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Background: Identifying optimal chemotherapy (CT) utilization rates can drive improvements in quality of care. We report a benchmarking approach to estimate the optimal rate of perioperative CT for muscle‐invasive bladder cancer (MIBC). Methods: The Ontario Cancer Registry and linked treated records were used to identify neoadjuvant and adjuvant CT rates among patients with MIBC during 2004‐2013. Monte Carlo simulation was used to estimate the proportion of observed rate variation that could be due to chance alone. The criterion‐based benchmarking approach was used to explore whether social and health‐system factors were associated with CT rates. We also used the "pared‐mean" approach to identify a benchmark population of hospitals with the highest treatment rates. Hospital CT rates were adjusted for case mix and simulated using a multi‐level multivariable model and a parametric bootstrapping approach. Results: The study population included 2581 patients; perioperative CT was delivered to 31% (798/2581). Multivariate analysis showed that treatment was strongly associated with patient socioeconomic status and hospital teaching status. The benchmark rate was 36%. Unadjusted CT rates were significantly different across hospitals (range 0%‐52%, P < .001). The unadjusted benchmark perioperative CT rate was 45% (95% CI 40%‐50%); utilization rate in nonbenchmark hospitals was 28% (95% CI 26%‐30%). When using simulated CT rates adjusted for case mix, the benchmark CT rate was 41% (95% CI 35%‐47%) and the nonbenchmark hospital CT rate was 30% (95% CI 28%‐32%). The simulation analysis suggested that the observed component of variation (38%) was outside the 95% CI (22%‐28%) of what could be expected due to chance alone. Conclusions: There is significant systematic variation in perioperative CT rates for MIBC across hospitals in routine practice. The benchmark perioperative CT rate for MIBC is 36%‐41%. [ABSTRACT FROM AUTHOR]

Objective To test the hypotheses that: (i) use of preoperative imaging for muscle-invasive bladder cancer ( MIBC) conforms to practice guidelines; (ii) preoperative imaging, through more accurate staging is associated with improved outcomes. Patient and Methods In this population-based cohort study, records of treatment were linked to the Ontario Cancer Registry to identify all patients with MIBC treated with cystectomy from 1994 to 2008. Utilisation of chest, abdomen-pelvis and bone imaging were evaluated. Trends were evaluated over time. Logistic regression was used to analyse factors associated with utilisation. Cox model analyses were used to explore associations between imaging and survival. Results In all, 2 802 patients with MIBC underwent cystectomy during 1994-2008. Over the three 5-year study periods there was an increase in the proportion of patients having preoperative: chest X-ray (55%, 64%, 63%, P < 0.001), computed tomography ( CT) of the chest (10%, 10%, 21%, P < 0.001), bone scan (30%, 34%, 36%; P = 0.04) and CT/magnetic resonance imaging/ultrasonography abdomen/pelvis (80%, 87%, 90%, P ≤ 0.001). Use of chest imaging was associated with age (odds ratio [ OR] 1.24-1.59 compared with the youngest age group), N-stage ( OR 0.79 for the NX group compared with the N+ group), surgeon volume ( OR 0.47-0.53 compared with the highest volume quartile) and geographic region ( OR 0.47-2.19 compared with the largest region). Use of bone scan was associated with N-stage ( OR 0.57 for the NX group compared with the N+ group) and geographic region ( OR 0.71-1.34 compared with the largest region). In adjusted analyses, we found that patients who did not have preoperative chest imaging had inferior overall survival ( OS), hazard ratio ( HR) 1.12 (95% confidence interval [ CI] 1.01-1.25) but not cancer specific survival ( CSS), HR 1.09 (95% CI 0.97-1.22); those who did not have preoperative bone scan had inferior OS ( HR 1.11, 95% CI 1.01-1.22) and CSS ( HR 1.09, 95% CI 1.01-1.25). Survival in the abdomen and pelvis imaging group was not evaluated due to lack of a suitable control group. Conclusion In routine clinical practice there is considerable variation in use of preoperative chest, body, and bone imaging. Preoperative chest and bone imaging is associated with improved outcomes; this association probably reflects better patient selection for cystectomy. [ABSTRACT FROM AUTHOR]

