Clinical and social determinants of definitive surgical management in bladder cancer: A two-decade population-based analysis from the United States.

Abstract

654 Background: Surgical management of bladder cancer ranges from bladder-preserving approaches to radical cystectomy. We examined factors associated with receipt of definitive bladder surgery using a large population-based cohort. Methods: We analyzed 386,304 bladder cancer patients from the SEER database (2000-2022). The primary outcome was receipt of definitive bladder surgery (excisional biopsy, partial cystectomy, or radical cystectomy) versus no surgery/local ablation only. Multivariable logistic regression was used to identify predictors adjusting for demographic, clinical, and socioeconomic factors. Results: Among 386,304 patients, 76.0% were male and 24.0% female. Median age was 72 years (IQR 63-78). The cohort was 82.6% Non-Hispanic White, 6.6% Hispanic, 5.4% Non-Hispanic Black, 4.3% Non-Hispanic Asian/Pacific Islander, and 0.4% Non-Hispanic American Indian/Alaska Native. By stage: 41.2% had carcinoma in situ, 30.3% localized disease, 5.9% regional disease, and 4.1% distant metastases. Most patients (58.2%) were married at diagnosis. Surgical Patterns: Overall, 66.6% underwent excisional biopsy (code 27), 10.8% had electrocautery/fulguration, 8.4% had no surgery, 3.4% underwent partial cystectomy (code 71), and 2.6% had radical cystectomy (code 61). Only 7.6% underwent lymph node dissection (6.8% with ≥4 nodes removed). Multivariable Analysis: In adjusted analysis (n=368,219 with complete data), factors associated with definitive surgery included: Increased likelihood: Male sex (OR 1.06, 95% CI: 1.04-1.08, p<0.001), higher income ($120,000+ vs <$40,000: OR 1.51, 95% CI: 1.39-1.64, p<0.001), extensive lymph node dissection (≥4 nodes removed: OR 20.16, 95% CI: 16.32-24.90, p<0.001). Decreased likelihood: Non-Hispanic White race (vs Hispanic: OR 0.94, 95% CI: 0.91-0.97, p<0.001), distant metastases (OR 0.37, 95% CI: 0.35-0.39, p<0.001), regional disease (OR 0.50, 95% CI: 0.48-0.54, p<0.001), unknown stage (OR 0.10, 95% CI: 0.09-0.11, p<0.001), unmarried status (single: OR 0.60, 95% CI: 0.58-0.62, p<0.001), increasing age (OR 0.999 per year, p=0.018). Conclusions: Definitive bladder surgery patterns reveal significant disparities. Male patients and those with higher socioeconomic status were more likely to receive surgical treatment, while racial minorities (specifically Hispanic patients) had higher surgery rates than Non-Hispanic Whites. Advanced disease and older age predicted non-surgical management. These findings suggest complex interactions between clinical factors and healthcare access that warrant further investigation to optimize treatment selection and address potential inequities in bladder cancer care.