Differences between urologists in United States and Canada in approach to bladder cancer

Current Standards in the Endoscopic Management of Bladder Cancer: A Survey Evaluation among Urologists in German-Speaking Countries

INTRODUCTION

To assess the current diagnostic, treatment, and documentation strategies for bladder cancer (BC) in German-speaking countries.

MATERIALS AND METHODS

A 14-item web-based survey was distributed among members of the German, Austrian, and Swiss Associations of Urology, addressing physicians who perform cystoscopies and transurethral resection of bladder tumors (TURB).

RESULTS

The survey was responded to by 308 of 5,564 urologists with a mean age of 49.5 years (response rate: 5.5%). The majority of participants (57.3%) practice in an outpatient setting. White light cystoscopy only is used by 60.2%, with additional photodynamic diagnosis and narrow band imaging by 36.8 and 12.5%, respectively. Endoscopic findings are documented in written form by 93.5%, followed by image capture (33.7%) and a central data archive (20.8%). Inpatient hospital urologists document cystoscopic findings by freehand drawing (21.4 vs. 11.4%, p = 0.017), and with a fixed bladder scheme (31.3 vs. 7.4%, <0.05) significantly more frequently. Cystoscopic findings are mainly conveyed to other health professionals in written form (77.4%), and significantly more often by inpatient urologists (p < 0.05).

CONCLUSIONS

Significant differences exist in the approach to documenting and communicating cystoscopic BC findings. Accurate graphic documentation of lesions, visualization of the mucosa's totality, and meticulous consultation of previous surgical reports require improvements to reduce recurrence and progression rates.

An international comparison of costs of end-of-life care for advanced lung cancer patients using health administrative data

BACKGROUND

Patterns of end-of-life cancer care differ in Canada and the United States; yet little is known about differences in service-specific and overall costs.

AIM

The aim of this study was to compare end-of-life costs in Ontario, Canada, and the United States, using administrative health data.

DESIGN

Advanced-stage nonsmall cell lung cancer patients who died from cancer at age ⩾ 65.5 years in 2001-2005 were selected from the US Surveillance, Epidemiology, and End Results-Medicare database (N = 16,858) and the Ontario Cancer Registry (N = 8643). We estimated total and service-specific costs (2009 US dollars) in each of the last 6 months of life from the public payer perspectives for short-term and long-term survivors (lived < 180 and ⩾ 180 days post-diagnosis, respectively). Services were defined for comparisons between systems.

RESULTS

Mean monthly costs increased as death approached, were higher in short-term than long-term survivors, and were generally higher in the United States than in Ontario until the month before death, when they were similar (long-term survivors: US$10,464 and US$10,094 (p = 0.53), short-term survivors US$14,455 and US$12,836 (p = 0.11), in Surveillance, Epidemiology, and End Results-Medicare and Ontario, respectively). Costs for Medicare hospice and Ontario's palliative care components were similar and increased closer to death. Inpatient hospitalization was the main cost driver with similar costs in both cohorts, despite lower utilization in the United States. The compositions of many services and costs differed.

CONCLUSION

Costs for nonsmall cell lung cancer patients were slightly higher in the United States than Ontario until 1 month before death. Administrative data allow exploration and international comparisons of reimbursement policies, health-care delivery, and costs at the end of life.

Initial treatment for newly diagnosed elderly colorectal cancer patients: patterns of care in Italy and the United States

Cancer is a major component of health-care expenditures in most developed countries. The costs of cancer care are expected to increase due to rising incidence (as the population ages) and increasing use of targeted anticancer therapies. However, epidemiological analysis of patterns of care may be required prior to empirically well-grounded cost analyses. Additionally, comparisons of care between health-care delivery systems and countries can identify opportunities to improve practice. They can also increase understanding of patient outcomes and economic consequences of differences in policies related to cancer screening, treatment, and programs of care. In this study, we compared patterns of colorectal cancer treatment during the first year following diagnosis in two cohorts of elderly patients from some areas of Italy and the United States using cancer registry linked to administrative data. We evaluated hospital use, initial treatments (surgery, chemotherapy, and radiation), and timeliness of surgery and adjuvant therapy, taking into account patient characteristics and clinical features, such as stage at diagnosis and the cancer subsite. We observed greater use of adjuvant chemotherapy in stage III and IV colon cancer patients and adjuvant therapy in all stages of rectal cancer patients in the US cohort. We found a higher rate of open surgeries in the Italian cohort, a similar rate of hospitalization, but a higher number of hospital days in the Italian cohort. However, in spite of structural differences between the United States and Italy in health-care organization and delivery as well as in data collection, patterns of care and the timing of care in the year after diagnosis are generally similar among patients within stage of disease at diagnosis. Comparative studies of the costs associated with patterns of cancer care will be important for future research.

