Extent of Risk-Aligned Surveillance for Cancer Recurrence Among Patients With Early-Stage Bladder Cancer

Abstract

Importance: Cancer care guidelines recommend aligning surveillance frequency with underlying cancer risk, ie, more frequent surveillance for patients at high vs low risk of cancer recurrence.

Objective: To assess the extent to which such risk-aligned surveillance is practiced within US Department of Veterans Affairs facilities by classifying surveillance patterns for low- vs high-risk patients with early-stage bladder cancer.

Design setting and participants: US national retrospective cohort study of a population-based sample of patients diagnosed with low-risk or high-risk early-stage bladder between January 1, 2005, and December 31, 2011, with follow-up through December 31, 2014. Analyses were performed March 2017 to April 2018. The study included all Veterans Affairs facilities (n = 85) where both low-and high-risk patients were treated.

Exposures: Low-risk vs high-risk cancer status, based on definitions from the European Association of Urology risk stratification guidelines and on data extracted from diagnostic pathology reports via validated natural language processing algorithms.

Main outcomes and measures: Adjusted cystoscopy frequency for low-risk and high-risk patients for each facility, estimated using multilevel modeling.

Results: The study included 1278 low-risk and 2115 high-risk patients (median [interquartile range] age, 77 [71-82] years; 99% [3368 of 3393] male). Across facilities, the adjusted frequency of surveillance cystoscopy ranged from 3.7 to 6.2 (mean, 4.8) procedures over 2 years per patient for low-risk patients and from 4.6 to 6.0 (mean, 5.4) procedures over 2 years per patient for high-risk patients. In 70 of 85 facilities, surveillance was performed at a comparable frequency for low- and high-risk patients, differing by less than 1 cystoscopy over 2 years. Surveillance frequency among high-risk patients statistically significantly exceeded surveillance among low-risk patients at only 4 facilities. Across all facilities, surveillance frequencies for low- vs high-risk patients were moderately strongly correlated (r = 0.52; P < .001).

Conclusions and relevance: Patients with early-stage bladder cancer undergo cystoscopic surveillance at comparable frequencies regardless of risk. This finding highlights the need to understand barriers to risk-aligned surveillance with the goal of making it easier for clinicians to deliver it in routine practice.

Figure 1.. Flow Diagram of Cohort Formation

The final cohort comprised 1278 patients with low-risk bladder cancer and 2115 patients with high-risk bladder cancer. VA indicates Department of Veterans Affairs.

Figure 2.. Facility-Level Variation in Adjusted Frequency of Cystoscopy Procedures for Low-Risk and High-Risk Patients

Facilities are ranked from lowest frequency to highest frequency of cystoscopy for patients with low-risk (A) and high-risk (B) bladder cancer. The mean frequency across all facilities is indicated on the y-axis. Error bars indicate 95% confidence intervals. Frequency of cystoscopy was adjusted for age, comorbidity, year of diagnosis, and length of follow-up.

Figure 3.. Facility-Level Correlation of Cystoscopy Frequency Between Low-Risk and High-Risk Patients

Each dot represents 1 facility. The line represents the same cystoscopy frequency for low-risk patients (x-axis) and high-risk patients (y-axis). The shaded area represents facilities where low-risk and high-risk patients undergo cystoscopy at comparable rates (ie, absolute difference of less than 1 cystoscopy over 2 years). Orange dots represent facilities with a statistically significantly higher frequency for high-risk vs low-risk patients.