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Purpose: Cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is standard of care for muscleinvasive bladder cancer (MIBC). However, NAC is used in less than 20% of patients with MIBC. Our goal is to investigate factors that contribute to underutilization NAC to facilitate more routine incorporation into clinical practice. Materials and Methods: We identified 5,915 patients diagnosed with cT2-T3N0M0 MIBC who underwent RC between 2004 and 2014 from the National Cancer Database. Univariate and multivariable models were created to identify variables associated with NAC utilization. Results: Only 18.8% of patients received NAC during the study period. On univariate analyses, NAC utilization was more likely at academic hospitals, US South and Midwest (p<0.05). Higher Charlson score was associated with decrease use of NAC (p<0.05). On multivariate analysis, treatment in academic hospitals (odds ratio [OR], 1.367; 95% confidence interval [CI], 1.186-1.576), in the Midwest (OR, 1.538; 95% CI, 1.268-1.977) and South (OR, 1.424; 95% CI, 1.139-1.781) were independently associated with NAC utilization. Older age (75 to 84 years old; OR, 0.532; 95% CI, 0.427-0.664) and higher Charlson score (OR, 0.607; 95% CI, 0.439-0.839) were associated with decreased NAC utilization. Sixty-eight percent of patients did not receive NAC because it was not planned and only 2.5% of patients had contraindications for NAC treatment. Conclusions: Our study demonstrates that NAC is underutilized. Decreased utilization of NAC was associated with older patients and higher Charlson score. This underutilization may be related to practice patterns as very few patients have true contraindications. [ABSTRACT FROM AUTHOR]