Bladder Ca guideline adherence confers survival benefit

July 16, 2018
Cheryl Guttman Krader, BS, Pharm

Cheryl Guttman Krader is a contributor to Dermatology Times, Ophthalmology Times, and Urology Times.

“We believe that our study underscores the importance of improving dissemination of the guidelines and their implementation and uptake in practice,” says researcher Nikhil Waingankar, MD, MSHP.

Incremental adherence to recommendations in National Comprehensive Cancer Network (NCCN) Guidelines for patients receiving definitive therapy for muscle-invasive bladder cancer (MIBC) confers additive survival benefit, according to an analysis of data from the National Cancer Database (NCDB).

Across the various surgical and chemoradiation guidelines, however, there is significant variation in the receipt of guideline-based care, reported Nikhil Waingankar, MD, MSHP, of Icahn School of Medicine at The Mount Sinai Hospital, New York.

“Delivery of guideline-based care may involve several factors, including awareness of the guidelines by the provider, application of each measure in the appropriate patient, and active participation by the patient. However, the guidelines are well-vetted and the recommendations are evidence-based; we believe that our study underscores the importance of improving dissemination of the guidelines and their implementation and uptake in practice,” Dr. Waingankar told Urology Times.

The study, presented at the AUA annual meeting in San Francisco, identified patients with non-metastatic MIBC (cT2-4aN0M0) who underwent radical cystectomy (RC) or bladder preservation therapy (BPT). Searching the NCDB for the years 2004 to 2014, it identified 20,079 patients who underwent RC and 8,774 who underwent BPT.

Care measures reviewed for the surgical cohort were use of neoadjuvant chemotherapy, adjuvant chemotherapy in high-risk patients, adequate lymph node dissection (≥10 nodes), and timeliness of care (within 90 days of diagnosis), and they were received by 15%, 22%, 59%, and 79% of patients, respectively. For the BPT cohort, the measures reviewed pertained to concurrent chemotherapy, appropriate radiation dose, and timeliness of care; the receipt rates for these measures were 61%, 58%, and 79.1%, respectively.

Next: “Only the recommendation for neoadjuvant chemotherapy has a category 1 evidence rating, but it was the measure with the lowest level of receipt."“Only the recommendation for neoadjuvant chemotherapy has a category 1 evidence rating, but it was the measure with the lowest level of receipt. Going forward with this treatment involves patient consent after an honest discussion of the risks and benefits of getting not only chemotherapy upfront but also having radical surgery, which may involve a range of potential complications. Adherence to the recommendation depends not only on it being presented to the patient. It also requires patient buy-in,” Dr. Waingankar said.

The impact of guideline-based care on survival was analyzed using an adjusted Cox proportional hazards regression model. In the surgical cohort, adequate lymph node dissection, receipt of perioperative chemotherapy, and timeliness of care were each associated with a significant improvement in survival. In the BPT cohort, receipt of concurrent chemotherapy and appropriate radiation dose also were associated with a significant survival benefit.

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Analysis of the survival impact from increasing the number of guideline measures met for the surgical cohort showed that the hazard of death was significantly reduced by 14% with receipt of one measure, 30% with receipt of two measures, and 41% with receipt of three measures. For the patients undergoing BPT, receipt of one guideline measure was associated with a 4% reduction in the hazard of death, which was not statistically significant. The benefit was statistically significant with receipt of additional measures and increased incrementally to 39% reduction in the hazard of death for receipt of two measures and 58% for receipt of three measures.

Although the survival analyses accounted for patient age and Charlson comorbidity index, Dr. Waingankar acknowledged that adjustment for additional factors that could impact survival was not possible because of the limited granularity of NCDB data. Nevertheless, he said he was confident in the findings that incremental adherence to guideline measures is associated with improved survival.