Regional differences in practice patterns and outcomes in patients treated with radical cystectomy in a universal healthcare system

INTRODUCTION

Our objective is to assess differences in practice patterns and outcomes across 3 regions in bladder cancer patients treated with radical cystectomy under a universal healthcare system.

METHODS

In total, we included 2287 patients treated with radical cystectomy at 8 Canadian centres from 1998 to 2008. Variables included various clinico-pathologic parameters, recurrence, and death stratified into different regions.

RESULTS

In total, 1105 patients were from the east region (group 1), 601 from the centre region (group 2), and 581 from the west region of Canada (group 3). The median follow-up of groups 1, 2, and 3 was 22.1, 17.1, and 28.6 months, respectively. Although the overall rate of neoadjuvant chemotherapy was low (3.1%), rates were higher in group 2 compared with groups 1 and 3 (p = 0.07). Continent diversions and extended lymphadenectomy were performed in 23.5%, 8.5%, 23.9% and 39.7%, 27.7%, 12.6% across groups 1, 2, and 3, respectively. There were statistically significant differences in gender distribution, performance of lymphadenectomy, presence of concomitant carcinoma in situ and lymphovascular invasion across the 3 groups. There were no differences among the 3 geographical locations in terms of stage, surgical margin status, and use of adjuvant chemotherapy. The mean number of days from the transurethral resection of the bladder tumour to cystectomy was 50, 79, 69 days for groups 1, 2, 3, respectively (p = 0.0006). The 5-year overall survival was 53.6%, 66.8%, and 52.4% for groups 1, 2 and 3, respectively (p < 0.0001).

CONCLUSIONS

Significant variations in practice patterns were noted across different geographic regions in a universal healthcare system. Use of continent diversions, extended lymphadenectomy, and neoadjuvant chemotherapy remains low across all 3 regions. Treatment delays are significant.

Factors associated with non-orthotopic urinary diversion after radical cystectomy

INTRODUCTION

Preoperative factors favoring the performance of non-orthotopic bladder substitution (OBS) after radical cystectomy for muscle-invasive bladder cancer were identified.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 730 patients who underwent radical cystectomy for urothelial carcinoma of the bladder. After excluding 75 patients who were unable to undergo OBS due to the tumor location or elevated serum creatinine level, we assessed the preoperative factors in the remaining 655 patients. Multivariate logistic regression analysis was performed to identify the independent preoperative predictors of type of urinary diversion.

RESULTS

Of the 655 patients, 171 (26.1%) underwent non-OBS. Patients who underwent non-OBS were more likely to be older and females, to have a lower educational status, non-organ confined disease, more comorbid medical conditions, more impaired performance status, lower body mass index, anemia, azotemia, and hypoalbuminemia, and to be treated by less-experienced surgeons (P < 0.05 each). After adjusting for provider-based factors, multivariate analysis showed that factors independently associated with non-OBS included advanced age (odds ratio [OR] 4.10, P < 0.001), female gender (OR 2.08, P = 0.027), ECOG performance status (≥ 1 vs 0, OR 5.20, P < 0.001), low educational status (OR 1.59, P = 0.042), clinically node-positive disease (OR 2.36, P = 0.003), anemia (OR 1.67, P = 0.041), azotemia (OR 3.97, P < 0.001), and hypoalbuminemia (OR 1.84, P = 0.046).

CONCLUSION

Several patient-based as well as provider-based factors were associated with the type of urinary diversion after radical cystectomy. Advanced age, female gender, low performance status, low education level, clinically node-positive disease, anemia, hypoalbuminemia, and azotemia were associated with non-OBS, as surgery was performed by relatively inexperienced surgeons.

