Understanding the Barriers to Neoadjuvant Chemotherapy in Patients with Muscle Invasive Bladder Cancer: A Quality Improvement Initiative.
Understanding the Barriers to Neoadjuvant Chemotherapy in Patients with Muscle Invasive Bladder Cancer: A Quality Improvement Initiative.
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DOI：
10.1097/upj.0000000000000200
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发表时间：
2021-03
期刊：
影响因子：
0.8
通讯作者：
Montgomery JS
中科院分区：
文献类型：
--
作者：
Andino JJ;Sessine M;Singhal U;Reichert ZR;Wray D;Shafer C;Moore M;Weizer AZ;Kaffenberger SD;Herrel LA;Morgan TM;Hafez KZ;Montgomery JS
新辅助化疗（NAC）在肌肉浸润性膀胱癌治疗中的应用仍然很低。我们试图了解我们使用NAC的实践，以便设计一种面向优化肿瘤转诊的质量改进方案。我们在2012-2017年间在我们的机构发现了339例接受根治性膀胱切除术治疗的≥cT2膀胱癌患者。我们评估了肿瘤内科转诊率、NAC给药率以及与NAC使用相关的医疗、患者和提供者变量。贝叶斯逻辑回归模型确定了与NAC使用相关的变量，图表回顾提供了细粒度的患者水平数据。85% （n=289）的患者转诊到内科肿瘤科，62.5% （n=212）的患者接受了NAC治疗。肾功能不全、听力损失和泌尿科治疗与NAC使用的低几率有决定性的联系。46例患者没有转诊到肿瘤内科，其中50%的患者有顺铂的医学禁忌症，这是没有转诊的原因。38例患者接受肿瘤内科治疗，但未接受NAC治疗。30例（79%）患者有影响该决定的合并症，15例（39%）患者因肾功能受损而不合格。尽管该队列的肿瘤转诊率和NAC使用率相对较高，但仍有机会提高这种做法的效率。质量改进举措可以优化≥T2膀胱癌患者的转诊，以考虑顺铂为基础的NAC，并为这些患者的管理建立一个重要的质量指标。
Utilization of neoadjuvant chemotherapy (NAC) for the management of muscle-invasive bladder cancer remains low. We sought to understand our practice of NAC use in order to design a quality improvement initiative geared towards optimizing medical oncology referral. We identified 339 patients with ≥cT2 bladder cancer treated with radical cystectomy between 2012-2017 at our institution. We assessed the rate of referral to medical oncology, rate of NAC administration, as well as medical, patient and provider variables associated with NAC use. Bayesian logistic regression modeling identified variables associated with NAC use and chart review provided granular patient-level data. 85% (n=289) of patients were referred to medical oncology and 62.5% (n=212) received NAC. Renal insufficiency, hearing loss, and treating urologist were conclusively associated with lower odds of NAC use. 46 patients were not referred to medical oncology and 50% of these had medical contraindications to cisplatin cited as the reason for no referral. 38 patients met with medical oncology but did not receive NAC. 30 (79%) had comorbidities that impacted this decision with 15 (39%) ineligible based on impaired renal function. Despite the relatively high rates of medical oncology referral and NAC use in this cohort, there are still opportunities to improve the efficiency of this practice. Quality improvement initiatives could optimize the referral of patients with ≥T2 bladder cancer for consideration of cisplatin-based NAC and establish an important quality metric in the management of these patients.