Objective To evaluate whether pathological factors are associated with differential effect of adjuvant chemotherapy ( ACT). Patients and Methods In this population-based retrospective cohort study, we linked electronic records of treatment and surgical pathology to the Ontario Cancer Registry. The study population included all patients with muscle-invasive bladder cancer undergoing cystectomy in Ontario 1994-2008. Factors associated with overall ( OS) and cancer-specific survival ( CSS) were evaluated using Cox proportional hazards. We tested for interaction between the following variables and ACT effect-size: N-stage, margin status, T-stage, and lymphovascular invasion ( LVI). Results The study population included 2802 patients; 19% were treated with ACT. Interaction terms with ACT for OS/ CSS are: N-stage (both P < 0.001); margin status ( P = 0.054/ P = 0.048); T-stage ( P = 0.509/ P = 0.286); and LVI ( P = 0.361/ P = 0.405). Magnitude of effect for ACT was greater for patients with node-positive disease [ OS: hazard ratio ( HR) 0.56, 95% confidence interval ( CI) 0.47-0.67; CSS: HR 0.60, 95% CI 0.49-0.72] than for patients with node-negative disease ( OS: HR 0.80, 95% CI 0.61-1.03; CSS: HR 0.79, 95% CI 0.59-1.07). ACT was also associated with greater effect among patients with involved margins ( OS: HR 0.45, 95% CI 0.33-0.62; CSS: HR 0.40, 95% CI 0.28-0.57) compared with patients with negative margins ( OS: HR 0.75, 95% CI 0.65-0.87; CSS: HR 0.79, 95% CI 0.67-0.93). Conclusions In this population-based cohort study we observe evidence of interaction between ACT effect and nodal stage and surgical margin status. Our results suggest that patients at highest risk of disease recurrence may derive greatest benefit from ACT. [ABSTRACT FROM AUTHOR]

BACKGROUND Practice guidelines recommend neoadjuvant chemotherapy (NACT) for bladder cancer. However, the evidence in support of adjuvant chemotherapy (ACT) is less robust. Here we describe whether the evidence of efficacy for NACT/ACT was sufficient to change clinical practice and whether the efficacy demonstrated in clinical trials was translated into effectiveness in the general population. METHODS Electronic records of treatment were linked to the population-based Ontario Cancer Registry to identify all patients with bladder cancer treated with cystectomy in Ontario 1994-2008. Utilization of NACT/ACT was compared across 1994-1998, 1999-2003, and 2004-2008. Logistic regression was used to analyze factors associated with NACT/ACT. Cox model and propensity score analyses were used to explore the association between ACT and survival. RESULTS Two thousand forty-four patients underwent cystectomy for muscle-invasive bladder cancer (MIBC). Use of NACT remained stable (mean, 4%), whereas utilization of ACT increased over time (16%, 18%, 22%; P = .001). Advanced stage (T3/T4; OR, 1.83; 95% CI, 1.38-2.46) and node-positive disease (OR, 8.10; 95% CI, 6.20-10.7) were associated with greater utilization of ACT. Five-year overall survival (OS) and cancer-specific survival (CSS) for all patients was 29% (95% CI, 28%-31%) and 33% (95% CI, 31%-35%), respectively. Utilization of ACT was associated with improved OS (HR, 0.71; 95% CI, 0.62-0.81) and CSS (HR, 0.73; 95% CI, 0.64-0.84). Results were consistent in propensity score analyses. CONCLUSIONS NACT remains substantially underutilized in routine clinical practice. Our results suggest that perioperative chemotherapy is associated with a substantial survival benefit in the general population. Patients who are planning to undergo cystectomy for bladder cancer should be reviewed by a multidisciplinary team. Cancer 2014;120:1630-1638. © 2013 American Cancer Society. [ABSTRACT FROM AUTHOR]

