# Trends in the Management of Bladder Cancer with Emphasis on Frailty: A Nationwide Analysis of More Than 49,000 Patients from a German Hospital Network

## TL;DR

This study examines how bladder cancer treatment and patient frailty have changed in Germany over six years, showing shifts in treatment approaches and the importance of considering frailty in care decisions.

## Contribution

The study provides a nationwide analysis of bladder cancer management trends in Germany, highlighting the role of frailty in treatment decisions and outcomes.

## Key findings

- The proportion of patients with low frailty increased from 73.4% to 75.5% between 2016–2019 and 2020–2022.
- Use of systemic therapy increased, especially among low frailty elderly patients, while early intravesical chemotherapy declined significantly, particularly in high frailty elderly patients.
- Hospital stay duration decreased by one day, but ICU admission rates and in-hospital mortality remained stable over time.

## Abstract

Background: Bladder cancer (BC) predominantly affects older patients, and their multidisciplinary treatment often includes surgical intervention. Frailty can influence treatment decisions and is associated with poorer outcomes. This study analyses trends in demographics, treatment patterns and frailty in a large, nationwide, real-world inpatient cohort in Germany. Methods: This retrospective observational study included a total of 49,139 consecutive patients, who received inpatient care for BC at all HELIOS hospitals in Germany between 2016 and 2022. Frailty was assessed using the Hospital Frailty Risk Score (HFRS) and categorised as low (<5), intermediate (5–15), or high (>15). Trends in HFRS, treatment modalities, and demographic variables were analysed using regression models and compared between the periods 2016–2019 and 2020–2022. Results: Of the 49,139 patients, 27,979 were treated between 2016–2019 and 21,160 between 2020–2022. Patients treated in the later period were slightly older but had a lower comorbidity index. The proportion of patients with low frailty increased (73.4% vs. 75.5%, p < 0.01), intermediate frailty decreased (23.5% vs. 21.5%, p < 0.01) and the proportion of highly frail patients remained stable at 3.0% (p = 0.95). Rates of transurethral resection declined over time, whereas rates of RC remained stable (p = 0.12). The use of systemic therapy increased (p = 0.003), particularly among low frailty elderly patients. Early intravesical chemotherapy following transurethral resection declined significantly in 2020–2022 (p < 0.001), particularly among elderly patients with high frailty. Mean length of hospital stay decreased by one day, while ICU admission rates and in-hospital mortality remained stable across time periods. Conclusions: This study shows frailty-specific changes in hospitalisation patterns and inpatient management of BC in Germany, underscoring the value of frailty assessment in population-based research. The proportion of patients classified as having low frailty increased over time. Significant changes in the use of intravesical chemotherapy and systemic therapy were associated with frailty. The decline in early intravesical chemotherapy may have implications for recurrence risk and downstream healthcare utilisation.