Schroeck Florian R, Lynch Kristine E, Chang Ji Won, MacKenzie Todd A, Seigne John D, Robertson Douglas J, Goodney Philip P, Sirovich Brenda
Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire (Schroeck, MacKenzie, Seigne); The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire (Schroeck, MacKenzie, Robertson, Goodney, Sirovich); Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire (Schroeck, Seigne); White River Junction VA Medical Center, White River Junction, Vermont (Schroeck, Robertson, Goodney, Sirovich); VA Salt Lake City Health Care System, Salt Lake City, Utah (Lynch, Chang); University of Utah, Salt Lake City (Lynch, Chang).
JAMA Netw Open. 2018 Sep;1(5). doi: 10.1001/jamanetworkopen.2018.3442. Epub 2018 Sep 28.
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.
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.
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.
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.
Adjusted cystoscopy frequency for low-risk and high-risk patients for each facility, estimated using multilevel modeling.
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 ( = 0.52; < .001).
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.
癌症护理指南建议根据潜在癌症风险调整监测频率，即癌症复发高风险患者的监测频率应高于低风险患者。
通过对早期膀胱癌低风险和高风险患者的监测模式进行分类，评估美国退伍军人事务部医疗机构中这种基于风险的监测的实施程度。
设计、设置和参与者：对2005年1月1日至2011年12月31日期间诊断为低风险或高风险早期膀胱癌的基于人群样本的患者进行美国全国性回顾性队列研究，并随访至2014年12月31日。分析于2017年3月至2018年4月进行。该研究包括所有治疗低风险和高风险患者的退伍军人事务部医疗机构（n = 85）。
根据欧洲泌尿外科学会风险分层指南的定义以及通过经过验证的自然语言处理算法从诊断病理报告中提取的数据，分为低风险与高风险癌症状态。
使用多级模型估计每个机构低风险和高风险患者的调整后膀胱镜检查频率。
该研究纳入了1278例低风险患者和2115例高风险患者（年龄中位数[四分位间距]为77[71 - 82]岁；99%[3393例中的3368例]为男性）。在各个机构中，低风险患者在2年内每位患者的调整后监测膀胱镜检查频率范围为3.7至6.2次（平均4.8次），高风险患者为4.6至6.0次（平均5.4次）。在85个机构中的70个机构中，低风险和高风险患者的监测频率相当，2年内相差不到1次膀胱镜检查。仅在4个机构中，高风险患者的监测频率在统计学上显著超过低风险患者。在所有机构中，低风险与高风险患者的监测频率呈中度强相关（r = 0.52；P <.001）。
早期膀胱癌患者无论风险如何，接受膀胱镜监测的频率相当。这一发现凸显了了解基于风险的监测障碍的必要性，目标是使临床医生在日常实践中更易于实施。
