Extent of Risk-Aligned Surveillance for Cancer Recurrence Among Patients With Early-Stage Bladder Cancer
Extent of Risk-Aligned Surveillance for Cancer Recurrence Among Patients With Early-Stage Bladder Cancer
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DOI：
10.1001/jamanetworkopen.2018.3442
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发表时间：
2018-09-01
影响因子：
13.8
通讯作者：
Sirovich, Brenda
中科院分区：
文献类型：
--
作者：
Schroeck, Florian R.;Lynch, Kristine E.;Sirovich, Brenda
重要性 癌症护理指南建议将监测频率与潜在癌症风险相结合，即对癌症复发高风险和低风险患者进行更频繁的监测。 目的 通过对低风险和高风险早期膀胱癌患者的监测模式进行分类，评估美国退伍军人事务部设施内实施这种风险调整监测的程度。 设计、设置和参与者 美国国家回顾性队列研究，针对诊断为低风险或低风险患者的人群样本进行2005 年 1 月 1 日至 2011 年 12 月 31 日期间对高风险早期膀胱进行研究，随访至 2014 年 12 月 31 日。分析于 2017 年 3 月至 2018 年 4 月进行。该研究包括所有退伍军人事务部设施 (n = 85)，其中低风险和高风险患者都接受了治疗。 暴露 低风险与高风险癌症状态，基于欧洲泌尿外科风险协会的定义分层指南以及通过经过验证的自然语言处理算法从诊断病理学报告中提取的数据。主要结果和措施使用多级模型估计每个机构的低风险和高风险患者的调整膀胱镜检查频率。结果该研究包括 1278 名低风险和 2115 名高风险患者（中位[四分位距]年龄，77 [71-82]岁；99% [3368 of 3393]男）。在各机构中，低风险患者的监测膀胱镜检查频率调整后，每名患者 2 年期间进行 3.7 至 6.2 次（平均 4.8 次）手术，高风险患者的每名患者 2 年期间调整后监测膀胱镜检查频率为 4.6 至 6.0 次（平均 5.4 次）手术。在 85 家机构中的 70 家中，对低风险和高风险患者进行了类似频率的监测，两年内相差不到 1 次膀胱镜检查。仅在 4 个机构中，高风险患者的监测频率在统计上显着超过低风险患者的监测频率。在所有机构中，低风险患者与高风险患者的监测频率呈中度强相关（r = 0.52；P < .001）。 结论和相关性 无论风险如何，早期膀胱癌患者均以相当的频率接受膀胱镜监测。这一发现强调需要了解风险相关监测的障碍，目的是使临床医生更容易在常规实践中进行监测。
IMPORTANCE Cancer care guidelines recommend aligning surveillance frequency with underlying cancer risk, ie, more frequent surveillance for patients at high vs low risk of cancer recurrence.OBJECTIVE To assess the extent to which such risk-aligned surveillance is practiced within US Department of Veterans Affairs facilities by classifying surveillance patterns for low- vs high-risk patients with early-stage bladder cancer.DESIGN, SETTING, AND PARTICIPANTS US national retrospective cohort study of a population-based sample of patients diagnosed with low-risk or high-risk early-stage bladder between January 1, 2005, and December 31, 2011, with follow-up through December 31, 2014. Analyses were performed March 2017 to April 2018. The study included all Veterans Affairs facilities (n = 85) where both low- and high-risk patients were treated.EXPOSURES Low-risk vs high-risk cancer status, based on definitions from the European Association of Urology risk stratification guidelines and on data extracted from diagnostic pathology reports via validated natural language processing algorithms.MAIN OUTCOMES AND MEASURES Adjusted cystoscopy frequency for low-risk and high-risk patients for each facility, estimated using multilevel modeling.RESULTS The study included 1278 low-risk and 2115 high-risk patients (median [interquartile range] age, 77 [71-82] years; 99% [3368 of 3393] male). Across facilities, the adjusted frequency of surveillance cystoscopy ranged from 3.7 to 6.2 (mean, 4.8) procedures over 2 years per patient for low-risk patients and from 4.6 to 6.0 (mean, 5.4) procedures over 2 years per patient for high-risk patients. In 70 of 85 facilities, surveillance was performed at a comparable frequency for low- and high-risk patients, differing by less than 1 cystoscopy over 2 years. Surveillance frequency among high-risk patients statistically significantly exceeded surveillance among low-risk patients at only 4 facilities. Across all facilities, surveillance frequencies for low- vs high-risk patients were moderately strongly correlated (r = 0.52; P < .001).CONCLUSIONS AND RELEVANCE Patients with early-stage bladder cancer undergo cystoscopic surveillance at comparable frequencies regardless of risk. This finding highlights the need to understand barriers to risk-aligned surveillance with the goal of making it easier for clinicians to deliver it in routine practice.