UCLA

Background

Multiple recurrences develop in patients with high-risk non-muscle-invasive bladder cancer. As neither the association of recurrences with survival nor the subsequent aggressive treatment in individuals with recurrent high-grade non-muscle-invasive bladder cancer has ever been quantified, we sought to determine whether the increasing number of recurrences is associated with higher subsequent treatment and mortality rates.

Methods

Using linked Surveillance, Epidemiology, and End Results-Medicare data, we identified subjects with recurrent high-grade, non-muscle-invasive disease diagnosed in 1992 to 2002 and followed up until 2007. Using competing-risks regression analyses, we quantified the incidence of radical cystectomy, radiotherapy, and systemic chemotherapy after each recurrence. We then performed a propensity-score adjusted competing-risks regression analysis to determine whether the increasing recurrences portend worse survival.

Results

Of 4,521 subjects, 2,694 (59.6%) had multiple recurrences within 2 years of diagnosis. Compared with patients who only had 1 recurrence, those with ≥ 4 recurrences were less likely to undergo radical cystectomy (hazard ratio [HR] = 0.73, 95% CI: 0.58-0.92), yet more likely to undergo radiotherapy (HR = 1.51, 95% CI: 1.23-1.85) and systemic chemotherapy (HR = 1.58, 95% CI: 1.15-2.18). For patients with ≥ 4 recurrences, only 25% were treated with curative intent. The 10-year cancer-specific mortality rates were 6.9%, 9.7%, 13.7%, and 15.7% for those with 1, 2, 3, and ≥ 4 recurrences, respectively.

Conclusions

Only 25% of patients with high-risk non-muscle-invasive bladder cancer who experienced recurrences at least 4 times underwent radical cystectomy or radiotherapy. Despite portending worse outcomes, increasing recurrences do not necessarily translate into higher treatment rates.