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. 2019 Sep:131:112-119.
doi: 10.1016/j.urology.2019.04.036. Epub 2019 May 28.

Overuse of Cystoscopic Surveillance Among Patients With Low-risk Non-Muscle-invasive Bladder Cancer - A National Study of Patient, Provider, and Facility Factors

David S Han  1 , Kristine E Lynch  2 , Ji Won Chang  2 , Brenda Sirovich  3 , Douglas J Robertson  3 , Amanda R Swanton  4 , John D Seigne  5 , Philip P Goodney  3 , Florian R Schroeck  6
Affiliations

Overuse of Cystoscopic Surveillance Among Patients With Low-risk Non-Muscle-invasive Bladder Cancer - A National Study of Patient, Provider, and Facility Factors

David S Han et al. Urology. 2019 Sep.

Abstract

Objective: To understand cystoscopic surveillance practices among patients with low-risk non-muscle-invasive bladder cancer (NMIBC) within the Department of Veterans Affairs (VA).

Methods: Using a validated natural language processing algorithm, we included patients newly diagnosed with low-risk (ie low-grade Ta) NMIBC from 2005 to 2011 in the VA. Patients were followed until cancer recurrence, death, last contact, or 2 years after diagnosis. Based on guidelines, surveillance overuse was defined as >1 cystoscopy if followed <1 year, >2 cystoscopies if followed 1 to <2 years, or >3 cystoscopies if followed for 2 years. We identified patient, provider, and facility factors associated with overuse using multilevel logistic regression.

Results: Overuse occurred in 75% of patients (852/1135) - with an excess of 1846 more cystoscopies performed than recommended. Adjusting for 14 factors, overuse was associated with patient race (odds ratio [OR] 0.49, 95% confidence interval [CI]: 0.28, 0.85 unlisted race vs White), having 2 comorbidities (OR 1.60, 95% CI: 1.00, 2.55 vs no comorbidities), and earlier year of diagnosis (OR 2.50, 95% CI: 1.29, 4.83 for 2005 vs 2011, and OR 2.03, 95% CI: 1.11, 3.69 for 2006 vs 2011). On sensitivity analyses assuming all patients were diagnosed with multifocal or large low-grade tumors (ie, intermediate-risk), overuse would have still occurred in 45% of patients.

Conclusion: Overuse of cystoscopy among patients with low-risk NMIBC was common, raising concerns about bladder cancer surveillance cost and quality. However, few factors were associated with overuse. Further qualitative research is needed to identify other determinants of overuse not readily captured in administrative data.

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Conflict of interest statement

Declarations of interest: JDS, 100 common stock of Johnson and Johnson. All additional coauthors, no conflict of interest.

Figures

Figure 1:
Figure 1:
Cohort selection flow diagram with inclusion and exclusion criteria.
Figure 2:
Figure 2:. Defining Overuse of Surveillance in Patients with Low-Risk Non-Muscle-Invasive Bladder Cancer:
2 or more cystoscopy procedures if followed for less than one year, 3 or more cystoscopies if followed between one to less than two years, and 4 or more cystoscopies if followed for two years after diagnosis.
See this image and copyright information in PMC

Comment in

  • EDITORIAL COMMENT.
    Gurung PMS, Messing EE, Joseph JV. Gurung PMS, et al. Urology. 2019 Sep;131:118-119. doi: 10.1016/j.urology.2019.04.038. Urology. 2019. PMID: 31451152 No abstract available.

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