Pattern of management of urologic cancer in Saudi Arabia

BACKGROUND

To compare the current uro-oncologic practice pattern in Saudi Arabia with the standard of care practice and to identify obstacles in our health care system that prevent offering such a treatment.

MATERIALS AND METHODS

We surveyed 247 practicing urologists in Saudi Arabia using a designed questionnaire. This questionnaire contains 19 questions focusing on management of bladder and renal cancers.

RESULTS

Of the 247 contacted urologists, 86 completed the questionnaire. Seventy six percent see more than 10 bladder cancer cases/year and 83% used rigid cystoscope for diagnosis under general anesthesia. Eighty two percent perform over 10 bladder tumor resections/year; however, 90% of them perform less than five cystectomies/year, if any. Seventy nine percent had intravesical therapy available at their hospitals and majority of them use it after resection in selected patients. Fifty percent preferred re-resection within 2-4 weeks for T1 and/or G3 tumors and majority of them (86%) perform cystectomy for muscle invasive disease and ninety six percent perform ileal conduit. Thirty four percent see over 10 renal cancers/year. Forty nine percent perform radical nephrectomy for less than 4 cm renal masses and for more than 4 cm, only 9% do laparoscopic nephrectomy while the majority preferred open technique although 77% of the hospitals participated in this survey have a urologist capable of doing laparoscopy.

CONCLUSION

A significant number of urologists in Saudi Arabia do not apply some of the well-accepted standard practices in urologic cancer. To improve this, we need to work on our referral system and establish education and training programs to make the urologist familiar with the new modalities of treatment.

Surgical management of ulcerative colitis: a comparison of Canadian and American colorectal surgeons

BACKGROUND

Ileal pouch anal anastomosis (IPAA) to surgically manage ulcerative colitis may involve multiple separate surgical procedures, impacting treatment costs, length of stay in hospital, complication rates and patient outcomes, and there is currently no accepted standard of care regarding the number of stages that should be performed. The purpose of this study was to compare the practice patterns of Canadian and American colorectal surgeons regarding the surgical management of ulcerative colitis.

METHODS

A questionnaire was mailed to all practisng fellows of the American Society of Colon and Rectal Surgeons (ASCRS) in Canada and the United States. Surgeons were asked to describe their typical practices for 3 clinical scenarios.

RESULTS

Questionnaires were mailed to 40 Canadian and 873 American ASCRS fellows with response rates of 86% and 62%, respectively. In the case of a patient who has had a prior colectomy, who is not taking steroids and in whom a tension-free IPAA is possible, 44% of Canadian surgeons would perform IPAA alone and 56% would perform IPAA with a loop ileostomy. In contrast, only 26% of American surgeons would perform IPAA alone and 74% would perform IPAA with a loop ileostomy (p = 0.002). In the case of a patient who has not had previous surgery, who is taking 10 mg/day of prednisone and in whom a tension-free IPAA is possible, the majority of both Canadian and American surgeons would perform an IPAA with a loop ileostomy (93% and 89%, respectively, p = 0.06). In the case of a patient who has not had previous surgery, who is taking 40 mg/day of prednisone and in whom a tension-free IPAA is possible, 45% of Canadian surgeons would perform a subtotal colectomy with an end ileostomy compared with 14% of American surgeons (p < 0.001).

CONCLUSION

There are significant differences in the surgical management of ulcerative colitis between Canadian and American colorectal surgeons.

End-of-life care for lung cancer patients in the United States and Ontario

BACKGROUND

Both the United States and Canada offer government-financed health insurance for the elderly, but few studies have compared care at the end of life for cancer patients between the two systems.

METHODS

We identified care for non-small cell lung cancer (NSCLC) patients who died of cancer at age 65 years and older during 1999-2003. Patients were identified from US Surveillance, Epidemiology, and End Results (SEER)-Medicare data (N = 13,533) and the Ontario Cancer Registry (N = 8100). Health claims during the last 5 months of life identified chemotherapy and emergency room use, hospitalizations, and supportive care. We estimated rates per person-months (PM) for short-term survivors (died <6 months after diagnosis) and longer-term survivors (died ≥6 months after diagnosis), adjusting for demographic differences. To test whether monthly rates in Ontario were statistically significantly different from the United States, standardized differences were computed, and a 99% confidence interval (CI) was constructed to account for the multiple tests performed. All statistical tests were two-sided.

