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Keywords:

  • bladder cancer;
  • intravesical therapy;
  • patterns of care;
  • physician survey

Study Type – Therapy (patterns of practice)

Level of Evidence 2b

What's known on the subject? and What does the study add?

Claims-based analyses suggest unexplained and potentially problematic variation in treatment intensity adherence to guidelines-recommended care in NMIBC. Previous physician surveys prior to the contemporary Clinical Practice Guidelines (CPGs) reported associations between variation in NMIBC care and practice type, years in practice, and other physician-related factors.

In the largest physician survey addressing the management of NMIBC, and the first to examine these questions after the promulgation of contemporary CPGs, US urologists report grade-specific utilization consistent with CPG recommendations, at rates higher than suggested by recent claims-based analyses. As with prior studies, practice type and years in practice were significantly associated with variation in practices. Further research is needed to reconcile these findings with administrative claims data.

OBJECTIVES

  • • 
    To determine self-reported practices of use of intravesical chemo- and immunotherapy for patients with non-muscle-invasive bladder cancer (NMIBC)
  • • 
    To evaluate the extent to which respondent characteristics were associated with any observed variation. Guidelines recommend intravesical therapy (IVT) in the management of NMIBC, but recent claims-based analyses suggest exceedingly low rates of use of some of these therapies.

MATERIALS AND METHODS

  • • 
    An electronic survey was developed by members of the Bladder Cancer Advocacy Network (BCAN) to elicit self-reported use of management strategies for NMIBC.
  • • 
    The survey was circulated to urologists via the American Urological Association, Society for Urologic Oncology and Large Urology Group Practice Association distribution lists.
  • • 
    In all, 512 respondents completed the survey.

RESULTS

  • • 
    In all, 63% reported routine perioperative mitomycin-c (MMC) after transurethral resection of bladder tumour (80% academic vs 54% private practice, P < 0.001).
  • • 
    Whereas 5% of respondents reported routine induction therapy with all new low-grade (LG) diagnoses, 99% reported routinely doing so in new high-grade (HG) cases; most commonly with single-agent bacille Calmette-Guérin (BCG) (94% vs 9% BCG/interferon and 5% MMC).
  • • 
    Reported induction therapy was higher in the setting of high-volume (77%) or frequently recurrent (44%) LG disease.
  • • 
    In all, 89% reported routinely using maintenance therapy for HG vs 29% for LG disease.
  • • 
    Routine biopsy after BCG, even with normal cystoscopy, was endorsed by 28% (39% academic vs 22% private practice, P < 0.001).

CONCLUSIONS

  • • 
    Urologists report grade-specific use of IVT for NMIBC, at rates higher than suggested in some claims-based analyses.
  • • 
    Further study is needed to corroborate these self-reported patterns of care with lower rates of use suggested by claims-based analyses.