Jan M. Hanley

Variations in Reconstruction After Radical Cystectomy

Most urologists specializing in the management of patients with bladder cancer consider continent urinary diversion the reconstructive technique that affords the best quality of life after radical cystectomy. The authors sought to evaluate factors that predict reconstructive technique after radical cystectomy.

Compliance with guidelines for patients with bladder cancer: variation in the delivery of care.

Clinical practice guidelines for the management of patients with bladder cancer encompass strategies that minimize morbidity and improve survival. In the current study, the authors sought to characterize practice patterns in patients with high‐grade non–muscle‐invasive bladder cancer in relation to established guidelines.

Urinary Diversion and Morbidity After Radical Cystectomy for Bladder Cancer

The rate of continent urinary diversion after radical cystectomy for bladder cancer varies by patient and provider characteristics. Demonstration of equivalent complication rates, independent of diversion type, may decrease provider reluctance to perform continent reconstructions. The authors sought to determine whether continent reconstructions confer increased complication rates after radical cystectomy.

Recurrence of high‐risk bladder cancer: A population‐based analysis

Patients with bladder cancer are apt to develop multiple recurrences that require intervention. The recurrence, progression, and bladder cancer–related mortality rates were examined in a cohort of individuals with high‐grade non–muscle‐invasive bladder cancer.

External validation of a claims-based algorithm for classifying kidney-cancer surgeries

BackgroundUnlike other malignancies, there is no literature supporting the accuracy of medical claims data for identifying surgical treatments among patients with kidney cancer. We sought to validate externally a previously published Medicare-claims-based algorithm for classifying surgical treatments among patients with early-stage kidney cancer. To achieve this aim, we compared procedure assignments based on Medicare claims with the type of surgery specified in SEER registry data and clinical operative reports.MethodsUsing linked SEER-Medicare data, we calculated the agreement between Medicare claims and SEER data for identification of cancer-directed surgery among 6,515 patients diagnosed with early-stage kidney cancer. Next, for a subset of 120 cases, we determined the agreement between the claims algorithm and the medical record. Finally, using the medical record as the reference-standard, we calculated the sensitivity, specificity, and positive and negative predictive values of the claims algorithm.ResultsAmong 6,515 cases, Medicare claims and SEER data identified 5,483 (84.1%) and 5,774 (88.6%) patients, respectively, who underwent cancer-directed surgery (observed agreement = 93%, κ = 0.69, 95% CI 0.66 – 0.71). The two data sources demonstrated 97% agreement for classification of partial versus radical nephrectomy (κ = 0.83, 95% CI 0.81 – 0.86). We observed 97% agreement between the claims algorithm and clinical operative reports; the positive predictive value of the claims algorithm exceeded 90% for identification of both partial nephrectomy and laparoscopic surgery.ConclusionMedicare claims represent an accurate data source for ascertainment of population-based patterns of surgical care among patients with early-stage kidney cancer.

Recurrence of high-risk bladder cancer

Patients with bladder cancer are apt to develop multiple recurrences that require intervention. The recurrence, progression, and bladder cancer–related mortality rates were examined in a cohort of individuals with high‐grade non–muscle‐invasive bladder cancer.

Quality of care in patients with bladder cancer: A case report?

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.

Treatment and survival in patients with recurrent high-risk non-muscle-invasive bladder cancer.

BACKGROUND Multiple recurrences develop in patients with high-risk non-muscle-invasive bladder cancer. As neither the association of recurrences with survival nor the subsequent aggressive treatment in individuals with recurrent high-grade non-muscle-invasive bladder cancer has ever been quantified, we sought to determine whether the increasing number of recurrences is associated with higher subsequent treatment and mortality rates. METHODS Using linked Surveillance, Epidemiology, and End Results-Medicare data, we identified subjects with recurrent high-grade, non-muscle-invasive disease diagnosed in 1992 to 2002 and followed up until 2007. Using competing-risks regression analyses, we quantified the incidence of radical cystectomy, radiotherapy, and systemic chemotherapy after each recurrence. We then performed a propensity-score adjusted competing-risks regression analysis to determine whether the increasing recurrences portend worse survival. RESULTS Of 4,521 subjects, 2,694 (59.6%) had multiple recurrences within 2 years of diagnosis. Compared with patients who only had 1 recurrence, those with ≥ 4 recurrences were less likely to undergo radical cystectomy (hazard ratio [HR] = 0.73, 95% CI: 0.58-0.92), yet more likely to undergo radiotherapy (HR = 1.51, 95% CI: 1.23-1.85) and systemic chemotherapy (HR = 1.58, 95% CI: 1.15-2.18). For patients with ≥ 4 recurrences, only 25% were treated with curative intent. The 10-year cancer-specific mortality rates were 6.9%, 9.7%, 13.7%, and 15.7% for those with 1, 2, 3, and ≥ 4 recurrences, respectively. CONCLUSIONS Only 25% of patients with high-risk non-muscle-invasive bladder cancer who experienced recurrences at least 4 times underwent radical cystectomy or radiotherapy. Despite portending worse outcomes, increasing recurrences do not necessarily translate into higher treatment rates.

Association Between Number of Endoscopic Resections and Utilization of Bacillus Calmette-Guérin Therapy for Patients with High-Grade, Non-Muscle-Invasive Bladder Cancer

&NA; Bacillus Calmette‐Guérin (BCG) is an effective yet underutilized treatment for high‐grade, non–muscle‐invasive bladder cancer. We evaluated the patterns of BCG utilization with respect to number of endoscopic resections in a Surveillance, Epidemiology, and End Results (SEER)‐Medicare linked database and found that BCG adoption is slow and incomplete. Methods to improve compliance with this therapy are warranted. Background: Bacillus Calmette‐Guérin (BCG) is the reference standard treatment for patients with high‐grade, non–muscle‐invasive bladder cancer (NMIBC). We previously described noncompliance with guidelines for BCG use in patients with high‐risk disease. In the current study, we sought to characterize how the number of endoscopic resections of bladder tumors affects BCG utilization using population‐level data. Patients and Methods: We queried a Surveillance, Epidemiology, and End Results (SEER)‐Medicare linked database to evaluate claims records of 4776 patients diagnosed with high‐grade NMIBC between 1992 and 2002 and followed until 2007, who survived for at least 2 years and who did not undergo definitive treatment with cystectomy, radiotherapy, or systemic chemotherapy. We stratified patients on the basis of the number of endoscopic resections of bladder tumors. We used chi‐square analysis to compare number of resections to BCG utilization and multinomial logistic regression analysis to quantify BCG utilization by patient and tumor characteristics. Results: Utilization of BCG increases with increasing endoscopic resections from 40% at diagnosis to 72% after 6 resections. The cumulative rate of at least an induction course of BCG plateaus after 3 resections. Lower BCG utilization was associated with advanced age (≥ 80 years), while increased utilization was associated with being married, higher disease stage (Tis and T1) and grade (undifferentiated), and increasing endoscopic resections. Conclusion: A significant fraction of patients with NMIBC do not receive induction BCG despite its proven benefit in minimizing recurrences. Most patients receive BCG only after multiple endoscopic resections. Strategies focused on earlier adoption of BCG to prevent recurrences instead of reacting to recurrences may limit progression and improve survival.