The majority of patients with high-grade non-invasive bladder cancer are not getting the care recommended by official guidelines from the American Urology Association and the National Comprehensive Cancer Network; essential treatment to minimize the chances of a recurrence or cancer progression, researchers from UCLA's Jonsson Comprehensive Cancer Center revealed in the journal Cancer. The scientists say their findings are "alarming".
In their study, only 1 bladder cancer patient received comprehensive recommended care out of a total of 4,545.
Dr. Karim Chamie explained that recommended care for this type of bladder cancer is crucial, because it significantly reduces mortality rates.
Dr. Chamie said:
"We were surprised by the findings in this study, particularly in an era when many suggest that doctors over-treat patients and do too much in the name of practicing defensive medicine. This study suggests quite the contrary, that we don't do enough for patients with bladder cancer. If this was a report card on bladder cancer care in America, I'd say we're earning a failing grade."
Non-adherence (non-compliance) was high and not influenced by such factors as the patient's ethnicity, age, race, or socioeconomic status. Non-compliance was mainly due to treatment decisions carried out by doctors.
Dr. Chamie said:
"It wasn't their age, race, ZIP code or how wealthy they were. It all came down to who their doctor was."
Senior study author, Dr. Mark S. Litwin is not sure why doctors are not following established treatment guidelines routinely.
Dr. Litwin said:
"It is puzzling, because strong evidence supports those guidelines. But this is a wakeup call to all physicians caring for patients with bladder cancer. We know definitively what constitutes high-quality care. Now we just need to make sure it happens."
Those with high-grade non-invasive bladder cancer have a 50% to 70% risk of cancer recurrence in the bladder after treatment. High-grade non-invasive bladder has not yet spread into the muscle of the bladder. They also have a 30% to 50% risk of the cancer spreading into the muscle - when this occurs, the bladder cancer is much more difficult to treat effectively. By then, the bladder and surrounding tissue and organs usually have to be surgically removed, significantly reducing the patient's quality of life and life-expectancy.
In three-quarters of bladder cancer diagnoses, the cancer has not yet spread into the muscle, Chamie explained. Therefore, treating them according to recommended guidelines helps reduce their risk of recurrence to a minimum, as well as preventing the invasion of muscle.
Guidelines recommend that a cancer-killing drug is injected directly into the bladder - this helps minimize progression and recurrence. There should be intense follow-up, including repeatedly using a scope (cystoscopy) to check the inside of the bladder. Urine tests to check for abnormal cells should be done every three months.
Just one patient in the study received the recommended care. The researchers had gathered data from the SEER (Surveillance, Epidemiology and End Results) Medicare-linked database. Half of the patients had not received at least one cancer-killing injection into the bladder, a urine test or a cystoscopy.
Either doctor reimbursements should be altered, or there should be a quality-improvement initiative to address this situation, Chamie and Litwin suggest.
Despite the poor adherence rate, bladder cancer is the costliest malignancy to treat on a per-patient level. Compliance would reduce the recurrence and progression rates, which would eventually bring down costs.
Dr. Chamie said:
"We have to improve compliance, and there are two ways to do that: Modify our reimbursement schedules to provide incentives to doctors to follow the guidelines, or go out and interact and educate the community urologists, who are delivering the vast majority of bladder cancer care, on the importance of providing compliant care. Unlike some patients diagnosed with bladder cancer after having it spread to other sites, when it's too late to treat effectively, or those with low-grade tumors that are not likely to ever be aggressive, this is a potentially curable cohort of patients. If we don't do a good enough job treating these cancers, we're going to lose these patients."
70,000 Americans will probably be diagnosed with bladder cancer in 2011, and 15,000 will die from the disease, the authors add.
"Compliance with guidelines for patients with bladder cancer"
Karim Chamie, Christopher S. Saigal, Julie Lai, Jan M. Hanley, Claude M. Setodji, Badrinath R. Konety, Mark S. Litwin
Written by Christian Nordqvist