Patients With Bladder Cancer Not Getting Recommended Care

Karim Chamie, MD

Study results published in the journal Cancer reveal that only a small fraction (ie, 0.02%) of patients with high-grade, noninvasive bladder cancer receive the appropriate treatment as directed by the American Urological Association and the National Comprehensive Cancer Network. The study showed that only 1 out of 4545 people with this type of cancer got the recommended treatments, significantly increasing a risk of disease recurrence.

The study was conducted at Jonsson Comprehensive Cancer Center at UCLA in Los Angeles, California. The participating patients all had primary bladder cancer that had not yet penetrated the bladder muscle. The investigators used Surveillance, Epidemiology, and End Results (SEER)/Medicare-linked data between 1992 and 2002 to identify patients who had survived ≥2 years without having undergone “definitive” treatment.

The authors were surprised by the study’s results, noting that, in this era of overtreating patients to prevent lawsuits, just the opposite is being done for patients with high-grade bladder cancer. “If this was a report card on bladder cancer care in America, I’d say we’re earning a failing grade,” lead study author Karim Chamie, MD, a postdoctoral fellow in urologic oncology at UCLA, said in a press release.

Surprisingly, the study found that poor compliance was not linked to a patient’s age, race, financial condition, or area of residence. Rather, compliance was attributed to the patient’s physician. Chamie warned that if physicians do not follow the guidelines, patients will die unnecessarily. However, it is not entirely clear why most physicians are not adhering to the guidelines.

Some clinicians find that the guidelines represent opinion and not actual clinical data. The guidelines are also complex and often require physicians to meticulously follow each step in order to achieve the best outcomes. However, the guideline-recommended treatment can cause adverse effects, leading many patients to shy away from treatment.

For example, after a patient receives a transurethral resection of the bladder tumor, the recommended care for the next two years includes at least 8 cytoscopies, 8 cytologies, 2 upper tract imaging studies, 1 installation of perioperative mitomycin-C, and 6 courses of Bacillus Calmette-Guerin or similar agent. The array of tests seems daunting, and without the appropriate counseling and follow-up by physicians, patients are not receiving the recommended care for this disease.

The authors of the study suggest that to improve compliance rates among physicians, reimbursement rates should be modified based on adherence to the guidelines. Also, the authors suggest additional research be conducted to determine exactly why most physicians are not complying with the guidelines.

Chamie K, Saigal CS, Lai J, et al. Compliance with guidelines for patients with bladder cancer: variation in the delivery of care [published online ahead of print July 11, 2011]. Cancer. doi:10.1002/cncr.26198.