Does treatment intensity matter in superficial bladder cancer? Consensus, clinical practice, and confounding.

JNCI | Editorials 543 The majority of patients who are diagnosed with bladder cancer initially present with noninvasive disease ( 1 ). Nevertheless, 40% – 80% of patients diagnosed with superficial bladder cancers will experience a recurrence, including 10% – 25% of those with potentially lethal muscle-invasive disease, within the first 3 years after diagnosis ( 2 – 4 ). Current guidelines from the American Urologic Association ( 5 , 6 ) and the National Comprehensive Cancer Network ( 5 , 6 ) recommend frequent cystoscopic surveillance of patients diagnosed with superficial bladder cancer. However, physicians treating patients with superficial bladder cancer vary widely in their adherence to surveillance guidelines ( 7 ). Practical and ethical considerations that preclude randomized controlled trials to establish the impact of surveillance on survival of patients with superficial bladder cancer include the high recurrence rate, the ability of cystoscopic surveillance to identify recurrence early, the demonstrated efficacy of local therapy in preventing or delaying the development of muscle-invasive disease, and the overall poor prognosis of muscle-invasive disease ( 7 – 10 ). The Surveillance, Epidemiology, and End Results (SEER) – Medicare database that links individual identifi ers in the SEER registry to the Medicare master enrollment fi les has been a valuable resource for evaluating patterns of health-care delivery to older cancer patients and their subsequent outcomes ( 11 ). In this issue of the Journal, Hollenbeck et al. ( 12 ) have used the SEER – Medicare database to identify 20 713 individuals who were diagnosed with early-stage bladder cancer (ie, superfi cial bladder cancer or stage 0 or I including Ta, T1, Tis) between 1992 and 2002 and the health-care provider who submitted the most bladder cancerrelated claims associated with each patient. The authors defi ne “treatment intensity” for each patient in terms of the inpatient and outpatient Medicare payments associated with the early-stage bladder cancer diagnosis, including payments for radical cystectomy. Providers were then ranked according to average early-stage bladder cancer Medicare expenditures. The association of these expenditure rankings with practice patterns related to bladder cancer management and outcomes was examined. The primary outcome of interest was all-cause mortality, whereas the secondary outcomes Does Treatment Intensity Matter in Superficial Bladder Cancer? Consensus, Clinical Practice, and Confounding