Patterns of care for early stage bladder cancer

Abstract

Background: Early stage bladder cancer is a heterogeneous disease with a variable risk of progression and mortality. Uncertainty surrounding the optimal care for these patients may result in a mismatch between disease risk and treatment intensity.

Methods: Using Surveillance, Epidemiology, End Results-Medicare data, we identified patients diagnosed with early stage bladder cancer (n = 24,980) between 1993 and 2002. We measured patients' treatment intensity by totaling all Medicare payments made for bladder cancer in the 2 years after diagnosis. Using multiple logistic regression, we assessed relationships between clinical characteristics and treatment intensity. Finally, we determined the extent to which a patient's disease risk matched with their treatment intensity.

Results: The average per capita expenditures increased from $6,936 to $7,642 over the study period (10.2% increase; P < .01). This increase was driven by greater use of intravesical therapy (2.6 vs 3.7 instillations per capita, P < .01) and physician office visits (3.0 vs 4.8 visits per capita, P < .01). Generally, treatment intensity was appropriately aligned with many clinical characteristics, including age, comorbidity, tumor stage, and grade. However, treatment intensity matched disease risk for only 55% and 49% of the lowest and highest risk patients, respectively.

Conclusions: The initial treatment intensity of early stage bladder cancer is increasing, primarily through greater use of intravesical therapy and office visits. Treatment intensity matches disease risk for many, but up to 1 in 5 patients may receive too much or too little care, suggesting opportunities for improvement.

(c) 2010 American Cancer Society.

Figures

Figure 1

Per capita Medicare payments (standardized to 2005 dollars and price adjusted by region) for early stage bladder cancer therapy increased significantly in the SEER 13 cohort. Overall per capita utilization increased in the SEER 17 cohort, driven by increased institutional outpatient expenditures. Use of physician services also increased, but did not achieve statistical significance.

Figure 2

Endoscopic surveillance was the most common service but remained relatively stable throughout the study. Use of intravesical therapy, and physician visits increased. Higher proportions of patients received induction intravesical therapy, but use of restaging TURBT and urinary cytology tests showed no significant linear trends over time.

Figure 3

The lowest risk of progression and recurrence category includes patients over 85 years of age with two or more comorbidities and Ta low grade disease. The highest risk category includes patients 65 to 74 years of age with no more than one comorbidity and T1 disease or CIS.