Background Patients with bladder cancer are apt to develop multiple recurrences that require intervention. We examined the recurrence, progression and bladder cancer-related mortality rates in a cohort of individuals with high-grade non-muscle-invasive bladder cancer. Methods Using linked SEER-Medicare data, we identified subjects with a diagnosis of high-grade, non-muscle-invasive disease in 1992–2002 and were followed until 2007. We then used multivariate competing-risks regression analyses to examine recurrence, progression, and bladder cancer-related mortality rates. Results Of 7,410 subjects, 2,897 (39.1%) experienced a recurrence without progression, 2,449 (33.0%) experienced disease progression, of whom 981 succumbed to bladder cancer. Using competing-risks regression analysis, we found the 10-year recurrence, progression, and bladder cancer-related mortality rates to be 74.3%, 33.3%, and 12.3%, respectively. Stage T1 was the only variable associated with a higher rate of recurrence. Women, black race, undifferentiated grade, stage Tis and T1 were associated with a higher risk of progression and mortality. Advanced age (≥70) was associated with a higher risk of bladder cancer-related mortality. Conclusions Nearly three-fourths of patients diagnosed with high-risk bladder cancer will recur, progress, or die within ten years of their diagnosis. Even though most patients do not die of bladder cancer, the vast majority endures the morbidity of recurrence and progression of their cancer. Increasing efforts should be made to offer patients intravesical therapy with the goal of minimizing the incidence of recurrences. Furthermore, the high recurrence rate seen during the first two years of diagnosis warrants an intense surveillance schedule.

Recent trends in epidemiology, practice patterns, resource utilization and costs for urological diseases have broad implications for quality of health care, access to care and the equitable allocation of scarce resources for clinical care and research.

Background-Most urologists specializing in the management of patients with bladder cancer consider continent urinary diversion the reconstructive technique that affords the best quality of life after radical cystectomy. We sought to evaluate factors that predict reconstructive technique following radical cystectomy. Methods-Using linked data from Medicare and the National Cancer Institute (NCI)'s Surveillance, Epidemiology, and End Results (SEER)-program, we identified 3,980 subjects who underwent radical cystectomy for bladder cancer diagnosed between 1991 and 2000, of whom 776 (19.5%) underwent continent and 3,204 (80.5%) underwent incontinent urinary diversion. We used multivariate logistic regression modeling to identify factors independently associated with utilization of continent reconstruction following radical cystectomy, incorporating patient and provider variables. Results-In multivariate analysis, the likelihood of continent diversion was inversely associated with African American race (OR 0.54, p=0.03) and higher Charlson comorbidity score (OR 0.66, p=0.01), and directly associated with older age (OR 0.92, p<0.001) and education level (OR 1.01, p=0.01). Treatment at academic (OR 1.48, p=0.002) and NCI-designated cancer centers (OR 4.01, p<0.001) and by high volume providers (OR 1.56, p<0.001) was independently associated with continent reconstruction. Conclusions-Disparities in the utilization of continent urinary diversion following radical cystectomy suggest that demographic, socioeconomic, provider-based, and clinical variables predict the likelihood that those undergoing radical cystectomy will receive continent reconstruction. Regionalization of bladder cancer care may ameliorate many of the disparities noted but must be balanced against the risk imposed by a delay in care.

the Urologic Diseases in America Project BACKGROUND: The rate of continent urinary diversion after radical cystectomy for bladder cancer varies by patient and provider characteristics. Demonstration of equivalent complication rates, independent of diversion type, may decrease provider reluctance to perform continent reconstructions. The authors sought to determine whether continent reconstructions confer increased complication rates after radical cystectomy. METHODS: From the Nationwide Inpatient Sample, the authors used International Classification of Disease (ICD-9) codes to identify subjects who underwent radical cystectomy for bladder cancer during 2001-2005. They determined acute postoperative medical and surgical complications from ICD-9 codes and compared complication rates by reconstruction type using the nearest neighbor propensity score matching method and multivariate logistic regression models. RESULTS: Adjusting for case-mix differences between reconstructive groups, continent diversions conferred a lower risk of medical, surgical, and disposition-related complications that was statistically significant for bowel (3.1% lower risk; 95% confidence interval [95% CI], À6.8% to À0.1%), urinary (1.2% lower risk; 95% CI, À2.3%, to À0.4%), and other surgical complications (3.0% lower risk; 95% CI, À6.2% to À0.4%), and discharge other than home (8.2% lower risk; 95% CI, À12.1% to À4.6%) compared with ileal conduit subjects. Older age and certain comorbid conditions, including congestive heart failure and preoperative weight loss, were associated with significantly increased odds of postoperative medical and surgical complications in all subjects. CONCLUSIONS: Mode of urinary diversion after radical cystectomy for bladder cancer is not associated with increased risk of immediate postoperative complications. These results may encourage broader consideration of continent urinary diversion without concern for increased complication rates. Cancer 2010;116:331-9.

Background Clinical practice guidelines for the management of patients with bladder cancer encompass strategies that minimize morbidity and improve survival. We sought to characterize practice patterns in patients with high-grade non-muscle-invasive bladder cancer in relation to established guidelines. Methods We used Surveillance, Epidemiology and End Results (SEER)-Medicare-linked data to identify subjects diagnosed with high-grade non-muscle-invasive bladder cancer in 1992–2002 who survived at least two years without undergoing definitive treatment (n=4,545). We used multilevel modeling to estimate the association and partitioned variation of patient sociodemographic, tumor, and provider characteristics with compliance measures. Results Of 4,545 subjects analyzed, only one received all the recommended measures. Approximately 42% of physicians have not performed on a single patient nested within their practice in a two-year period, at least one cystoscopy, cytology and a single instillation of immunotherapy. After 1997, only utilization of radiographic imaging (OR 1.19; 95% CI 1.03–1.37) and instillation of immunotherapy (OR 1.67; 95% CI 1.39–2.01) significantly increased. Surgeon-attributable variation for individual guideline measures (cystoscopy 25%; cytology 59%; radiographic imaging 10%; intravesical chemotherapy 45%; and intravesical immunotherapy 26%) contributes to this low-compliance rate. Conclusion There is marked underuse of guideline-recommended care in this potentially curable cohort. Unexplained provider-level factors significantly contribute to this low-compliance rate. Future studies that identify barriers and modulators of provider-level adoption of guidelines are critical to improving care for patients with bladder cancer.