Contemporary practice patterns and survival outcomes for locally advanced urethral malignancies: A National Cancer Database Analysis

Purpose Primary urethral carcinoma (PUC) has an aggressive natural history; however, controversy exists regarding the role of multimodal therapy for its treatment. Our objective was to examine practice patterns and survival outcomes for locally advanced urethral cancers. Methods The National Cancer Database was queried for patients with T2–4 or N1–2M0 PUC with urothelial, squamous, or adenocarcinoma histology from 2004 to 2013. Temporal trends for receipt of local or definitive surgery, radiotherapy (XRT), and systemic therapy were assessed. Adjusting for clinicopathologic characteristics, we evaluated the effect of tumor stage and histology on receipt of definitive multimodal therapy (cystectomy + chemotherapy ± XRT) and effects of treatment on overall survival. Results A total of 1,749 patients met inclusion criteria (22.2% adenocarcinoma, 29.3% squamous, and 48.5% urothelial). Only 29.6% underwent cystectomy ± XRT, and 15.6% underwent definitive multimodal therapy. Following adjustment, older patients (age 50–75: odds ratio [OR] = 0.42 [95% CI: 0.28–0.63]; age 75+: OR = 0.06 [95% CI: 0.03–0.13]) and those with squamous histology (OR = 0.46 [95% CI: 0.3–0.7]) were less likely to receive definitive multimodal therapy. More advanced stage (T3: OR = 1.66 [95% CI: 1.15–2.41]; T4: OR = 3.57 [95% CI: 2.47–5.16]); and N2 status (OR = 1.88 [95% CI: 1.27–2.78]) were more likely to receive definitive multimodal therapy. On adjusted analysis, an overall survival benefit was only observed with definitive multimodal therapy for PUC of urothelial origin (hazard ratio = 0.61 [95% CI: 0.45–0.83]). Conclusions Despite a survival benefit, most patients with locally advanced PUC do not undergo definitive multimodal therapy. We advocate for a multidisciplinary-based treatment approach for these patients. Future prospective trials of multimodal therapy are crucial.