Surveillance testing, treatment may be overused in low-risk bladder cancer subgroup
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Efforts to limit overuse of surveillance testing and treatment for low-risk nonmuscle-invasive bladder cancer are needed to alleviate increasing costs of care, results of a population-based cohort study suggested.
The study, published in JAMA Network Open showed patients experienced frequent surveillance testing despite low disease recurrence and progression rates.
Background and methodology
Although low-risk nonmuscle-invasive bladder cancer is associated with extremely low rates of progression and cancer-specific mortality, patients may often receive nonguideline-recommended and potentially costly surveillance testing and treatment, Stephen B. Williams, MD, MS, FACS, chief of the division of urology and professor of urology and radiology at The University of Texas Medical Branch, and colleagues wrote.
Their analysis included 13,054 patients aged 66 to 90 years (median age at diagnosis, 76 years; interquartile range, 71-81; 73.5% men; 92.9% white) with a diagnosis of low-grade papillary Ta nonmuscle-invasive bladder cancer in the SEER-linked Medicare database with claims from 2004 through 2013.
Patterns in population-level surveillance and treatment over time among these patients served as the primary outcome. Secondary outcomes included recurrence, progression and costs of care.
Key findings
Researchers found increased rates of all forms of surveillance testing modalities: surveillance cystoscopy increased from 79.3% in 2004 to 81.5% in 2013 (patients received a median three cystoscopies per year);upper tract imaging increased from 30.4% in 2004 to 47% in 2013 (patients received a median two imaging tests per year); and urine cytologic testing or other urine biomarker assessment increased from 44.8% in 2004 to 54.9% in 2013.
Rates of adherence to current guidelines changed little over time; for example, a median 4,398 patients (55.2%) received two or fewer cystoscopies per year from 2004 to 2008 vs. a median 2,736 patients (53.8%) from 2009 to 2013.
As far as treatment trends, they reported that 2,250 patients (17.2%) received intravesical bacillus Calmette-Guérin and 792 patients (6.1%) received intravesical chemotherapy.
Only 217 patients (1.7%) experienced disease recurrence and 52 (0.4%) experienced disease progression. Meanwhile, the total annual median costs of low-grade Ta surveillance testing and treatment increased by 60%, from $34,792 in 2004 to $53,986 in 2013. Researchers noted higher 1-year median expenditures among patients who experienced disease recurrence ($76,669) vs. no disease recurrence ($53,909).
Williams told Healio he was surprised by “the large population-based impact of surveillance and treatment patterns with substantial costs.”
“These provide a benchmark to base value-based decisions and global payment models that may mitigate [increasing costs of care],” he said.
Implications
Further studies are warranted with more recent data and long-term descriptions of diagnostics, treatments, outcomes and global costs of care, Williams said.
In a corresponding editorial, Grayden S. Cook, BS, and Jeffrey M. Howard, MD, PhD, both of University of Texas Southwestern Medical Center, wrote that the researchers “provide an important population-based analysis that objectively illustrates a pattern of increased intensity of cancer surveillance” within this population.
“The impact of these patterns is substantial and may have negative consequences for both patients and the health care system. Thus, it is imperative to move forward with initiatives that provide higher value and are more evidence-based and patient-centered,” Cook and Howard wrote.
References:
Bree KK, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.3050.
Cook GS, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.3055.
For more information:
Stephen B. Williams, MD, MS, FACS, can be reached at Division of Urology, Department of Surgery, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555; email: stbwilli@utmb.edu.
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