257, 32.2% | |
PLND | <0.001 | ||
0 LNs | 1371, 8.7% | 982, 9.7% | |
1–14 LNs | 6989, 44.5% | 4739, 47.8% | |
15+ LNs | 7337, 46.7% | 4405, 43.5% |
Univariate | Multivariate | |||
---|---|---|---|---|
OR (CI) | p-Value | aOR (CI) | p-Value | |
Age (continuous) | 0.963 (0.961–0.966) | <0.001 | 0.961 (0.957–0.964) | <0.001 |
Sex (Ref = Male) | ||||
Female | 0.990 (0.932–1.051) | 0.736 | 1.009 (0.947–1.075) | 0.786 |
Race (Ref = White) | ||||
Black | 0.984 (0.881–1.100) | 0.782 | 0.874 (0.777–0.985) | 0.027 |
Other | 0.961 (0.853–1.081) | 0.504 | 0.820 (0.724–0.928) | 0.002 |
CCI (Ref = 0) | ||||
1 | 0.743 (0.696–0.793) | <0.001 | 0.838 (0.782–0.897) | <0.001 |
2 | 0.698 (0.628–0.776) | <0.001 | 0.744 (0.666–0.831) | <0.001 |
3 | 0.838 (0.725–0.969) | 0.017 | 0.820 (0.705–0.954) | 0.01 |
Insurance (Ref = Federal) | ||||
Private | 1.501 (1.422–1.585) | <0.001 | 0.989 (0.924–1.058) | 0.989 |
Uninsured | 1.106 (0.928–1.318) | 0.259 | 0.737 (0.588–0.860) | <0.001 |
Income (Ref = High Income) | ||||
Low Income | 0.810 (0.768–0.854) | <0.001 | 0.803 (0.759–0.850) | <0.001 |
Facility Type (Ref = Non-Academic) | ||||
Academic | 1.295 (1.230–1.363) | <0.001 | 1.262 (1.196–1.332) | <0.001 |
Year of Diagnosis (Ref = 2004–2011) | ||||
2012–2019 | 3.061 (2.881–3.252) | <0.001 | 3.273 (3.073–3.485) | <0.001 |
cT (Ref = 2) | ||||
3 | 1.083 (1.001–1.172) | 0.047 | 1.123 (1.032–1.223) | 0.008 |
4 | 1.209 (1.097–1.332) | <0.001 | 1.215 (1.094–1.349) | <0.001 |
cN (Ref = 0) | ||||
1 | 1.823 (1.611–2.075) | <0.001 | 1.750 (1.528–2.005) | <0.001 |
2 | 1.463 (1.267–1.689) | <0.001 | 1.398 (1.198–1.631) | <0.001 |
3 | 2.351 (1.727–3.202) | <0.001 | 1.702 (1.233–2.349) | 0.001 |
Receipt of PLND (≥1) | ||||
---|---|---|---|---|
Univariate | Multivariate | |||
OR (CI) | p-Value | aOR (CI) | p-Value | |
Age (continuous) | 0.983 (0.979–0.988) | <0.001 | 0.984 (0.978–0.989) | <0.001 |
Sex (Ref = Male) | ||||
Female | 1.002 (0.908–1.107) | 0.965 | 1.025 (0.927–1.134) | 0.626 |
Race (Ref = White) | ||||
Black | 1.002 (0.834–1.204) | 0.981 | 0.898 (0.743–1.085) | 0.264 |
Other | 1.022 (0.840–1.244) | 0.828 | 0.860 (0.704–1.050) | 0.138 |
CCI (Ref = 0) | ||||
1 | 1.071 (0.963–1.191) | 0.208 | 1.151 (1.033–1.283) | 0.011 |
2 | 1.075 (0.905–1.275) | 0.411 | 1.144 (0.962–1.362) | 0.128 |
3 | 1.159 (0.903–1.487) | 0.247 | 1.176 (0.913–1.514) | 0.21 |
Insurance (Ref = Federal) | ||||
Private | 1.185 (1.079–1.301) | <0.001 | 0.985 (0.881–1.101) | 0.784 |
