Treatment patterns among Medicare beneficiaries with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC) during 2020-2024.

Abstract

701 Background: Neoadjuvant (NADJ) and adjuvant (ADJ) therapies are recommended to complement RC in MIBC to improve patient outcomes. However, their use decreases with age, and patients (pts) ≥65 y are often underrepresented in clinical trials. This study describes real-world treatment patterns in NADJ and ADJ settings among elderly US pts with MIBC who underwent RC. Methods: This observational cohort study used data from the CMS 100% Medicare Fee-for-Service database. Pts ≥65 y who underwent RC on or after urothelial carcinoma (UC) diagnosis from 1/1/20 to 9/30/24 and had ≥12 months of continuous enrollment pre-RC were included; all pts had ≥6 months post-RC follow-up. NADJ therapy was defined as any treatment from 180 days until the day before RC; ADJ therapy was any treatment within 120 days post-RC through first of discontinuation, start of new therapy, progression to locally advanced/metastatic UC, end of follow-up, or death. All analyses were descriptive. Results were stratified by age (65–74 vs ≥75 y) and setting (NADJ and ADJ). Results: Overall, 6441 pts were included; mean (SD) age was 75.4 (5.4) y and 76.8% were male. Mean (SD) NCI Comorbidity Index was 0.9 (0.7), 0.8 (0.7), and 0.9 (0.7) in overall, 65–74 y, and ≥75 y subgroups. Overall, 40.3% of pts received NADJ therapy and 13.2% received ADJ therapy; 6.9% received both; 53.3% received neither. Median (IQR) time from NADJ treatment discontinuation to RC was 4.6 (2.6, 7.6) wks, and ADJ therapy started at median (IQR) of 9.1 (7.0, 12.1) wks post-RC; both were similar across subgroups. NADJ therapy was used more often in pts 65–74 y vs ≥75 y (46.6% vs 33.8%), ADJ therapy use was comparable (13.5% vs 12.9%). Conclusions: Systemic treatment utilization was low in Medicare pts, with over half receiving neither NADJ nor ADJ. Further work is needed to understand barriers to use and improve treatment options for elderly pts on Medicare. NADJ and ADJ treatment regimens. Regimen, n/N (%) Total NADJ (N=2597) 65–74 y NADJ (n=1533) ≥75 y NADJ (n=1064) Total ADJ (N=851) 65–74 y ADJ (n=444) ≥75 y ADJ (n=407) Platinum-based chemotherapy 2094/2597 (80.6) 1282/1533 (83.6) 812/1064 (76.3) 167/851 (19.6) 101/444 (22.7) 66/407 (12.6) Cisplatin-based 1951/2094 (93.2) 1217/1282 (94.9) 734/812 (90.4) 130/167 (77.8) 81/101 (80.2) 49/66 (74.2) Cisplatin + gemcitabine 1465/1951 (75.1) 873/1217 (71.7) 592/734 (80.7) 109/130 (83.8) 68/81 (84.0) 41/49 (83.7) DDMVAC 251/1951 (12.9) 180/1217 (14.8) 71/734 (9.7) <11 (*) <11 (*) 0 Other 235/1951 (12.0) 164/1217 (13.5) 71/734 (9.7) <23 (*) <22 (*) <11 (*) Non-platinum–based chemotherapy 305/2597 (11.7) 153/1533 (10.0) 152/1064 (14.3) <28 (*) <22 (*) <22 (*) Immunotherapy 171/2597 (6.6) 82/1533 (5.3) 89/1064 (8.4) 640/851 (75.2) 325/444 (73.2) 315/407 (77.4) EV monotherapy/EV combinations <11 (*) <11 (*) <11 (*) 13/851 (1.5) <11 (*) <11 (*) *Blinded per CMS requirements.