title: Adherence to surveillance guidelines after radical cystectomy: a population-based analysis.
abstract: OBJECTIVE
  Surveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database.
  
  
  METHODS
  The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients aged ≥66 years diagnosed with nonmetastatic bladder cancer who had undergone radical cystectomy between 2000 and 2007. Medicare claims information identified recommended surveillance tests for 2 years after cystectomy as outlined in the NCCN guidelines. Adherence was defined as receipt of urine cytology and imaging of the chest, abdomen, and pelvis in each year. We evaluated the effect of patient and provider characteristics on adherence, controlling for demographic and disease characteristics.
  
  
  RESULTS
  Of 3,757 patients who had undergone radical cystectomy, 2,990 (80%) were alive after 2 years. Adherence to all recommended investigations was 17% for the first and the second years following surgery. Among patients surviving 2 years, only 9% had complete surveillance in both years. In either year, adherence was less likely in patients with advanced pathologic stage (III/IV) (adjusted odds ratio [AOR] = 0.74, 95% CI: 0.60-0.91) and unmarried patients (AOR = 0.82, 95% CI: 0.68-0.99). Adherence was more likely in patients treated by high-volume surgeons (AOR = 2.00, 95% CI: 1.70-2.36) and those who saw a medical oncologist (AOR = 1.52, 95% CI: 1.27-1.82). We also observed significant geographic variability in adherence.
  
  
  CONCLUSIONS
  Patterns of surveillance after radical cystectomy deviate considerably from NCCN recommendations. Despite increased utilization of radiographic imaging investigations, the omission of urine cytology significantly contributed to the low rate of overall adherence to surveillance guidelines. Uniform adherence to surveillance guidelines was observed in patients treated by high-volume surgeons. This suggests an important opportunity for quality improvement in bladder cancer care.
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY. Electronic address: ehdaieb@mskcc.org.
authors.forename: Behfar
authors.initials: B
authors.lastname: Ehdaie
authors.affiliation: Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY.
authors.forename: Coral L
authors.initials: CL
authors.lastname: Atoria
authors.affiliation: Urology Division, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT.
authors.forename: William T
authors.initials: WT
authors.lastname: Lowrance
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
authors.forename: Harry W
authors.initials: HW
authors.lastname: Herr
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
authors.forename: Bernard H
authors.initials: BH
authors.lastname: Bochner
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
authors.forename: S Machele
authors.initials: SM
authors.lastname: Donat
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
authors.forename: Guido
authors.initials: G
authors.lastname: Dalbagni
authors.affiliation: Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY.
authors.forename: Elena B
authors.initials: EB
authors.lastname: Elkin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015653:Cystectomy / Q000379:methods*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D017408:Guidelines as Topic / Q000592:standards*; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D008991:Monitoring, Physiologic / Q000379:methods / Q000592:standards; D011159:Population Surveillance; D011184:Postoperative Period; D018426:SEER Program / Q000706:statistics & numerical data; D014481:United States; D001749:Urinary Bladder Neoplasms / Q000175:diagnosis / Q000601:surgery*
keywords: Bladder cancer; Guidelines; Health outcomes; Radical cystectomy; Surveillance