Uninsured | 1.090 (0.814–1.459) | 0.564 | 0.904 (0.665–1.228) | 0.518 |
Income (Ref = High Income) | ||||
Low Income | 0.891 (0.818–0.971) | 0.009 | 0.905 (0.829–0.989) | 0.027 |
Facility Type (Ref = Non-Academic) | ||||
Academic | 2.348 (2.145–2.570) | <0.001 | 2.340 (2.135–2.563) | <0.001 |
Year of Diagnosis (Ref = 2004–2011) | ||||
2012–2019 | 1.546 (1.419–1.685) | <0.001 | 1.538 (1.409–1.679) | <0.001 |
cT (Ref = 2) | ||||
3 | 0.994 (0.870–1.136) | 0.93 | 0.962 (0.839–1.102) | 0.576 |
4 | 0.720 (0.621–0.834) | <0.001 | 0.653 (0.560–0.760) | <0.001 |
cN (Ref = 0) | ||||
1 | 1.693 (1.294–2.215) | <0.001 | 1.768 (1.344–2.325) | <0.001 |
2 | 2.046 (1.473–2.843) | <0.001 | 2.290 (1.638–3.203) | <0.001 |
3 | 1.315 (0.730–2.371) | 0.362 | 1.119 (0.660–2.177) | 0.552 |
Receipt of PLND (≥15) | ||||
Univariate | Multivariate | |||
OR (CI) | p-Value | aOR (CI) | p-Value | |
Age (continuous) | 0.979 (0.977–0.982) | <0.001 | 0.982 (0.979–0.985) | <0.001 |
Sex (Ref = Male) | ||||
Female | 1.004 (0.946–1.066) | 0.883 | 1.022 (0.960–1.087) | 0.5 |
Race (Ref = White) | ||||
Black | 1.002 (0.896–1.119) | 0.977 | 0.911 (0.811–1.023) | 0.115 |
Other | 1.056 (0.939–1.188) | 0.364 | 0.902 (0.799–1.018) | 0.095 |
CCI (Ref = 0) | ||||
1 | 0.829 (0.778–0.883) | <0.001 | 0.892 (0.835–0.952) | <0.001 |
2 | 0.779 (0.704–0.863) | <0.001 | 0.838 (0.754–0.931) | <0.001 |
3 | 0.834 (0.723–0.962) | 0.013 | 0.864 (0.745–1.001) | 0.052 |
Insurance (Ref = Federal) | ||||
Private | 1.362 (1.289–1.440) | <0.001 | 1.103 (1.031–1.180) | 0.004 |
Uninsured | 1.028 (0.864–1.224) | 0.752 | 0.817 (0.679–0.983) | 0.032 |
Income (Ref = High Income) | ||||
Low Income | 0.885 (0.840–0.933) | <0.001 | 0.903 (0.855–0.954) | <0.001 |
Facility Type (Ref = Non-Academic) | ||||
Academic | 2.115 (2.008–2.229) | <0.001 | 2.118 (2.009–2.233) | <0.001 |
Year of Diagnosis (Ref = 2004–2011) | ||||
2012–2019 | 1.573 (1.489–1.662) | <0.001 | 1.606 (1.518–1.700) | <0.001 |
cT (Ref = 2) | ||||
3 | 0.983 (0.908–1.064) | 0.673 | 1.000 (0.920–1.087) | 0.994 |
4 | 0.882 (0.797–0.975) | 0.014 | 0.861 (0.774–0.957) | 0.006 |
cN (Ref = 0) | ||||
1 | 1.127 (0.989–1.284) | 0.073 | 1.104 (0.963–1.266) | 0.155 |
2 | 1.108 (0.958–1.282) | 0.167 | 1.147 (0.984–1.337) | 0.079 |
3 | 1.465 (1.059–2.027) | 0.021 | 1.254 (0.898–1.750) | 0.184 |
HR | 95% CI | p-Value | |
---|---|---|---|
Age (continuous) | 1.026 | 1.023–1.028 | <0.001 |
Sex (Ref = Male) | |||
Female | 1.022 | 0.980–1.065 | 0.315 |
Race (Ref = White) | |||
