title: Variability of treatment selection among surgeons for patients with cT1 urothelial carcinoma.
abstract: OBJECTIVE
  To report the heterogeneity in the treatment of patients with cT1 urothelial carcinoma by different surgeons, and to report outcomes in patients with and without bacillus Calmette-Guérin (BCG) treatment.
  
  
  METHODS
  We retrospectively reviewed 396 patients who had undergone a re-staging transurethral resection (TUR) for cT1 bladder cancer. We assessed both differences in the treatment by surgeon, and the association of early treatment with BCG with recurrence, progression and bladder cancer-specific death.
  
  
  RESULTS
  Muscle was captured in the re-staging TUR specimen in a median of 76% of patients (range 50-94 when stratified by surgeon). On multivariable analysis there was significant heterogeneity among surgeons in the use of early cystectomy (P < 0.001), deferred cystectomy (P < 0.001), and BCG (P= 0.014). However, there was no significant heterogeneity between surgeons in clinical outcome for recurrence (P= 0.9) and overall survival (P= 0.3). Among 288 patients placed on surveillance, the 5-year probability (95% confidence interval) of freedom from recurrence was 45 (36-54)% for those receiving and 54 (44-62)% for those not receiving early BCG. On multivariable analysis, early BCG was not significantly associated with recurrence (P= 0.14). The cumulative incidence of progression was ≈10% for both groups, and the cumulative incidence of bladder cancer-specific death was ≈7% for both groups. The cumulative incidence of deferred cystectomy before progression was 14% for those receiving and 15% for those not receiving early BCG.
  
  
  CONCLUSIONS
  There is a significant variability among surgeons in the management of patients with T1 disease. The similar outcome for the BCG-treated and -untreated patients in our study is most likely confounded by patient selection.
authors.affiliation: The Division of Urology and Division of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, NewYork, NY, USA.
authors.forename: Guido
authors.initials: G
authors.lastname: Dalbagni
authors.forename: Matthew
authors.initials: M
authors.lastname: Kaag
authors.forename: Angel
authors.initials: A
authors.lastname: Cronin
authors.forename: Kinjal
authors.initials: K
authors.lastname: Vora
authors.forename: Bernard
authors.initials: B
authors.lastname: Bochner
authors.forename: S Machele
authors.initials: SM
authors.lastname: Donat
authors.forename: Harry W
authors.initials: HW
authors.lastname: Herr
mesh_terms: D000276:Adjuvants, Immunologic / Q000627:therapeutic use*; D000283:Administration, Intravesical; D000368:Aged; D001500:BCG Vaccine / Q000627:therapeutic use*; D003131:Combined Modality Therapy / Q000379:methods; D015653:Cystectomy; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010818:Practice Patterns, Physicians'; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*
chemical_list: D000276:Adjuvants, Immunologic; D001500:BCG Vaccine