Search

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 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]

Objective To describe the relationships between procedure volume and late survival after cystectomy for muscle-invasive bladder cancer (MIBC) and explore variables explaining any effect. Materials and Methods Electronic records of treatment and surgical pathology reports were linked to a population-based registry to identify patients who underwent cystectomy during 1994-2008 in Ontario, Canada. Explanatory variables included adjuvant chemotherapy, lymph node dissection (LND), and margin status. A Cox proportional hazards regression model was used to explore associations between volume and cancer-specific survival (CSS) as well as overall survival. Results The cohort included 2802 MIBC patients treated with cystectomy. High-volume hospitals were more likely to have used adjuvant chemotherapy (25% vs 18%; P <.001), more likely to have performed an LND (83% vs 53%; P <.001), and associated with a lower 90-day mortality (6% vs 10%; P = .032). Low-volume hospitals had a lower 5-year CSS rate of 32% (28%-36%) compared with those of high-volume centers at 38% (33%-42%). Individual surgeon volume was similarly associated with both early- and long-term outcomes. In multivariate analysis, both surgeon and hospital volumes were associated with CSS and overall survival. The surgeon volume effect on long-term outcomes was modestly modified by indicators of the quality of the LND, with little effect of the other explanatory variables. Conclusion Higher provider volume is associated with higher CSS in patients with MIBC in the general population. The volume effect was modestly mediated by the quality of LND. [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]

Abstract: Despite clinical evidence and recommendations from international treatment guidelines, the use of perioperative chemotherapy for muscle-invasive bladder cancer in routine practice remains low. Although multiple studies have described underutilization, there is an urgent need to better understand the elements contributing to the observed gaps in care. In this commentary, we explore what is known about the factors contributing to underutilization of perioperative chemotherapy for muscle-invasive bladder cancer. We also propose a framework to guide future knowledge translation activities in an effort to improve the care and outcomes of patients with this disease. [Copyright &y& Elsevier]

Objective To assess radical cystectomy (RC) outcomes and adjuvant chemotherapy (ACT) use in the elderly in routine practice. Bladder cancer occurs most commonly in the elderly. RC, standard treatment for muscle-invasive bladder cancer, presents challenges in older patients. Suboptimal evidence guides ACT use. Methods All patients undergoing RC for urothelial cancer in Ontario from 1994 to 2008 were identified using the Ontario Cancer Registry. Pathology reports and treatment records were linked to the database. Patients were age stratified as <70, 70-74, 75-79 and ≥80 years. Logistic regression and Cox proportional hazards identified associations with and effectiveness of ACT use. Results We identified 3320 patients: 1362 (41%) aged <70 years; 674 (20%) aged 70-74 years; 674 (19%) aged 75-79 years, and 657 (20%) aged ≥80 years. Thirty-day (1%, 2%, 2%, 6%; P <.0001) and 90-day (5%, 8%, 9%, 15%; P <.0001) mortality increased with age. Age-stratified 5-year cancer-specific survival was 42%, 37%, 34%, and 32%, respectively ( P <.001); 5-year overall survival was 40%, 34%, 28%, and 23%, respectively ( P <.001). ACT decreased with age (27%, 16%, 12%, 5%; P <.0001). Among ACT patients, 87% aged <70 years received cisplatin vs 73% aged ≥70 years ( P = .003). ACT was associated with improved cancer-specific survival (hazard ratio [HR] = 0.73 and 95% confidence interval [CI] = 0.59-0.89 for age <70 years and HR = 0.73 [95% CI = 0.59-0.89] for ≥70 years) and overall survival (HR = 0.70 [95% CI = 0.58-0.85] for age <70 years and HR = 0.70 [95% CI = 0.59-0.84] for ≥70 years) across all age groups. Conclusion Cystectomy carries a higher risk of postoperative mortality in elderly patients in routine clinical practice. ACT is used infrequently in older patients despite a substantial survival benefit observed across all age groups. [ABSTRACT FROM AUTHOR]

Background To understand barriers and enablers to use of curative-intent radiotherapy (RT) for muscle-invasive bladder cancer using the Theoretical Domains Framework (TDF). Methods Canadian urologists, radiation oncologists (ROs) and medical oncologists (MOs) participated in a web-based survey to assess barriers and enablers to use of RT. Survey questions were thematically mapped to TDF domains. Logistic regression was used to identify TDF domains associated with high referral/use of RT. Results 64 urologists, 29 ROs and 26 MOs participated. Participants reported comparable survival at five years with cystectomy (51%) and RT with concurrent chemotherapy (50%). Despite this, participants reported low RT referral/treatment rates: Urologists referred a median of 2/10 patients to RO; ROs treated a median of 5/10 patients referred; and MOs referred a median of 2/8 patients not referred to RO by urology. Among urologists, the TDF domains ‘beliefs about consequences’ (OR = 8.1, 95% CI 1.5–44.9), ‘social and professional role’ (OR = 11.2, 95% CI 2.3–53.6) and ‘environmental context and resources’ (OR = 5.9, 95% CI 1.5–23.3) were associated with higher rates of RO referral. Conclusions We have identified factors associated with referral for RT among patients with bladder cancer. These factors should be addressed as part of a concerted effort to increase utilization of RT. [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]

Purpose: Clinical trials have shown that the addition of chemotherapy to radiation therapy (RT) improves survival in advanced head-and-neck cancer. The objective of this study was to describe the effectiveness of concomitant chemoradiation therapy (C-CRT) in routine practice. Methods and Materials: This was a population-based cohort study. Electronic records of treatment from all provincial cancer centers were linked to a population--based cancer registry to describe the adoption of C-CRT for head-and-neck cancer patients in Ontario, Canada. The study population was then divided into pre- and postadoption cohorts, and their outcomes were compared. Results: Between 1992 and 2008, 18,867 patients had diagnoses of head-and-neck cancer in Ontario, of whom 7866 (41.7%) were treated with primary RT. The proportion of primary RT cases that received C-CRT increased from 2.2% in the preadoption cohort (1992-1998) to 39.3% in the postadoption cohort (2003-2008). Five-year survival among all primary RT cases increased from 43.6% in the preadoption cohort to 51.8% in the postadoption cohort (P<.001). Over the same period, treatment-related hospital admissions increased significantly, but there was no significant increase in treatment-related deaths. Conclusions: C-CRT was widely adopted in Ontario after 2003, and its adoption was temporally associated with an improvement in survival. [Copyright &y& Elsevier]

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]