Purpose Reasons for low uptake of perioperative chemotherapy for muscle-invasive bladder cancer are not well described. Herein, we report referral patterns from urology to medical oncology (MO) in Ontario, Canada, and subsequent use of chemotherapy. Methods Electronic treatment records were linked to the Ontario Cancer Registry to describe referral patterns and use of neoadjuvant/adjuvant chemotherapy (NACT/ACT) among patients with muscle-invasive bladder cancer treated with cystectomy in Ontario from 1994 to 2008. Logistic regression identified factors associated with referral to MO and use of NACT/ACT. Results Overall, 18% (520/2,944) of patients were seen by MO before cystectomy, and 25% (128/520) of referred cases were treated with NACT. Among patients not treated with NACT or radiation, 39% (1,085/2,809) were seen by MO following cystectomy; 51% (548/1,085) of referred patients had ACT. There was wide geographic variation in MO referral rates before (range: 5%–40%) and after cystectomy (range: 26%–59%). Patients seen by MO from 2004 to 2008 were more likely to receive ACT (57%) compared with patients in earlier years (41% in 1994–1998 and 46% in 1999–2003, P <0.001). Conclusions Lack of referral to MO is an important barrier to use of NACT/ACT. Upstream decision making by urologists is an important target in future knowledge translation. [ABSTRACT FROM AUTHOR]

Objective: To describe lymph node counts in routine clinical practice and evaluate their association with outcomes to explore its utility as a quality indicator.Methods and Materials: Electronic records of treatment and surgical pathology reports were linked with the population-based Ontario Cancer Registry to identify all patients who underwent cystectomy between 1994 and 2008. Temporal trends were described over 3 periods: 1994 to 1998, 1999 to 2000, and 2004 to 2008. Multivariate generalized linear regression analysis was used to determine the factors associated with the use of pelvic lymph node dissection (PLND). A Cox proportional hazards regression model was used to explore the associations between PLND and survival.Results: The study population included 2,802 patients. Use of PLND (50%, 62%, and 85%, correspondingly), median node yield (5, 6, and 9, correspondingly), and node density (56%, 50%, and 39%, correspondingly) all improved over the study periods, 1994 to 1998, 1999 to 2000, and 2004 to 2008 (P<0.001). In multivariate analysis, factors associated with not having PLND include advanced age, female sex, lower socioeconomic status, low surgeon volume, and partial cystectomy. In adjusted analyses, patients who did not receive a PLND had inferior overall (hazard ratio = 1.26, 95% CI: 1.15-1.38) and cancer-specific (hazard ratio = 1.23, 95% CI: 1.11-1.36) survival. Node yield, as well as density, was also associated with long-term survival.Conclusions: There is significant variation in use and quality of PLND at cystectomy in routine practice. Node counts are independently associated with long-term survival, and this association is persistent despite adjustment for provider-related variables. These results suggest that lymph node counts are a valid quality indicator of surgical care of muscle-invasive bladder cancer. [ABSTRACT FROM AUTHOR]

Background: Uptake of perioperative chemotherapy for muscle-invasive bladder cancer (MIBC) has been historically poor. We describe contemporary use of neoadjuvant (NACT) and adjuvant chemotherapy (ACT) as well as medical oncology (MO) referral patterns in routine practice.Methods: Electronic treatment records were linked to the population-based Ontario Cancer Registry to identify all MIBC patients treated with cystectomy in Ontario 1994 to 2013. Physician billing records were used to identify consultation with MO. Practice patterns in the contemporary era (2009-2013) are compared with data from 1994 to 2008.Results: A total of 5,582 patients had cystectomy for MIBC. Use of NACT increased from 4% in 1994 to 2008 to 19% in 2009 to 2013 (P<0.001); rates continued to rise in the most recent era from 12% in 2009 to 27% in 2013 (P<0.001). ACT was delivered to 20% of patients in 2009 to 2013 (19% in 1994-2008, P = 0.875). Use of any chemotherapy (NACT or ACT) in 2009 to 2013 was 35% compared to 23% in 1994 to 2008 (P<0.001). Preoperative referral rates during 2009 to 2013 to MO were greater than 1994 to 2008 (32% vs. 11%, P<0.001); referral rates continued to increase in recent years from 21% in 2009 to 44% in 2013 (P<0.001). The proportion of referred patients ultimately treated with NACT increased substantially; from 32% in 1994 to 1998 to 54% in 2009 to 2013 (P<0.001).Conclusions: After many years of practice lagging behind evidence, use of NACT in the general population has increased substantially. Our results suggest that increased uptake has been driven by greater preoperative referral to MO as well as greater propensity of MOs to treat referred patients. [ABSTRACT FROM AUTHOR]