Matthew Fowler

Research presented during the 2020 Society of Urologic Oncology Annual meeting showed how the swift implementation of a telehealth program mitigated an initial pandemic-induced spike in cancellations of urologic oncology appointments.

“When comparing between 2019 and 2020, our data show decreases in new patient appointment rates for certain urologic cancers (renal and testicular) and comparable rates for others (prostate and bladder),” wrote the researchers. “These differences are likely attributed to varying requirements for visits for different oncologic conditions (physical exam, in-office procedure). The implementation of telehealth helped reverse the initial urologic-oncologic outpatient volume decline at our institution.”

A significant decrease in urologic-oncologic outpatient visits (n = 1381) was seen in 2020 during weeks 1 to 3 of the study (average weekly percentage change [AWPC]: -28.1%; 

 <.001), while weeks 1 to 4 saw a significant increase in oncology telehealth appointments (AWPC: +391.2%; 

 <.001). More, overall appointments increased significantly from week 6, when the overall appointment trend inflected, to week 13 (AWPC: +7.3%; 

In 2019, urologic-oncologic appointments (n = 2100) saw no significant changes for overall, new and established patient visits (AWPC: -0.2%, -1.9%, +0.5%; all 

 >0.2). Meanwhile in 2020, new patient oncologic visits saw a sharp decrease while established patient oncologic visits sharply increased (AWPC: -3.2% vs +0.8%; 

 <.001). Further, cancellations significantly increased in the first 3 weeks of 2020 that were studied (AWPC: +54.9%; 

 <.001) but stabilized following that period (AWPC: +5.2; 

Broken down by cancer type, patients evaluated via telehealth were 58.2% for prostate cancer, 51.7% for renal cancer, 54.2% for testicular cancer and 42.1% for bladder cancer. When comparing new appointment rates for 2019 and 2020, the percentages were 22.7% versus 21.4% for prostate cancer, 19.2% versus 12.3% for renal cancer, 13.7% versus 13.8% for bladder cancer and 26.5% versus 14.1% for testicular cancer, respectively.

“Our data show significant contrasting trends for overall new and established patient oncologic visits,” wrote the researchers. “We see differing rates of telehealth usage for different urologic-oncologic conditions.”

The researchers performed a retrospective analysis of the urologic-oncologic visits performed at a tertiary referral center from March 1 to June 1, 2020. Then, they implemented a join-point regression model to examine statistically significant trends of patient visits over time. The team used AWPC to summarize the linear trends identified.

Moving forward, the researchers stress that further research is necessary to “clarify clinical implications and potential deficits” in patient care during the COVID-19 pandemic given the appointment and telehealth utilization trends identified.

“With its rapid implementation, it is important to study whether telehealth adequately supplemented in-person medical appointments,” wrote the researchers. “Additionally, it is important to identify potentially differential impacts on frequently encountered urologic oncologic conditions.”

1. Sanford D, Reddy SS, Park D, et al. Join-Point Regression Modeling of Trends in Urologic Oncologic Outpatient Appointments and Telehealth Usage at a Tertiary Referral Center during the COVID-19 Pandemic. Presented at: 21st Annual Meeting of the Society of Urologic Oncology; December 3, 2020. Poster #67.

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The data demonstrate how the implementation of a telehealth pathway helped reverse the initial urologic-oncologic outpatient volume decline at an institution during the pandemic. 

Study shows how telehealth alleviated pandemic’s impact on urologic oncology appointments

Select patients with small renal masses (SRM) suspicious for clinical stage T1a (≤4 cm) renal cell carcinoma (RCC) can be effectively managed with active surveillance.

Long-term outcomes from a comparative study shared during the 2020 Society of Urologic Oncology Annual Meeting showed that cancer-specific survival was noninferior for active surveillance compared with primary intervention in this population.

Overall survival (OS) was found to be worse in the active surveillance group, signaling both measured and unmeasured competing risks of mortality in the patient population.

“[Active surveillance] is not inferior to [primary intervention] for carefully selected patients with SRM suspicious for renal cell carcinoma,” wrote the researchers. “The difference in OS between [active surveillance] and [primary intervention] is mostly attributable to the increased risk of death from competing causes among [active surveillance] patients.”

Of the 862 patients enrolled in the study, 785 patients had follow-up data available. In total, 434 patients (55.3%) chose active surveillance and 351 patients (44.7%) chose primary intervention. Progression-free survival (PFS) at 7 years was 62.1% for patients on active surveillance, with 76.4% of progressions due to a growth rate of greater than 0.5 cm/year.

The data showed that 71 of the 434 patients who chose active surveillance (16.4%) crossed over to delayed intervention. The median follow-up time was 3.3 years (IQR, 1.5-6.6), with 292 patients (37.2%) followed for 5 years or more. While there was no difference in cancer-specific survival for active surveillance and primary intervention patients (

 = .6), active surveillance patients saw worse OS compared to primary intervention patients (

“Elevated growth rate predicts [delayed intervention] but does not impact biological outcomes, including adverse pathology, recurrence, or CSS rates,” wrote the researchers. “Increasing tumor size at enrollment and throughout [active surveillance] predicts [delayed intervention] and biological outcomes. Tumor size should be considered the primary trigger for DI in patients with SRM.”

