title: Association Between Number of Endoscopic Resections and Utilization of Bacillus Calmette-Guérin Therapy for Patients With High-Grade, Non-Muscle-Invasive Bladder Cancer.
abstract: Bacillus Calmette-Guérin (BCG) is the reference standard treatment for patients with high-grade, non-muscle-invasive bladder cancer (NMIBC). We previously described noncompliance 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.
  
  
  
  We queried a Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to evaluate claims records of 4776 patients diagnosed with high-grade NMIBC between 1992 and 2002 and followed until 2007, who survived for at least 2 years and who did not undergo definitive treatment with cystectomy, radiotherapy, or systemic chemotherapy. We stratified patients on the basis of the number of endoscopic resections of bladder tumors. We used chi-square analysis to compare number of resections to BCG utilization and multinomial logistic regression analysis to quantify BCG utilization by patient and tumor characteristics.
  
  
  
  Utilization of BCG increases with increasing endoscopic resections from 40% at diagnosis to 72% after 6 resections. The cumulative rate of at least an induction course of BCG plateaus after 3 resections. Lower BCG utilization was associated with advanced age (≥ 80 years), while increased utilization was associated with being married, higher disease stage (Tis and T1) and grade (undifferentiated), and increasing endoscopic resections.
  
  
  
  A significant fraction of patients with NMIBC do not receive induction BCG despite its 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.
authors.affiliation: Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Lenis
authors.affiliation: Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
authors.forename: Nicholas M
authors.initials: NM
authors.lastname: Donin
authors.affiliation: Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; RAND Corporation, Santa Monica, CA; Department of Health Policy & Management, University of California Los Angeles School of Public Health, Los Angeles, CA.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Litwin
authors.affiliation: Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; RAND Corporation, Santa Monica, CA.
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Saigal
authors.affiliation: RAND Corporation, Santa Monica, CA.
authors.forename: Julie
authors.initials: J
authors.lastname: Lai
authors.affiliation: RAND Corporation, Santa Monica, CA.
authors.forename: Jan M
authors.initials: JM
authors.lastname: Hanley
authors.affiliation: Department of Urology, University of Minnesota, Minneapolis, MN.
authors.forename: Badrinath R
authors.initials: BR
authors.lastname: Konety
authors.affiliation: Department of Urology, Health Services Research Group, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA. Electronic address: kchamie@mednet.ucla.edu.
authors.forename: Karim
authors.initials: K
authors.lastname: Chamie
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000008:administration & dosage* / Q000652:urine; D001500:BCG Vaccine / Q000008:administration & dosage* / Q000627:therapeutic use; D004724:Endoscopy; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D060787:Neoplasm Grading; D018426:SEER Program; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy* / Q000601:surgery*
chemical_list: D000970:Antineoplastic Agents; D001500:BCG Vaccine
keywords: Calmette-guerin bacillus; Guideline adherence; Quality of health care; Recurrence; Urinary bladder neoplasms