Bladder cancer holds the dubious distinction of being among the most expensive malignancies to treat in the United States. Much of the associated cost is specifically attributable to nonmuscle-invasive disease (NMIBC), due to factors including a favorable long-term survival paired with a high recurrence rate. The American Urological Association (AUA) and Society of Urologic Oncology (SUO) guidelines for NMIBC were created based on evidence from the published literature combined with expert opinion to develop appropriate management strategies that weigh the risks and benefits of various approaches.
A broad lesson from the AUA/SUO guidelines is that while there are certainly circumstances warranting aggressive diagnostic and treatment measures, there are also opportunities to curb both morbidity and cost, especially for low-risk NMIBC. For instance, minimizing or even avoiding surveillance cystoscopy is reasonable for many patients, as is moving away from the use of routine urinary biomarkers, like urinary cytology. We wanted to determine the impact the guidelines have had on clinical practice in the four years since their release and identify specific areas where adherence was lowest.
The decision to distribute the survey only to SUO members was both a pragmatic and strategic one. We were unable to partner effectively with other clinical organizations to distribute our survey on a broader scale while targeting practicing urologists but excluding other clinicians (i.e. nurse practitioners, physician’s assistants). There is value, however, in limiting our distribution to SUO members since it is likely that the proportion of oncology patients they are treating is much higher than what is seen in general urology practice. In this way we are not necessarily trying to generalize our conclusions for all urologists, but rather finding out what constitutes daily practice among a population with more regular exposure to these patients.
Overall, our response rate of 16.2% was lower than desired but completely in line with what is typically reported for similar online-only surveys. As anticipated, the majority of respondents were fellowship-trained urologic oncologists (84%). We were pleased to have obtained a nearly even mix of early (36%), mid (27%), and late (37%) career clinicians, which allowed for more robust comparison based on clinical experience. Early career respondents were more likely than those in their late career to adhere to recommendations regarding less frequent cystoscopic surveillance of low-risk disease (61% v. 37%; p=0.01). Otherwise, adherence to specific statements covering the use of upper tract imaging (36% v. 30%; p=0.48) and urinary cytology (47% v. 47%; p=0.96) were similarly poor regardless of experience. It was in these three areas (surveillance cystoscopy, upper tract imaging, and urinary cytology) that we identified the poorest overall guidelines compliance, specifically for low-risk NMIBC.
This effort represents just an initial step in improving NMIBC care by attempting to identify the gaps between evidence-based recommendations and daily clinical practice. Overuse of cytology, imaging, and surveillance cystoscopy in low-risk disease was obvious in our data and can now be more directly addressed in future study designs.
Written by: Ashish Kamat, MD, MBBS, Professor of Urology and Cancer Research and Wayne B. Duddleston Professor of Cancer Research at MD Anderson Cancer Center in Houston, Texas. Dr. Kamat serves as President of International Bladder Cancer Group, (IBCG), and Co-President of International Bladder Cancer Network.
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