Anderson Christopher B, Alvarez JoAnn, Koyama Tatsuki, Penson David F, Barocas Daniel A
Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York.
Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee.
Urol Pract. 2014 Sep;1(3):146-150. doi: 10.1016/j.urpr.2014.06.002. Epub 2014 Jun 26.
Although women are less likely to be diagnosed with bladder cancer than men, they experience a disproportionally high rate of cancer specific mortality. Underuse of evidence-based processes of care may contribute to this mortality difference. We explored variation in the use of pelvic lymphadenectomy at the time of radical cystectomy between men and women, and determined if this was impacted by surgeon or hospital volume.
We identified all patients with bladder cancer who underwent radical cystectomy from 1996 to 2009 in the New York, Maryland and Florida State Inpatient Databases. The effect of gender on the use of pelvic lymphadenectomy was analyzed using multivariate logistic regression models.
Approximately 25% of our cohort was female. Compared to men, women were less likely to be treated with pelvic lymphadenectomy (54% vs 60%, p <0.001), and tended to be treated by lower volume surgeons and at lower volume hospitals. Women had 21% lower odds (95% CI 5-35) of undergoing pelvic lymphadenectomy compared to men when adjusting for patient characteristics, even when treated by high volume surgeons and at high volume hospitals.
At radical cystectomy women were less likely to undergo pelvic lymphadenectomy even when treated by high volume providers. Since pelvic lymphadenectomy is an evidence-based process of care that is associated with improved survival in patients with bladder cancer, lower use of pelvic lymphadenectomy may contribute to the lower bladder cancer survival rate observed in women. Our findings identify an opportunity to improve quality of care in women with bladder cancer.
尽管女性被诊断出患有膀胱癌的可能性低于男性，但她们的癌症特异性死亡率却高得不成比例。循证护理流程的使用不足可能导致了这种死亡率差异。我们探讨了男性和女性在根治性膀胱切除术时盆腔淋巴结清扫术使用情况的差异，并确定这是否受到外科医生或医院手术量的影响。
我们在纽约、马里兰州和佛罗里达州住院患者数据库中识别出1996年至2009年期间所有接受根治性膀胱切除术的膀胱癌患者。使用多因素逻辑回归模型分析性别对盆腔淋巴结清扫术使用情况的影响。
我们的队列中约25%为女性。与男性相比，女性接受盆腔淋巴结清扫术的可能性较小（54%对60%，p<0.001），并且倾向于由手术量较低的外科医生治疗，且所在医院的手术量也较低。在调整患者特征后，即使由手术量高的外科医生在手术量高的医院治疗，女性接受盆腔淋巴结清扫术的几率也比男性低21%（95%可信区间5-35）。
在根治性膀胱切除术中，即使由手术量高的医疗人员治疗，女性接受盆腔淋巴结清扫术的可能性也较小。由于盆腔淋巴结清扫术是一种循证护理流程，与膀胱癌患者生存率提高相关，盆腔淋巴结清扫术的较低使用率可能导致女性膀胱癌生存率较低。我们的研究结果表明有机会提高膀胱癌女性患者的护理质量。