Black | 1.073 | 0.991–1.162 | 0.084 |
Other | 0.913 | 0.836–0.997 | 0.044 |
CCI (Ref = 0) | |||
1 | 1.213 | 1.162–1.265 | <0.001 |
2 | 1.451 | 1.357–1.550 | <0.001 |
3 | 1.539 | 1.394–1.700 | <0.001 |
Insurance (Ref = Federal) | |||
Private | 0.931 | 0.889–0.976 | 0.003 |
Uninsured | 0.948 | 0.831–1.083 | 0.432 |
Income (Ref = High Income) | |||
Low Income | 1.088 | 1.049–1.129 | <0.001 |
Facility Type (Ref = Non-Academic) | |||
Academic | 0.936 | 0.902–0.971 | <0.001 |
Year of Diagnosis (Ref = 2004–2011) | |||
2012–2019 | 0.859 | 0.827–0.892 | <0.001 |
cT (Ref = 2) | |||
3 | 1.318 | 1.250–1.389 | <0.001 |
4 | 1.668 | 1.566–1.776 | <0.001 |
cN (Ref = 0) | |||
1 | 1.302 | 1.191–1.424 | <0.001 |
2 | 1.804 | 1.647–1.975 | <0.001 |
3 | 1.577 | 1.277–1.948 | <0.001 |
NAC Receipt (Ref = No NAC) | |||
NAC Treatment | 0.835 | 0.801–0.871 | <0.001 |
PLND (Ref = No PLND) | |||
>0 & <14 LNs | 0.93 | 0.876–0.987 | 0.017 |
≥ 15 LNs | 0.757 | 0.711–0.806 | <0.001 |
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Antar, R.M.; Xu, V.E.; Adesanya, O.; Drouaud, A.; Longton, N.; Gordon, O.; Youssef, K.; Kfouri, J.; Azari, S.; Tafuri, S.; et al. Income Disparities in Survival and Receipt of Neoadjuvant Chemotherapy and Pelvic Lymph Node Dissection for Muscle-Invasive Bladder Cancer. Curr. Oncol. 2024, 31, 2566-2581. https://doi.org/10.3390/curroncol31050192
Antar RM, Xu VE, Adesanya O, Drouaud A, Longton N, Gordon O, Youssef K, Kfouri J, Azari S, Tafuri S, et al. Income Disparities in Survival and Receipt of Neoadjuvant Chemotherapy and Pelvic Lymph Node Dissection for Muscle-Invasive Bladder Cancer. Current Oncology. 2024; 31(5):2566-2581. https://doi.org/10.3390/curroncol31050192
Chicago/Turabian StyleAntar, Ryan M., Vincent E. Xu, Oluwafolajimi Adesanya, Arthur Drouaud, Noah Longton, Olivia Gordon, Kirolos Youssef, Jad Kfouri, Sarah Azari, Sean Tafuri, and et al. 2024. "Income Disparities in Survival and Receipt of Neoadjuvant Chemotherapy and Pelvic Lymph Node Dissection for Muscle-Invasive Bladder Cancer" Current Oncology 31, no. 5: 2566-2581. https://doi.org/10.3390/curroncol31050192
APA StyleAntar, R. M., Xu, V. E., Adesanya, O., Drouaud, A., Longton, N., Gordon, O., Youssef, K., Kfouri, J., Azari, S., Tafuri, S., Goddard, B., & Whalen, M. J. (2024). Income Disparities in Survival and Receipt of Neoadjuvant Chemotherapy and Pelvic Lymph Node Dissection for Muscle-Invasive Bladder Cancer. Current Oncology, 31(5), 2566-2581. https://doi.org/10.3390/curroncol31050192