Patients with high-grade noninvasive bladder cancer do not receive recommended care

A new study has found that almost all patients with high-grade noninvasive bladder cancer do not receive complete care as recommended by current guidelines. Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the study indicates that efforts are needed to identify and overcome barriers to providing optimal care to patients with bladder cancer.

High-grade noninvasive bladder cancer has up to a 70 percent chance of recurring after treatment and up to a 50 percent chance of progressing to a more invasive tumor. Effective treatment for patients with high-grade noninvasive bladder cancer is critical. If the bladder tumor recurs and remains noninvasive, patients must undergo multiple operations; if it recurs and progresses to an invasive cancer, patients are at risk of having the cancer spread, and they may need to have their bladder removed and undergo radiation and chemotherapy treatments.

Medical guidelines advocate for delivering anticancer chemotherapy directly into the bladder (intravesical therapy) in order to minimize recurrence and progression of bladder cancer. They also recommend an intense follow-up schedule involving the use of a scope to evaluate the bladder (cytoscopy) and a urine test (cytology) every three months. To see whether patients are actually receiving this recommended care, Karim Chamie, MD, MSHS of the University of California Los Angeles led a team of researchers from UCLA's Jonsson Comprehensive Cancer Center that analyzed information on 4,545 patients diagnosed with high-grade noninvasive bladder cancer from 1992 to 2002 whose data were contained in the Surveillance, Epidemiology and End Results (SEER)-Medicare database, which links cancer registry information to a master file of Medicare enrollment. "To our surprise, out of the 4,545 patients, only one received care that was compliant with all the guideline recommendations," said Dr. Chamie. "In addition, nearly half of urologists have not performed at least one cystoscopy, one cytology, and one instillation of intravesical therapy for any given patient in the first two years after diagnosis."

The researchers measured whether patients' age, race, socioeconomic status, severity of other medical conditions, and extent of their bladder cancer contributed to the low compliance rate with guideline recommendations. They discovered that these patient-level factors had little effect. Rather, the most important predictor of whether a patient underwent recommended care was the physician. Additional studies are needed to identify why the vast majority of physicians are not following medical guidelines related to bladder cancer.

Based on these findings, "one would deduce that more than 99 percent of patients with high-risk bladder cancer are not receiving recommended care. This is significantly less than what most patients with bladder cancer, their physicians, and policy makers believe is happening," said Dr. Chamie. "We hope that shedding light on the level of discordance between ideal and routine care will prompt policy makers to modify reimbursement policies or support quality-improvement initiatives in the future."