RESULTS

Rates of chemotherapy use were statistically significantly higher for SEER-Medicare patients than Ontario patients in every month before death (short-term survivors at 5 months before death: SEER-Medicare, 33.2 patients per 100 PM vs Ontario, 9.5 per 100 PM, rate difference = 23.7 per 100 PM, 99% CI = 18.3 to 29.1 per 100 PM, P < .001; longer-term survivors at 5 months before death: SEER-Medicare, 24.4 patients per 100 PM vs Ontario, 14.5 per 100 PM, rate difference = 9.9 per 100 PM, 99% CI = 7.7 to 12.1 per 100 PM, P <. 001). During the last 30 days of life, fewer SEER-Medicare than Ontario patients were hospitalized (short-term survivors, 49.9 vs 78.6 patients per 100 PM, rate difference = 28.6 per 100 PM, 95% CI = 22.9 to 34.4 per 100 PM, P <. 001; longer-term survivors, 44.1 vs 67.1 patients per 100 PM, rate difference = 23.0 per 100 PM, 95% CI = 18.5 to 27.5 per 100 PM, P < .001).

CONCLUSIONS

NSCLC patients in both Ontario and the United States used extensive end-of-life care. Limited availability of hospice care in Ontario and differing attitudes between the United States and Ontario regarding end-of-life care may explain the differences in practice patterns.

Does management of erectile dysfunction after radical prostatectomy meet patients' expectations? Results of a national survey (REPAIR) by the French Urological Association

INTRODUCTION

Little stress has been placed on patients' satisfaction with regard to management of erectile dysfunction (ED) after radical prostatectomy (RP) and on how physicians' and patients' views may differ in this respect.

AIM

To assess the extent to which urologists' perceptions of their patients' expectations and the actual needs expressed by these patients coincide with regard to ED and its management.

METHODS

Those French urologists who provisionally accepted to participate in the survey (760/1,272; 59.7%) received a physician survey instrument, 10 patient data forms to be completed during the first 10 consultations of patients who had undergone RP less than 12 months previously, and 10 copies of a questionnaire for patients to complete. MAIN OUTCOME MEASURES; Patient-reported sexual activity, satisfaction with sexual activity (Male Sexual Health Questionnaire), and treatment expectations; urologists' subjective assessment of the importance given by their patients to ED; the timing they propose for starting ED treatment.

RESULTS

Overall, 535/1,272 urologists (42%) returned the physician survey instrument (45.6 +/- 8.7 years, 28-67) and 2,644 patients completed the patient questionnaire (64.0 +/- 6.1 years, 44-79). The percentage of patients having intercourse pre RP was highly age-dependent (89% at 55-59 years; 56% at > or = 70 years); 70-75% of patients claimed to be satisfied with their pre-RP sexual activity. Post RP, 27-53% of patients (depending upon length of follow-up), who were sexually active pre RP, had intercourse. Only 18% (< 5 months' follow-up) or 28% (> 5 months' follow-up) were satisfied. Over half (53%)--and especially the younger patients--expected early ED treatment (1 or 3 months post RP). Agreement between patients' expectations and urologists beliefs on timing of ED treatment was poor. At the 1- or 2-month visits, 73% of patients were already finding ED frustrating.

CONCLUSIONS

Erectile dysfunction is an important issue for patients who have undergone RP. Urologists tend to underestimate patients' distress and desire for early treatment.

How urologists manage erectile dysfunction after radical prostatectomy: a national survey (REPAIR) by the French urological association

INTRODUCTION

There is little sound information on how urologists manage erectile dysfunction (ED) arising after radical prostatectomy (RP) in a real-world situation.

AIM

To perform a national survey of how French urologists manage ED after RP in routine practice.

MAIN OUTCOME MEASURES

Choice of first-line treatment, type of treatment (rehabilitation of erectile function vs. treatment on demand for intercourse), and timing and duration of treatment.

METHODS

All French urologists were invited to take part in a survey; 59.7% accepted provisionally (760/1,272). They received the survey questionnaire and 10 patient data forms to be completed during the visits of the first 10 patients with fewer than 12 months follow-up post-RP. These were returned to an independent third party for analysis.

