EURURO Vol. 71 No. 4

688 692

Words of Wisdom
Re: Management of Nonmuscle Invasive Bladder Cancer:
A Comprehensive Analysis of Guidelines from the Unites
States, Europe, and Asia
Tan WS, Rodney S, Lamb B, Feneley M, Kelly J
Cancer Treat Rev 2016;47:22–31
Expert’s summary:
This paper gives concise standard of care guidelines drawn
from the world’s literature. Patients with bladder cancer, at
the time of initial resection, they state, ‘‘all guidelines support
the use of an immediate instillation (or within 24 h) of
intravesical chemotherapy (IVC) post-transurethral resec-
tion of bladder tumor’’ unless there is any suspicion of blad-
der perforation or significant bleeding, requiring bladder
irrigation.
Expert’s comments:
These guidelines are essentially unchanged for a number of
years—reiterated at virtually every American Urological Asso-
ciation (AUA) meeting and in AUA home study courses. There-
fore, it is reasonable to expect that all urologists follow these
guidelines. In an abstract at the 2015 AUA meeting, Nabbout
and Elliott reported on 14 302 patients with stage
T1 tumors utilizing a Surveillance, Epidemiology, and End
Results-Medicare database. Of which, 7.5% received IVC. We
found virtually, identical numbers in a Californian database
(2005–2012). In this database of 21 teaching facilities, the best
adherence to IVC guidelines was 24.6%: UC Davis was at 21.1%.
Neither are acceptable. Over the past 2 yr, we gathered this
data prospectively giving feedback to the treating urologists.
Adherence rates jumped to 77% for IVC. Kobayashi et al
reported from Japan after a similar type of intervention—
adherence to IVC guidelines went from 41.2% to 72%. There-
fore, in a single institution, low level intervention worked.
However, 80% of patients are treated outside of major cancer
centers—will the same approach be effective? Montie et al
led such an effort in their Multi-practice Quality Improvement
Collaborative. The collaborative decided on their definition of
an ideal patient for IVC. Of 840 resected patients, they declared
264 (31.4%) ideal for IVC; 92 patients received IVC. Therefore,
of 840 patients, 11% received the standard of care. It seems
inappropriate that at an academic institution, you have a 70%
chance of receiving the standard of care but in the collabora-
tive setting this drops to 11%. Considering the increase in the
aging population over the next 14 yr and remembering that
bladder cancer is a disease of aging—we are only going to have
more patients presenting with this disease. It seems incredibly
important that we assure these patients of the best treatment
possible. Remembering that, in the states, we are presently
spending 17.6% of our gross domestic product on healthcare. If
we, the urology community, do not find a way to improve
adherence to standard of care guidelines—ways will be im-
posed upon us. We, clearly, need to think how we do this and
to admit that our present form of education is totally and
unacceptable inadequate.[1_TD$DIFF]
Conflicts of interest: The author has nothing to disclose.
References
[1]
[2]
[3]
[4]
Ralph de Vere Whit
Department of Urology, UC Davis Cancer Center, Sacramento, CA, USA
*4501 X Street, Suite 3003, Sacramento, CA 95817, USA.
E-mail address:
# 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
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