Introduction:

The American Urological Association (AUA) introduced evidence-based guidelines for the management of non-muscle invasive bladder cancer (NMIBC) in 2016. These advocate a risk-adapted approach to NMIBC diagnosis, treatment, and surveillance, weighing the risk of progression to muscle-invasive disease against the cost and morbidity of specific interventions. Although not designed to replace clinical judgement, these guidelines provide a useful framework for managing NMIBC. We sought to assess the implementation of the AUA NMIBC guidelines in the three years since their release among urologists who are members of the Society of Urologic Oncology (SUO).

Methods:

An SUO Survey Committee-approved survey was distributed to 747 members in December 2018, with a closing date in February 2019. This 14-question online survey (Qualtrics, SAP SE, Germany) consisted of 38 individual items addressing specific statements from the AUA NMIBC guidelines within 3 broad categories: initial diagnosis, surveillance, and imaging/biomarkers. Where applicable, questions included sub-categories for low-, intermediate-, and high-risk NMIBC. Adherence to guidelines was assessed by dichotomizing responses to each item that was related to recommended action statement within the guidelines. Statistical analysis was applied using Pearson’s chi-squared test, where a p-value of <0.05 was considered statistically significant.

Results:

Complete survey responses were received from 121 (16.2%) members. One-hundred fourteen (94%) respondents listed their primary specialty as urologic oncology; 96 (84%) respondents completed urologic oncology fellowship (Figure 1). A total of 43 (35.5%), 45 (37.2%) and 86 (71.1%) of respondents were early career (1-5yrs), late career, and in academic practice, respectively. The mean individual rate of adherence to guidelines across all risk-categories was 71%, with better adherence for intermediate- and high-risk NMIBC (82% and 76%, respectively) than low-risk NMIBC (58%). The lack of adherence among low-risk patients tended to involve overtreatment: 77% of clinicians ordered routine upper tract imaging, 53% routinely ordered urinary cytology, and 51% performing follow-up surveillance at intervals of less than 1 year in the absence of recurrences. There were no statistically significant differences in adherence with regards to upper tract imaging and use of urine cytology for low-risk patients based on years in practice, fellowship training, or practice setting (Table 1). Adherence to guideline recommended cystoscopic surveillance intervals for low-risk disease differed based on clinical experience (60.9% [<10 years] v. 36.8% [≥10 years], p=0.01) and type of fellowship training (55.2% [urologic oncology] v. 28.0% [none/other], p=0.02).

Conclusion:

Of respondents, adherence to guidelines across all risk-categories was 71% with improved adherence among intermediate and high-risk patients. Decreased adherence observed among low-risk patients resulted in excessive use of cytology, imaging, and surveillance cystoscopy. These results support targeted interventions to support high-value care among low-risk patients.

Funding: Wayne B. Duddleston Sr. Professorship