This multi-institutional comparative study prospectively enrolled patients from 2009-2019 with SRM who underwent active surveillance or primary intervention. Both primary and secondary outcomes were analyzed with the Kaplan-Meier survival analysis and a log-rank test.

The primary end points for the data were CSS and OS, with secondary end points of PFS and recurrence-free survival. The main objective of the research was to report on the 10-year outcomes of patients enrolled in the Delayed Intervention and Surveillance for Small Renal Masses registry.

Currently, active surveillance remains underutilized as an alternative option to primary intervention, employed in only 10-20% of eligible patients. The lack of strong, prospective data regarding this strategy is cause for such underutilization.

Looking ahead, the researchers recommend that “a priori definitions of progression, including growth rate, should be re-considered.”

1. Cheaib JG, Patel HD, Alam R, et al. Active Surveillance versus Primary Intervention for Clinical T1a Kidney Tumors: Ten-Year Experience of the DISSRM Prospective Comparative Study. Presented at: 21st Annual Meeting of the Society of Urologic Oncology; December 3, 2020. Poster 96.

Cancer-specific survival is noninferior for active surveillance compared with primary intervention in select patients with small renal masses suspicious for renal cell carcinoma. 

Active surveillance feasible for certain patients with small renal masses suspicious for RCC

A delay from diagnosis to radical cystectomy was associated with poorer overall survival in certain patients with muscle-invasive bladder cancer, according to a poster shared during the 2020 Society of Urologic Oncology Annual Meeting.

The researchers also determined that healthcare disparities were linked to cystectomy delay, including access issues related to sex, race, education, treating hospital, and insurance status.

“Our results indicate that delaying cystectomy just 60 days leads to increased mortality in those who do not receive [neoadjuvant chemotherapy],” the researchers wrote. “In those receiving [neoadjuvant chemotherapy], cystectomy delays were not associated with an increased mortality until [radical cystectomy] was delayed greater than 210 days after diagnosis.”

The researchers found an increased mortality rate with delayed cystectomy beyond 60 days for the non-neoadjuvant chemotherapy cohort (HR, 1.06; 95% CI, 1.00-1.13) and 210 days for the neoadjuvant chemotherapy cohort (HR, 1.20; 95% CI, 1.04-1.39).

More, a univariate analysis determined that distance from a medical provider and insurance status were also associated with delayed cystectomy regardless of neoadjuvant chemotherapy status (

Specifically, for the non-neoadjuvant chemotherapy cohort, a number of factors including increasing age, Hispanic race, non-private insurance, surgery at an academic center, and higher Charlson scores were associated with delayed cystectomy, while female gender was associated with timely cystectomy.

For the neoadjuvant chemotherapy cohort, a higher tumor stage and non-private insurance were factors associated with delayed cystectomy, while procedure at a non-academic comprehensive community center and residency in areas with the highest high-school graduation rates were associated with timely cystectomy.

“Interestingly, we found that care at an academic center was associated with [delayed cystectomy],” wrote the researchers. “Receipt of [radical cystectomy] at academic centers has been associated with decreased perioperative morbidity and mortality, suggesting that a more expedient referral system and timely transfer of medical services to these institutions is needed. Importantly, we found that Hispanic race was associated with [delayed cystectomy], suggesting an important socioeconomic disparity not described in the literature.”

Found through the National Cancer Database, the study consisted of 11,468 patients who were diagnosed with stage II-IV bladder urothelial carcinoma who previously underwent radical cystectomy from 2004 to 2013. The researchers created 2 cohorts: those who received neoadjuvant chemotherapy (n = 3348) and those who did not receive neoadjuvant chemotherapy (n = 8120).

Looking ahead, the researchers suggest that future studies need to examine inequities to health care delivery for patients with bladder cancer. More, an expedited referral system and timely transfer of medical services is needed to ultimately decrease latency to radical cystectomy.

“In conjunction with data suggesting African American patients are more likely to have worse

outcomes after [radical cystectomy], our analysis indicates that greater attention is needed to ensure minority groups receive appropriate and timely care,” wrote the researchers. “Though our study is limited by its retrospective nature, we present important associations in the largest population-based study to date.”

1. Dall CP, Egan J, Carvalho FLF, et al. Delays from diagnosis to radical cystectomy are associated with worse survival in muscle-invasive bladder cancer. Presented at: 21st Annual Meeting of the Society of Urologic Oncology; December 3, 2020. Poster 19.

The researchers also determined that healthcare disparities were associated with cystectomy delay.

Matthew Fowler

Articles

Study shows how telehealth alleviated pandemic’s impact on urologic oncology appointments

Active surveillance feasible for certain patients with small renal masses suspicious for RCC

Delayed radical cystectomy linked to increased mortality in bladder cancer