Ehdaie Behfar, Atoria Coral L, Lowrance William T, Herr Harry W, Bochner Bernard H, Donat S Machele, Dalbagni Guido, Elkin Elena B
Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY.
Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY.
Urol Oncol. 2014 Aug;32(6):779-84. doi: 10.1016/j.urolonc.2014.01.024. Epub 2014 Jun 13.
Surveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database.
The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients aged ≥66 years diagnosed with nonmetastatic bladder cancer who had undergone radical cystectomy between 2000 and 2007. Medicare claims information identified recommended surveillance tests for 2 years after cystectomy as outlined in the NCCN guidelines. Adherence was defined as receipt of urine cytology and imaging of the chest, abdomen, and pelvis in each year. We evaluated the effect of patient and provider characteristics on adherence, controlling for demographic and disease characteristics.
Of 3,757 patients who had undergone radical cystectomy, 2,990 (80%) were alive after 2 years. Adherence to all recommended investigations was 17% for the first and the second years following surgery. Among patients surviving 2 years, only 9% had complete surveillance in both years. In either year, adherence was less likely in patients with advanced pathologic stage (III/IV) (adjusted odds ratio [AOR] = 0.74, 95% CI: 0.60-0.91) and unmarried patients (AOR = 0.82, 95% CI: 0.68-0.99). Adherence was more likely in patients treated by high-volume surgeons (AOR = 2.00, 95% CI: 1.70-2.36) and those who saw a medical oncologist (AOR = 1.52, 95% CI: 1.27-1.82). We also observed significant geographic variability in adherence.
Patterns of surveillance after radical cystectomy deviate considerably from NCCN recommendations. Despite increased utilization of radiographic imaging investigations, the omission of urine cytology significantly contributed to the low rate of overall adherence to surveillance guidelines. Uniform adherence to surveillance guidelines was observed in patients treated by high-volume surgeons. This suggests an important opportunity for quality improvement in bladder cancer care.
根治性膀胱切除术后建议进行监测，以检测肿瘤复发和治疗并发症。我们使用一个大型的基于人群的数据库评估了对美国国立综合癌症网络（NCCN）指南的遵循情况。
利用监测、流行病学和最终结果-医疗保险数据库，识别出2000年至2007年间年龄≥66岁、被诊断为非转移性膀胱癌且接受了根治性膀胱切除术的患者。医疗保险理赔信息确定了NCCN指南中概述的膀胱切除术后2年的推荐监测检查。遵循情况定义为每年接受尿细胞学检查以及胸部、腹部和骨盆的影像学检查。我们评估了患者和医疗服务提供者特征对遵循情况的影响，并对人口统计学和疾病特征进行了控制。
在3757例接受了根治性膀胱切除术的患者中，2990例（80%）在2年后存活。术后第一年和第二年对所有推荐检查的遵循率均为17%。在存活2年的患者中，只有9%在两年内都进行了全面监测。在任何一年中，病理分期为晚期（III/IV期）的患者（调整优势比[AOR]=0.74，95%可信区间：0.60-0.91）和未婚患者（AOR=0.82，95%可信区间：0.68-0.99）的遵循可能性较低。由高年资外科医生治疗及看过肿瘤内科医生的患者遵循可能性更高（AOR分别为2.00，95%可信区间：1.70-2.36；AOR为1.52，95%可信区间：1.27-1.82）。我们还观察到遵循情况存在显著的地域差异。
根治性膀胱切除术后的监测模式与NCCN的建议有很大偏差。尽管影像学检查的使用有所增加，但尿细胞学检查的遗漏显著导致了对监测指南的总体遵循率较低。高年资外科医生治疗的患者对监测指南的遵循情况较为一致。这表明在膀胱癌护理质量改进方面存在重要机遇。
