title: Trends in the utilization of imaging for upper tract urothelial carcinoma.
abstract: OBJECTIVE
  To evaluate the changes in use of the different imaging modalities for diagnosing upper tract urothelial carcinoma (UTUC) and assess how these changes have affected tumor stage at the time of surgery.
  
  
  METHODS
  We assessed the Surveillance, Epidemiology, and End Results (SEER) cancer registry and linked Medicare claims data (1992-2009) for 5377 patients who underwent surgery for UTUC. We utilized International Classification of Disease-Oncology 3 codes to identify UTUC. International Classification of Disease, ninth Revision, Clinical Modification and Current Procedure Terminology codes identified surgical treatment and imaging modalities. We assessed for use of intravenous pyelography, retrograde pyelography (RGP), computed tomography urography (CTU), magnetic resonance urography (MRU), and endoscopy. For each modality, patients were categorized as having received the modality at least once or not at all. Patient characteristics were compared using chi-squared tests. Usage of imaging modalities and tumor stage was trended using Cochran-Armitage tests. We stratified our data into 2 multivariate logistic regression models to determine the effect of imaging modalities on tumor stage: 1992 to 1999 with all modalities except MRU, and 2000 to 2009 with all modalities.
  
  
  RESULTS
  Our patient population was predominantly White males of more than 70 years old. Intravenous pyelography and RGP declined in use (62% and 72% in 1992 vs. 6% and 58% in 2009, respectively) while computed tomography urography, MRU, and endoscopy increased in use (2%, 0%, and 37% in 1992 vs. 44%, 6%, and 66% in 2009, respectively). In both regression analyses, endoscopy was associated with lower-stage tumors. In the 2000 to 2009 model, RGP was associated with lower-stage tumors, and MRU was associated with higher-stage tumors. Finally, our data showed an increasing number of modalities utilized for each patient (1% receiving 4 modalities in 1992 vs. 20% in 2009).
  
  
  CONCLUSIONS
  We found trends toward the utilization of newer imaging modalities to diagnose UTUC and more modalities per patient. Endoscopy and RGP were associated with smaller tumors, whereas MRU was associated with larger tumors. Further studies are needed to evaluate the utility of the different modalities in diagnosing UTUC.
authors.affiliation: Division of Urologic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO. Electronic address: amohapatra@wustl.edu.
authors.forename: Anand
authors.initials: A
authors.lastname: Mohapatra
authors.affiliation: Urology Associates of Houston, Houston, TX.
authors.forename: Goutham
authors.initials: G
authors.lastname: Vemana
authors.affiliation: Division of Urologic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO.
authors.forename: Sam
authors.initials: S
authors.lastname: Bhayani
authors.affiliation: Division of Biostatistics, School of Medicine, Washington University in St. Louis, St. Louis, MO.
authors.forename: Jack
authors.initials: J
authors.lastname: Baty
authors.affiliation: Division of Urologic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO.
authors.forename: Joel
authors.initials: J
authors.lastname: Vetter
authors.affiliation: Division of Urologic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO.
authors.forename: Seth A
authors.initials: SA
authors.lastname: Strope
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000000981:diagnostic imaging*; D016009:Chi-Square Distribution; D004724:Endoscopy / Q000706:statistics & numerical data / Q000639:trends; D005260:Female; D006801:Humans; D016015:Logistic Models; D008279:Magnetic Resonance Imaging / Q000706:statistics & numerical data / Q000639:trends; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D064847:Multimodal Imaging / Q000706:statistics & numerical data / Q000639:trends; D015999:Multivariate Analysis; D018426:SEER Program / Q000706:statistics & numerical data; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data / Q000639:trends; D014481:United States; D014551:Urinary Tract / Q000000981:diagnostic imaging* / Q000473:pathology; D014567:Urography / Q000706:statistics & numerical data* / Q000639:trends; D014571:Urologic Neoplasms / Q000000981:diagnostic imaging*
keywords: Diagnosis; Endoscopy; Imaging; Surgery; Upper Tract Urothelial Cancer