- 59% for cytology
- 45% for perioperative intravesical chemotherapy
- 26% for postoperative instillation of Bacillus Calmette-Guérin (BCG) immunotherapy
- 25% for cystoscopy
"We could do a better job standardizing our management of bladder cancer," agreed J. Stuart Wolf, Jr., MD, of the University of Michigan in Ann Arbor and chair of the AUA practice guidelines committee.
The AUA needs to improve dissemination of its guidelines, likely through getting local "champions" involved and providing physician feedback on performance, he suggested in an interview with MedPage Today.
Unless such a broad quality improvement initiative is implemented to provide clinically effective care, "many more unnecessary disease recurrences, procedures, and deaths will be realized," Chamie's group warned in the paper.
However, the study may have somewhat overstated the problem, Wolf argued.
"I think their criteria for compliance may have been a bit too rigorous," he said.
Based on guidelines from the NCCN in 1998, AUA in 1999, and European Association of Urology in 2002, which had only slight variation among them, the researchers determined bladder cancer patients should have received:
- Frequent surveillance to detect recurrence and progression with cystoscopy and urine cytology every three months for the first two years after diagnosis.
- Upper tract imaging at diagnosis and at least every two years thereafter for a total of at least eight cystoscopies, eight cytologies, and two upper tract imaging studies.
- At least one treatment with intravesical chemotherapy in the form of perioperative mitomycin C (Mutamycin) after transurethral urethral resection of the bladder tumor.
- At least six instillations of BCG immunotherapy postoperatively to minimize recurrence and progression.
Wolf cautioned that the data on perioperative mitomycin was only beginning to come out in the mid- to late-1990s, which may have played a role in lower adherence during the study period.
Even excluding the mitomycin and upper tract imaging requirements, 99% of physicians did not provide the full number of other treatments to a single patient.
While 99% noncompliance is "hard to fathom," eight cystoscopies in two years might be excessive for some patients, Wolf noted, calling it a high bar for compliance.
Yet further relaxing the definition for compliance still yielded poor results.
In the study, 42% of physicians did not perform at least one cystoscopy, one cytology, and one instillation of immunotherapy for even a single patient in their practice in the first two years after diagnosis.
The criteria had to drop to requiring only one cystoscopy and one BCG immunotherapy instillation before what at least half of patients received could be considered compliant care (53.6%).
The only patient or provider adherence measures that improved significantly after the guidelines came out were use of radiographic imaging (odds ratio 1.19, 95% confidence interval 1.03 to 1.37) and immunotherapy (OR 1.67, 95% CI 1.39 to 2.01).
The researchers suggested that physicians have little excuse for poor compliance, since cystoscopy, cytology, and intravesical treatments for bladder cancer are office-based procedures.
"By limiting our cohort to those patients with high-grade disease, we expected preference-sensitive variation to err on the side of overuse, not gross underuse," they chided in the paper.
The group cautioned, though, that their observational study may have been confounded by patient preferences for surveillance and treatment and lack of data on who withdrew from therapy due to side effects, as well as limited in generalizability to patients under age 65 or with private insurance.
The study was supported by the American Cancer Society, Ruth L. Kirschstein National Research Service Award Extramural, Jonsson Comprehensive Cancer Center Seed Grant, and National Institute of Diabetes and Digestive and Kidney Diseases.
The researchers reported having no conflicts of interest to declare.
Wolf reported having no conflicts of interest to declare.
