Muscle invasive bladder cancer treatment selection in an emerging treatment era: A patient preference study.

Abstract

753 Background: Patients with muscle invasive bladder cancer (MIBC) face a preference-sensitive choice among various treatment alternatives. MIBC is typically treated with radical cystectomy (RC) or bladder-sparing chemoradiation, but systemic therapy also plays a conjunctive role in reducing recurrence rates. This study elicited preferences for available and emerging systemic treatments among MIBC patients in the United States. Methods: Patients with self-reported MIBC participated in an online survey. A discrete-choice experiment elicited preferences for attributes of existing and emerging systemic treatments that could be administered with either RC or bladder-sparing approaches. Evidence-based attributes (and levels) included timing and duration of therapy (3 months before and/or 9-12 months after primary treatment); time in delaying cancer recurrence (20-64 months); overall survival (OS) rate at 5 years (40%-85%); chance of treatment-related adverse events (AEs), including fatigue (from none to moderate-severe), neuropathy (from none to moderate-severe), and risk of immune-related AEs that require oral steroid treatment (0%-25%). Conditional relative importance of attributes and risk tolerance were calculated from random-parameters logit models. In addition, direct-elicitation questions offered choices between fixed profiles of bladder-sparing treatment and RC with adjuvant and neoadjuvant systemic treatments. The Shared Decision Making (SDM) Questionnaire (SDM-Q-9) was also included, revealing patients’ levels of satisfaction with previous real-world choices. Responses to the fixed-profile questions and SDM-Q-9 were analyzed descriptively. Results: 202 participants completed the survey. Of the treatment attributes and levels evaluated, improvements in efficacy were most important (OS at 5 years, followed by delaying cancer recurrence). The average patient was tolerant of AEs and willing to accept high levels of risks (greater than those presented in the survey) and severity for any of the OS improvements offered. Two-thirds of respondents (66.8%) preferred RC plus neo- and adjuvant intravenous treatment in a profile with a 25-percentage-point increase in OS at 5 years, a 40-month delay in recurrence, and a 15% risk of immune-related AEs, mild fatigue, and nerve damage over a bladder-preserving treatment with chemoradiation and no AEs. Almost 20% of respondents disagreed with the statement “My doctor asked me which treatment option I prefer” when reflecting on their SDM experiences. Conclusions: Improving OS and delaying recurrence were the most important attributes to patients in this sample, and patients were willing to accept clinically relevant treatment-related AEs for the improvements in efficacy. Patients demonstrated heterogeneous preferences; efforts to promote shared decision-making are therefore warranted.