RESULTS

The final response rate was 535/1,272 (42%). Before performing RP, 80% of the urologists assessed sexual activity and 76% erectile function; 9% did neither. Thirty-eight percent reported that they systematically proposed ED treatment to their patients post-RP ("routine prescribers"). The remainder was treated on occasion, either at the patients' request (49%) or at their own discretion (13%). Routine prescribers tended to be younger and had performed more RPs in the preceding year. Most urologists (88%) always used the same first-line treatment: regular intracavernosal injections (ICIs) for rehabilitation, 39%; ICI on demand for intercourse, 30%; phosphodiesterase type 5 (PDE5) inhibitors on demand, 16%, or regular PDE5 inhibitors for rehabilitation, 8%; alternating ICI and PDE5 inhibitors, 7%; vacuum device, <1%. ED treatment was initiated within 3 months of RP by 72% of the urologists (92% of routine prescribers). The percentage of urologists recommending ED treatment for 6 months was 20%, 38% for 1 year, and 33% for 2 years.

CONCLUSION

ED was commonplace after RP. French urologists reported a proactive attitude to ED treatment, many favoring pharmacologic rehabilitation therapy. ICI was their first-line treatment of choice.

Low incidence of perioperative chemotherapy for stage III bladder cancer 1998 to 2003: a report from the National Cancer Data Base

PURPOSE

Studies of perioperative chemotherapy for muscle invasive bladder cancer have shown a survival benefit with combined modality therapy. We reviewed chemotherapy use in patients with stage III transitional cell carcinoma of the bladder from 1998 to 2003 to evaluate perioperative chemotherapy treatment patterns.

MATERIALS AND METHODS

The National Cancer Data Base collected data on approximately 60% of all newly diagnosed bladder cancer cases in the United States from 1998 to 2003. We queried the National Cancer Data Base for all treatment of male and female patients 18 years old or older with bladder transitional cell carcinoma diagnosed between 1998 and 2003. A total of 224,060 bladder transitional cell carcinoma records were reviewed. Perioperative chemotherapy was defined as chemotherapy given within 4 months before and 4 months after surgery. Of 11,339 cases of stage III bladder cancer treatment, analysis was possible for 7,161.

RESULTS

Treatment patterns were analyzed in 7,161 patients with stage III bladder transitional cell carcinoma. Perioperative chemotherapy was administered to 11.6% of patients with stage III bladder transitional cell carcinoma with 10.4% receiving adjuvant chemotherapy and 1.2% receiving neoadjuvant chemotherapy. When comparing perioperative chemotherapy use by diagnosis year in 1998 and 2003, a small statistically significant increase was observed using the Pearson's chi-square test with Bonferroni correction (p <0.05) at 11.3% of patients in 1998 vs 16.8% in 2003.

CONCLUSIONS

Perioperative chemotherapy is underused in the management of surgically resectable stage III transitional cell carcinoma of the bladder. This finding may reflect a delay in implementing the results of recently reported randomized trials, a low incidence of referrals by urologists for chemotherapy and/or confidence in salvage chemotherapy as an equivalent alternative. Further followup will determine if this treatment pattern changes in the future.

Neoadjuvant chemotherapy for bladder cancer

The 30-45% failure rate after radical cystoprostatectomy mandates that we explore and optimize multimodal therapy to achieve better disease control in these patients. Cisplatin-based multi-agent combination chemotherapy has been used with success in metastatic disease and has therefore also been introduced in patients with high-risk but non-metastatic bladder cancer. There is now convincing evidence that chemotherapy given pre-operatively can improve survival in these patients. In this review we establish the need for peri-operative chemotherapy in bladder cancer patients and summarize the evidence for the efficacy of neoadjuvant chemotherapy. The advantages and disadvantages of neoadjuvant versus adjuvant chemotherapy are discussed, and the main shortcomings of both--treatment-related toxicity and the inability to prospectively identify likely responders--are presented. Finally, a risk-adapted approach to neoadjuvant chemotherapy is presented, whereby the highest risk patients are offered treatment while those unlikely to benefit are spared the treatment-related toxicity.

A re-staging transurethral resection predicts early progression of superficial bladder cancer

OBJECTIVE

To determine whether pathology on a re-staging transurethral resection (TUR) predicts the early progression of superficial bladder cancer.

