Temporal trends in receipt of adequate lymphadenectomy in bladder cancer 1988 to 2010

Abstract

Introduction and objective: The importance of pelvic lymphadenectomy (LND) for diagnostic and therapeutic purposes at the time of radical cystectomy (RC) for bladder cancer is well documented. Although some debate remains on the optimal number of lymph nodes removed, 10 nodes has been proposed as constituting an adequate LND. We used data from the Surveillance, Epidemiology, and End Results database to examine predictors and temporal trends in the receipt of an adequate LND at the time of RC for bladder cancer.

Material and methods: Within the Surveillance, Epidemiology, and End Results database, we extracted data on all patients with nonmetastatic bladder cancer receiving RC in the years 1988 to 2010. First, we assess the proportion of individuals undergoing RC who received an adequate LND (≥10 nodes removed) over time. Second, we calculate odds ratios (ORs) of receiving an adequate LND using logistic regression modeling to compare study periods. Covariates included sex, race, age, region, tumor stage, urban vs. rural location, and insurance status.

Results: Among the 5,696 individuals receiving RC during the years 1988 to 2010, 2,576 (45.2%) received an adequate LND. Over the study period, the proportion of individuals receiving an adequate LND increased from 26.4% to 61.3%. The odds of receiving an adequate LND increased over the study period; a patient undergoing RC in 2008 to 2010 was over 4-fold more likely to receive an adequate LND relative to a patient treated in 1988 to 1991 (OR = 4.63, 95% CI: 3.32-6.45). In addition to time of surgery, tumor stage had a positive association with receipt of adequate LND (OR = 1.49 for stage IV [T4 N1 or N0] vs. stage I [T1 or Tis], 95% CI: 1.22-1.82). Age, sex, marital status, and race were not significant predictors of adequate LND.

Conclusion: Adequacy of pelvic LND remains an important measure of surgical quality in bladder cancer. Our data show that over the years 1988 to 2010, the likelihood of receiving an adequate LND has increased substantially; however, a substantial minority of patients still does not receive LND. Further study into factors leading to adequate LND is needed to increase the use of this important technique.

Keywords: Bladder cancer; Epidemiology; Health services research; Lymph node dissection; Lymphadenectomy; Quality improvement; Radical cystectomy; Urothelial carcinoma of urinary bladder.