Jeffrey C. Bassett

Increasing Use of Observation among Men at Low Risk for Prostate Cancer Mortality

PURPOSE There are growing concerns regarding the overtreatment of localized prostate cancer. It is also relatively unknown whether there has been increased uptake of observational strategies for disease management. We assessed the temporal trend in observation of clinically localized prostate cancer, particularly in men with low risk disease, who were young and healthy enough to undergo treatment. MATERIALS AND METHODS We performed a retrospective cohort study using the SEER-Medicare database in 66,499 men with localized prostate cancer between 2004 and 2009. The main study outcome was observation within 1 year after diagnosis. We performed multivariable analysis to develop a predictive model of observation adjusting for diagnosis year, age, risk and comorbidity. RESULTS Observation was performed in 12,007 men (18%) with a slight increase with time from 17% to 20%. However, there was marked increase in observation from 18% in 2004 to 29% in 2009 in men with low risk disease. Men 66 to 69 years old with low risk disease and no comorbidities had twice the odds of undergoing observation in 2009 vs 2004 (OR 2.12, 95% CI 1.73-2.59). Age, risk group, comorbidity and race were independent predictors of observation (each p <0.001), in addition to diagnosis year. CONCLUSIONS We identified increasing use of observation for low risk prostate cancer between 2004 and 2009 even in men young and healthy enough for treatment. This suggests growing acceptance of surveillance in this group of patients.

Variation in the intensity of hematuria evaluation: a target for primary care quality improvement

BACKGROUND Hematuria is a common clinical finding and represents the most frequent presenting sign of bladder cancer. The American Urological Association recommends cystoscopy and abdomino-pelvic imaging for patients aged more than 35 years. Nonetheless, less than half of patients presenting with hematuria undergo proper evaluation. We sought to identify clinical and nonclinical factors associated with evaluation of persons with newly diagnosed hematuria. METHODS We performed a retrospective cohort study, using claims data and laboratory values. The primary exposure was practice site, as a surrogate for nonclinical, potentially modifiable sources of variation. Primary outcomes were cystoscopy or abdomino-pelvic imaging within 180 days after hematuria diagnosis. We modeled the association between clinical and nonclinical factors and appropriate hematuria evaluation. RESULTS We identified 2455 primary care patients aged 40 years or more and diagnosed with hematuria between 2004 and 2012 in the absence of other explanatory diagnosis; 13.7% of patients underwent cystoscopy within 180 days. Multivariate logistic regression revealed significant variation between those who did and did not undergo evaluation in age, gender, and anticoagulant use (P < .001, P = .036, P = .028, respectively). Addition of practice site improved the predictive discrimination of each model (P < .001). Evaluation was associated with a higher rates of genitourinary neoplasia diagnosis. CONCLUSIONS Patients with hematuria rarely underwent complete evaluation. Although established risk factors for malignancy were associated with increasing use of diagnostic testing, factors unassociated with risk, such as practice site, also accounted for significant variation. Inconsistency across practice sites is undesirable and may be amenable to quality improvement interventions.

Management of superficial and muscle-invasive urothelial cancers of the bladder.

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.

Knowledge of the harms of tobacco use among patients with bladder cancer

The objective of this study was to determine tobacco use knowledge and attribution of cause in patients with newly diagnosed bladder cancer.

Treating octogenarians with muscle-invasive bladder cancer: Preoperative opportunities for increasing the benefits of surgical intervention

The question posed to the authors is whether surgery is the best treatment option for octogenarians with invasive bladder cancer. Herein, we detail the rationale in favor of radical cystectomy and opportunities for improvement in the processes of care for those who may be surgical candidates.

