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Racial Disparities in the Receipt of Quality Metrics Among Patients Undergoing Radical Cystectomy for Muscle-Invasive Urothelial Carcinoma of the Bladder
Alexander P. Cole, MD1, Stephanie A. Mullane, BS2, Christian P. Meyer, MD3, Mark A. Preston, MD, MPH1, Adam S. Kibel, MD1, Quoc-Dien Trinh, MD1.
1Harvard Medical School, Brigham and Womens Hospital, Boston, MA, USA, 2Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA, USA, 3Harvard Medical School, Center for Surgery and Public Health, Boston, MA, USA.

Introduction: Race-based disparities in outcomes are well documented in Bladder Cancer (BCa). Specifically, while non-Hispanic white men and women are twice as likely to develop BCa, blacks are more likely to die from the disease, even when controlling for stage. Given that quality differences among racial minorities have been observed in other areas of cancer care, we sought to assess for differences in care of muscle invasive BCa—the most lethal form of the disease. To do this, we designed a retrospective, observational study to assess for race-based differences in receipt of four quality metrics across a large national sample of patients who received radical cystectomy (RC).
Materials and Methods: The National Cancer Database (NCDB) is a comprehensive clinical surveillance resource for cancer care in the United States. It includes data from >1500 accredited cancer programs and captures 70% of newly diagnosed cancer cases in the US. Using the NCDB, we identified 19,744 men and women undergoing radical cystectomy for muscle-invasive BCa between 2003 and 2012. Race was stratified into non-Hispanic white (white), black, Asian and Hispanic. We extracted data on four quality metrics: (1) receipt of neoadjuvant chemotherapy, (2) treatment ≤ three months from diagnosis, (3) ≥ten lymph nodes removed at time of RC, and (4) use of continent urinary diversion. We compared these four quality metrics by race. Uni- and multivariate analyses were used to examine the association between race and receipt of quality metrics. Cox regression model was used to examine the association between race and overall survival.
1
Results: Baseline characteristics differed according to race. With respect to quality metrics, blacks and Asians were less likely to receive treatment within 90 days of diagnosis compared to whites (OR: 0.81 [CI:0.70-0.95]), p=0.009, (OR: 0.69 [CI:0.54-0.87], p=0.002). Blacks were less likely to receive a continent diversion (OR: 0.70 [CI:0.51-0.95], p=0.022), and Hispanics were more (OR: 1.43 [CI: 1.02-2.00], p=0.039). Blacks had significantly worse overall survival after adjustment for confounders (OR: 1.23 [CI: 1.12-1.36], p<0.001). These findings remained significant in sensitivity analyses accounting for receipt of quality metrics (OR: 1.22 [CI: 1.11-1.35], p<0.001).
Conclusions: Even after accounting for comorbidities and treatment disparities, blacks have a worse overall survival. The well-documented race-based disparities in BCa outcomes are likely multifactorial. While our study confirms that there may be statistically significant race-based differences in some important quality metrics, the magnitude of the differences is small and does not fully account for the racial disparities in BCa outcomes. This suggests that underlying differences in tumor biology, environmental risk factors or other unknown and unmeasured aspects of care may account for the marked race-based survival disparity.


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