Login to Access Video or Poster Abstract: MP16-19
Sources of Funding: none

Introduction

Nephroureterectomy is the mainstay therapy for high-grade upper tract urothelial carcinoma (UTUC). As the survival remains poor for high-grade UTUC following nephroureterectomy, a number of ongoing studies are investigating the utility of neoadjuvant chemotherapy (NAC) in this disease. While awaiting these results, our objective is to examine the utilization of NAC, impact on outcomes following surgery and overall survival in a national hospital-based analysis.

Methods

We identified subjects diagnosed with urothelial carcinoma of the kidney or ureter from the National Cancer Database during 2004-2014, who underwent nephroureterectomy. These subjects were then stratified on the basis of receipt of NAC, and univariable and multivariable analysis was performed to identify patient and provider factors associated with use of NAC. Thirty-day mortality and readmission were assessed by chi-squared analysis. Adjusted Cox-regression was used to evaluate overall survival.

Results

We identified 26,309 subjects who underwent nephroureterectomy for UTUC, and 421 (1.6%) received NAC. Median follow-up was 33 months (interquartile range 14-62). Utilization of NAC significantly increased over the study period (OR=1.3 year over year, p<0.001). Younger patients (OR=0.97 per year, p<0.001) and those with metastatic disease (lymph node OR=2.0 and metastasis positive OR=1.6, p<0.001) were more likely to receive NAC in their treatment regimens. NAC was more likely to be given at academic centers (OR =3.1 p<0.001); however, hospital UTUC volume was not associated with NAC use. Patient demographics such as race, income, and level of education were not associated NAC utilization. NAC was associated with better perioperative outcomes (30-day mortality 2.2% vs. 1.6%, p=0.7 and 30-day readmission 3.9% vs. 3.1%, p=0.02). Hazard ratios adjusting for age, pathologic stage, lymph node and metastasis status demonstrated that NAC was associated with survival [HR 0.82 (95% CI0.69-0.98) p=0.029].

Conclusions

In our observational, hospital-based study, NAC is associated with improved survival without adversely affecting perioperative outcomes in those with high grade UTUC. Although use is increasing over time and greater at academic medical centers, it remains low overall. Prospective studies are needed to confirm these findings and identify optimal characteristics associated with improved outcomes.

Funding

none