Introduction

While use of neo?adjuvant chemotherapy (NAC) prior to radical cystectomy (RC) for muscle?invasive bladder cancer (MIBC) has been steadily increasing over the last decade, the majority of patients are not receiving NAC. Little is known about the reasons as to why these patients do not receive NAC. Our objective was to evaluate the rate of patient refusal of NAC, and examine descriptive characteristics associated with patient refusal of NAC.

Methods

Using the National Cancer Data Base, patients who underwent RC between 2004?2013 for a diagnosis of cT2 MIBC were included. Among patients who did not receive NAC, patients were categorized as (i) having been recommended NAC and refused, or (ii) not recommended NAC due to patient risk factors. Bivariable analysis was used to determine associations for not receiving NAC between age, gender, race, income level, insurance status, education level, type of facility, distance to oncology provider, and trend over time.

Results

Of 8298 patients who underwent cystectomy, 524 did not receive NAC and had complete data regarding reasons for declining treatment. 58% of those included were recommended NAC but refused (n = 305), while 42% of patients were not recommended NAC due to risk factors (n = 219). Over the defined timeframe, an increasing trend toward patient refusal of NAC was seen (49% over 2004?2007, 59% over 2008?2010, 63% over 2011?2013, p = 0.06). Many patients (58%) seen at academic or comprehensive community cancer programs did not receive NAC due to patient refusal (58% vs. 42%, p=0.06). Patients with lower levels of education were less likely to refuse NAC, however these findings were not statistically significant. Travel distance to provider was also not associated with likelihood of patient refusal of NAC (p = 0.45). No statistically significant association was found between age, gender, race, income or insurance status and the reason why NAC was not administered.

Conclusions

Patient refusal of NAC prior to RC for MIBC is becoming more common. A higher education level and care received at an academic or comprehensive cancer facility was more likely to be associated with refusal of NAC, suggesting that patient counseling affects patient treatment choice prior to RC.

Funding

none