Variation in the Diagnostic Evaluation among Persons with Hematuria: Influence of Gender, Race and Risk Factors for Bladder Cancer

Purpose: We sought to determine whether race, gender and number of bladder cancer risk factors are significant predictors of hematuria evaluation. Materials and Methods: We used self‐reported data from SCCS (Southern Community Cohort Study) linked to Medicare claims data. Evaluation of subjects diagnosed with incident hematuria was considered complete if imaging and cystoscopy were performed within 180 days of diagnosis. Exposures of interest were race, gender and risk factors for bladder cancer. Results: Of the 1,412 patients evaluation was complete in 261 (18%). On our adjusted analyses African American patients were less likely than Caucasian patients to undergo any aspect of evaluation, including urology referral (OR 0.72, 95% CI 0.56–0.93), cystoscopy (OR 0.67, 95% CI 0.50–0.89) and imaging (OR 0.75, 95% CI 0.59–0.95). Women were less likely than men to be referred to a urologist (OR 0.59, 95% CI 0.46–0.76). Also, although all patients with 2 or 3 risk factors had 31% higher odds of urology referral (OR 1.31, 95% CI 1.02–1.69), adjusted analyses indicated that this effect was only apparent among men. Conclusions: Only 18% of patients with an incident hematuria diagnosis underwent complete hematuria evaluation. Gender had a substantial effect on referral to urology when controlling for socioeconomic factors but otherwise it had an unclear role on the quality of evaluation. African American patients had markedly lower rates of thorough evaluation than Caucasian patients. Number of risk factors predicted referral to urology among men but it was otherwise a poor predictor of evaluation. There is opportunity for improvement by increasing the completion of hematuria evaluations, particularly in patients at high risk and those who are vulnerable.

Developments and controversies in the management of noninvasive bladder cancer.

Purpose of review To summarize recent developments and controversies in the diagnosis and management of nonmuscle invasive bladder cancer (NMIBC). Recent findings The majority of incident bladder cancer diagnoses are noninvasive. The mainstay of diagnosis remains cystoscopy and transurethral resection, with enhanced optical techniques potentially improving detection of nascent disease. Intravesical chemotherapeutic and immunotherapeutic agents reduce the likelihood of recurrence and progression, with novel agents showing promise. The identification of variant histology with aggressive phenotypes permits identification of patients unlikely to respond to intravesical agents, in whom early cystectomy is advocated. Risk stratification of patients with NMIBC continues to improve and should be used to inform surveillance and treatment paradigms. Tobacco cessation may improve disease-specific endpoints and overall mortality. Summary NMIBC encompasses a variety of tumors with heterogeneous natural histories, making clinical management challenging. Improved detection with novel technologies and optimization of existing treatment modalities hold promise of improving oncologic outcomes in the future.

Guideline-Based Management of Non-muscle Invasive Bladder Cancer: Comparison of the AUA, EAU, ICUD, and NCCN Guidelines

A number of evidence-based guidelines exist for the management of non-muscle invasive bladder cancer (NMIBC), including those published by the American Urological Association (AUA), the European Association of Urology (EAU), the International Consultation on Urological Disease (ICUD), and National Comprehensive Cancer Network (NCCN). These guidelines serve to equip the clinician with an evidence base for treatment decisions at various points in the clinicopathologic course, of import given the complexity of managing a neoplasm with a high likelihood of recurrence and progression. Herein we detail the methodology utilized in the creation of the aforementioned guidelines, noting the similarities and differences in the panels’ approach. We apply the AUA, EAU, ICUD, and NCCN guidelines to specific clinical vignettes oft encountered in the management of NMIBC, highlighting where consensus and dissensus exist. Finally, we discuss the strengths and limitations of guideline-based management, in particular the ability of guidelines to account for clinically relevant variables such as patient age, preferences, and response to treatment.

Treatment patterns in patients with recurrent high-risk bladder cancer.

303 Background: Patients with high-risk bladder cancer are apt to develop multiple recurrences. Since the association of recurrences with aggressive treatment in individuals with recurrent high-grade disease has not been quantified, we sought to determine whether increasing number of recurrences correlates with higher treatment rates. Methods: Using linked SEER-Medicare data, we identified subjects with recurrent high-grade, non-muscle-invasive disease diagnosed in 1992–2002 and followed until 2007. Using propensity score and competing-risks regression analyses, we quantified the incidence of radical cystectomy, radiotherapy, and systemic chemotherapy after each recurrence. We further restricted our analyses of treatment in auspicious environments, defined as those patients most suited for aggressive intervention: age <70, Charlson 0, and undifferentiated T1 tumors treated at academic cancer centers. Results: Of 4,521 subjects, (59.6%) 2,694 recurred more than once within two years of diagnosis. Compared ...