Quality of Care In Patients With Bladder Cancer A Case Report?

Jonsson Comprehensive Cancer Center, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
Cancer (Impact Factor: 4.89). 03/2012; 118(5):1412 - 1421. DOI: 10.1002/cncr.26402
Source: PubMed


Although there is level I evidence demonstrating the superiority of intravesical therapy in patients with bladder cancer, surveillance strategies are primarily founded on expert opinion. The authors examined compliance with surveillance and treatment strategies and the pursuant impact on survival in patients with high-grade disease.
Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the authors identified subjects with a diagnosis of high-grade, non–muscle-invasive disease between 1992 and 2002 who survived 2 years and did not undergo definitive treatment during that time. Nonlinear mixed-effects regression analyses was used to examine compliance with surveillance and treatment strategies. After adjusting for confounders using a propensity score-weighted approach, the authors determined whether individual and comprehensive strategies during the initial 2 years after diagnosis were associated with survival after 2 years.
Of 4790 subjects, only 1 received all the recommended measures. Although mean utilization for most measures significantly increased after 1997, only compliance with an induction course of bacillus Calmette-Guerin (BCG) increased (13% to 20%; P < .001). On multivariate analysis, compliance with ≥ 4 cystoscopies, ≥ 4 cytologies, and BCG instillation was found to be lower among octogenarians and higher among those with undifferentiated, Tis, and T1 tumors, and among those individuals diagnosed after 1997. Subjects compliant with these measures had a lower hazard of mortality (hazard ratio, 0.41; 95% confidence interval, 0.18-0.93) than those who received < 4 cystoscopies, < 4 cytologies, and no BCG.
There was a statistically significant survival advantage found among those who received at least half of the recommended care. Improving compliance with these process-of-care measures via systematic quality improvement initiatives serves as the primary target to meliorate bladder cancer care. Cancer 2012;.

Download full-text


Available from: Christopher S Saigal,

  • The Journal of urology 03/2012; 187(5):1575-6. DOI:10.1016/j.juro.2011.12.162 · 4.47 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Nonmuscle invasive bladder cancer represents a large majority of patients diagnosed with this disease. Precise definition and risk stratification are paramount in this group as high-risk patients have higher rates of progression and mortality and may benefit from early identification and aggressive treatment. The mainstay definitions of high-risk nonmuscle invasive bladder cancer are based on grade and stage. Recently, efforts have been made to incorporate other clinical variables into multivariate risk assessment tools and nomograms to predict disease behavior and guide management. Variant histology and molecular biomarkers are being explored as tools to refine risk stratification; however, results are still preliminary and need validation. Future research should concentrate on ways to better risk-stratify patients and identify early those that are most likely to recur and progress quickly. Topics of focus should be on better multivariate risk assessment tools and nomograms providing continuous scales and incorporating molecular markers with validation in large multi-institutional cohorts.
    Current opinion in urology 07/2012; 22(5):385-9. DOI:10.1097/MOU.0b013e328356aecf · 2.33 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose of review: To summarize recent developments and controversies in the management of both nonmuscle-invasive and muscle-invasive urothelial carcinoma of the bladder. Recent findings: Bladder cancer remains a commonly diagnosed disease both within the United States and worldwide. Despite improvements in diagnosis and management of nonmuscle-invasive bladder tumors, the risk of both recurrence and progression remains significant. Tobacco use remains the single most common modifiable causative factor and there is recent evidence to suggest the favorable effect of urologist involvement in tobacco cessation. While radical cystectomy remains the mainstay of treatment for muscle-invasive disease, there is a growing body of evidence supporting the use of minimally invasive radical cystectomy. Ongoing randomized studies will improve our understanding of the comparative effectiveness and harms of both minimally invasive cystectomy as well as the optimal extent of pelvic lymphadenectomy at the time of radical cystectomy. Summary: Bladder cancer remains a complex and heterogeneous disease. Careful attention to risk stratification of patients with nonmuscle-invasive tumors permits appropriate timing of intravesical therapy and radical cystectomy. Ongoing efforts to improve the quality of data surrounding the comparative effectiveness and harms of interventions for both nonmuscle-invasive and muscle-invasive disease will enhance our ability to predict which treatments work in which patients, and under what circumstances and at what cost.
    Current opinion in oncology 02/2013; 25(3). DOI:10.1097/CCO.0b013e32835eb583 · 4.47 Impact Factor
Show more