PATIENTS AND METHODS

In all, 710 patients presenting with multiple superficial bladder cancers were evaluated by re-staging TUR and followed for 5 years. Tumours were classified by stage as confined to mucosa (Ta) or invading submucosa (T1), and by grade (low- or high-grade). Pathology on re-staging TUR was correlated with the endpoints of tumour recurrence and stage progression.

RESULTS

Of the 710 patients, 490 (69%) had a recurrence and 149 (21%) progressed over 5 years. Eighty patients had high-grade invasive (T1G3) cancer on re-staging TUR and 61 (76%) progressed to muscle invasion (median time to progression 15 months), compared with 88 of 630 (14%) who had no evidence of tumour (T0) or other than T1 tumours detected on re-staging TUR.

CONCLUSION

A re-staging TUR identifies patients with superficial bladder cancer who are at high risk of early tumour progression.

Current Practice in the Management of Superficial Bladder Cancer in the Netherlands and Belgian Flanders: A Survey

OBJECTIVE

Because there is no national guideline for the diagnosis, therapy and follow up of (superficial) bladder cancer in the Netherlands and Belgium, the actual patient management may differ between urologists. The purpose of this study is to get insight in the current way urologists diagnose, treat and follow patients with superficial bladder cancer.

METHODS

All practising urologists in the Netherlands (n = 293) and Flemish speaking Belgium (Flanders, n = 223) received a questionnaire with regard to the current management of patients with superficial bladder cancer. The results were compared with the guidelines provided by the European Association of Urology (EAU). Also a comparison was made between the two countries and between university and community hospitals.

RESULTS

The results show a wide variation in current practice for superficial bladder cancer. Although the majority of urologists do not follow the EAU guidelines, current practice roughly matches these guidelines. There are no major differences between the two countries or between different types of hospitals. Discrepancies between current practice and guidelines are mostly too frequent use of techniques for the diagnosis, treatment and follow-up.

CONCLUSION

In all, there is a need for clear guidelines in superficial bladder cancer and an effective implementation of such guidelines into everyday practice.

Versorgung der erektilen Dysfunktion nach radikaler Prostatektomie in Deutschland

INTRODUCTION

The aim of this national study was to evaluate ED management after RPX (without any postoperative adjuvant therapy or tumor relapse) from the patient's view compared to the urologist's view.

MATERIAL AND METHODS

In May 2003 we queried 1063 urologists and 801 patients following radical prostatectomy without adjuvant therapy. They were asked about preserved potency without erectile aid, existing wish for ED therapy, recommended or tested erectile aid (oral, transurethral, intracorporal, vacuum constriction device[VCD], penile implant) as well as the long-term use. Return rate: patients 80.1%, urologists 26.7%.

RESULTS

According to the urologists' view 9.1% of their affected patients were potent postoperatively without a device, but according to the polled patients only 4.7%. The wish to be treated for erectile dysfunction existed in the urologists' opinion in 46.1% of their patients, while they considered that 44.8% had no wish for treatment. On the other hand, 59.3% of the patients would like to be treated and only 28.5% did not want any kind of treatment. Regarding the long-term use of therapy for ED, the urologists thought that 26.1% of their patients did not receive therapy for the problem, and 69.7% of the patients stated they received no long-term therapy. Only 30.3% of the patients confirmed long-term therapy, while the urologists thought that 73.9% of the patients used an erectile aid. Definite therapy in the urologists' opinion involved: oral medication in 38.4%, MUSE in 3.6%, (SKAT) in 37.3%, VCD in 20.4%, and a prosthesis in 0.3%. Indeed 19.8% of the patients used oral medication, 1.7% MUSE, 26.7% SKAT, 50.9% VCD, and 0.9% penile implant. Considering the satisfaction of patients, urologists thought that 46.2% of the patients were satisfied with their treatment of ED, but only 28.9% of the patients were actually satisfied themselves.

CONCLUSIONS

The comparison of patients' and urologists' views shows a clearly different description of the ED situation after RPX. The proportion of patients with a wish for treatment and the proportion of dissatisfied patients are much higher from the patients' view. This demonstrates an undertreatment of ED patients after RPX, which should also be taken into account under the current changes in the German health care system.