NMIBC guideline compliance remains low

Urologists’ compliance with nonmuscle-invasive bladder cancer guidelines has improved with respect to delivery of perioperative mitomycin, but other care measures continue to be suboptimal, according to a new study.

The AUA released its nonmuscle-invasive bladder cancer management guidelines in 1999, along with updates in 2007 and 2016. But urologists’ compliance with the guidelines has never been good. A study by Chamie et al suggested suboptimal compliance among physicians in the specialty from 1992 to 2002. And in this update, little had changed, except urologists’ improving compliance with the delivery of perioperative mitomycin.

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The findings suggest more is needed to disseminate and implement guideline-based care, according to the authors.

“Treatment guidelines exist for managing cancer patients based on the best available evidence. It is important to measure compliance with guideline-based practices to define what is happening in ‘real-world’ practice and where there are care gaps between recommended guidelines and actual practice,” said senior author Ken Nepple, MD, of the University of Iowa Health Care, Iowa City.

“Specifically in high-grade nonmuscle-invasive bladder cancer, there is an association where patients who have higher compliance with guideline-based care have improved survival. That association, which is likely a result of both patient-specific and treatment-specific effects, should prompt urologists to continue to try and adhere to guidelines whenever possible.”

But, as the study implies, making big changes in practice isn’t easy, according to Dr. Nepple.

The authors referred to the Surveillance, Epidemiology, and End Results-Medicare 1992-2009 database to identify 865 Iowans who had been diagnosed with high-grade nonmuscle-invasive bladder cancer, survived 2 years, and had not had cystectomy or radiation therapy. During 2 years’ follow-up, the authors assessed whether the patients had received guideline-based care, including perioperative mitomycin C, instillations, cystoscopy, cytology, and bacillus Calmette-Guerin (BCG), according to the study.

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They found appropriate use of perioperative mitomycin C rose significantly from 2.5% in 1992-1997 to 28.2% in 2004-2009. But average use of other guideline-based care recommendations was low and stayed that way. Patients received an average 6.22 BCG instillations, 4.89 cystoscopies, and 1.77 cytologies. Only 40% of those studied received at least one cystoscopy, one cytology, and one BCG instillation.

Patients with carcinoma in situ, as well as those treated at academic cancer centers, were more likely than the other nonmuscle-invasive bladder cancer patients to receive guideline-based care, the authors wrote.

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“Guidelines provide a road map to define how urologists should care for patients. In practice, there may occasionally be reasons to deviate from guideline-based care, but in general, the guidelines illustrate a default practice pattern which is based on the best available literature and is the result of a rigorous peer-review process,” Dr. Nepple said. “I have no doubt that urologists are trying to do what is best for their patients, but the reality is that delivering guideline-based care in the setting of a busy clinical practice is challenging.”

Efforts to improve compliance with the guidelines would include improving both the structure of guidelines and redesigning the processes of bladder cancer care delivery to support urologists in delivering the best care possible, according to Dr. Nepple.