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Aggressive treatment for early-stage bladder cancer does not appear to benefit patients with the disease and may even increase the likelihood for later intervention compared with less-intensive treatment.
How to best care for patients with early-stage bladder cancer is not known, said senior author Brent K. Hollenbeck, MD, MS, assistant professor of urology at the University of Michigan Health System, Ann Arbor. What is known is that bladder cancer is expensive to treat due to the protracted nature of its early stages.
Dr. Hollenbeck and colleagues, using Surveillance, Epidemiology and End Results-Medicare data from 1992 to 2005, identified 27,979 patients with early-stage bladder cancer. Treatment intensity was measured according to average Medicare expenditures in the first 2 years following diagnosis. The researchers compared expenditures with outcomes, including the need for aggressive therapy, such as radical cystectomy, and overall and cancer-specific survival.
Initial intensive management did not reduce the need for later intervention, and patients in high-intensity regions were potentially more likely to undergo a later major intervention than patients treated in low-intensity regions were (p=.1).
"In this context, more treatment is not necessarily better," Dr. Hollenbeck told Urology Times. "Differences in treatment intensity are not necessarily translated into any benefit, as measured by survival or avoidance of major intervention, such as radical cystectomy."
Improving the evidence base
Dr. Hollenbeck characterized the evidence base underlying treatment approaches to bladder cancer patients as "suboptimal," focusing only on preventing or reducing recurrences and not necessarily considering how best to manage patients.
"Empirical support for intensive use of endoscopy is just not there," he said. "There's been only one randomized trial of just under 100 patients to tackle the question of how best to follow these patients. Obviously, because of the small size of that study, the findings were limited."
Going forward, Dr. Hollenbeck suggested that a clinical trial studying surveillance of bladder cancer patients would be a useful step in determining how to care for these patients.
When asked whether an update of current AUA bladder cancer practice guidelines would be beneficial, he said, "The guidelines are a starting point, but the guidelines are only as good as the evidence base." Tailoring guidelines to better convey the risk of the cancer to the individual patient would be helpful, he added.
"Low-grade disease in an 85-year-old poses a different kind of risk than does high-grade T1 disease to a 60-year-old," Dr. Hollenbeck said. "Those cancers shouldn't necessarily be managed the same in terms of surveillance or treatment."
Initial results from this study were reported in the Journal of the National Cancer Institute (2009; 101:571-80).