Association Between Number of Endoscopic Resections and Utilization of Bacillus Calmette-Guerin Therapy for Patients with High-Grade, Non-Muscle Invasive Bladder Cancer

• Published in: Clinical genitourinary cancer Vol. 15; no. 1; pp. e25 - e31
• Main Authors: Lenis, Andrew T., MD MS, Donin, Nicholas M., MD, Litwin, Mark S., MD, MPH, Saigal, Christopher S., MD, MPH, Lai, Julie, MS, Hanley, Jan M., MS, Konety, Badrinath R., MD, MBA, Chamie, Karim, MD, MSHS
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.02.2017
• Subjects: Aged; Aged, 80 and over; Antineoplastic Agents - administration & dosage; Antineoplastic Agents - urine; BCG Vaccine - administration & dosage; BCG Vaccine - therapeutic use; Calmette-guerin bacillus; Endoscopy; Female; Guideline adherence; Hematology, Oncology and Palliative Medicine; Humans; Logistic Models; Male; Neoplasm Grading; Quality of health care; Recurrence; SEER Program; Treatment Outcome; Urinary bladder neoplasms; Urinary Bladder Neoplasms - drug therapy; Urinary Bladder Neoplasms - surgery; Urology; Recurrence; Quality of Healthcare; Urinary Bladder Neoplasms; Guideline Adherence; Calmette-Guerin Bacillus; Calmette-guerin bacillus; Guideline adherence; Urinary bladder neoplasms; Quality of health care
• ISSN: 1558-7673; 1938-0682
• DOI: 10.1016/j.clgc.2016.06.014

Abstract Background Bacillus Calmette-guerin (BCG) is the gold standard treatment for patients with high-grade, non-muscle-invasive bladder cancer (NMIBC). We previously described non-compliance with guidelines for BCG use in patients with high-risk disease. In the current study we sought to characterize how the number of endoscopic resections of bladder tumors affects BCG utilization using population-level data. Methods We queried a SEER-Medicare linked database to evaluate claims records of 4,776 patients diagnosed with high-grade NMIBC between 1992 and 2002 and followed until 2007, who survived for at least two years and did not undergo definitive treatment with cystectomy, radiotherapy, or systemic chemotherapy. We stratified patients based on the number of endoscopic resections of bladder tumors. We used chi-squared analysis to compare number of resections to BCG utilization and multinomial logistic regression analysis to quantify BCG utilization by patient and tumor characteristics. Results Utilization of BCG increases with increasing endoscopic resections from 40% at diagnosis to 72% after six resections. The cumulative rate of at least an induction course of BCG plateaus after three resections. Lower BCG utilization was associated with advanced age (≥80 years), while increased utilization was associated with being married, higher stage (Tis and T1) and grade (undifferentiated), and increasing endoscopic resections. Conclusions A significant fraction of patients with NMIBC do not receive induction BCG despite proven benefit in minimizing recurrences. Most patients receive BCG only after multiple endoscopic resections. Strategies focused on earlier adoption of BCG to prevent recurrences instead of reacting to recurrences may limit progression and improve survival.