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Bladder Cancer: No adequate research to guide treatment decisions

Posted by medconsumers on May 1, 2009

“Bladder cancer is among the most prevalent and expensive cancers to treat in the U.S.” This is the opening line of a new study that looked at how early-stage bladder cancer is treated. It showed that treatment is all over the lot—from mild and minimally invasive to extreme and mutilating—because no head-to-head comparison study has ever been conducted to identify which is best.

The new study, based on information from Medicare claims, shows that the people treated least aggressively survived just as long as those treated aggressively. Moreover, the initial high-intensity treatments failed to prevent the need for more interventions in later years. These findings were published recently in the JNCI (Journal of the National Cancer Institute) by Brent K. Hollenbeck, MD, and colleagues at the University of Michigan.

Details about the first two years of care given to over 20,000 people, diagnosed with early-stage bladder cancer from 1992 through 2002, were taken from the Surveillance, Epidemiology, and End Results-Medicare database. Early-stage bladder cancer is defined as a cancer that has not spread to the muscle of the bladder wall.

“What our study highlights is that physicians who practice aggressively in terms of surveillance [followup procedures like cystoscopy] also practice aggressively in terms of the major interventions [e.g., chemotherapy, removal of all or part of the bladder etc.]. That’s their practice pattern,” said the lead author, Dr. Hollenbeck in a telephone interview. The “more is better” paradigm is pervasive among patients as well as physicians, he added, and it is encouraged by our medical care system that pays physicians for doing more.

“What makes bladder cancer so expensive to treat is that about 80% of patients have the chronic form and our study indicates that intensive management of early-stage bladder cancer is common but potentially unnecessary,” said Dr. Hollenbeck who is the Director of the Division of Oncology, Department of Urology at the University of Michigan.

For example, the main diagnostic and surveillance technique is cystoscopy, which involves the insertion of a thin tube into the bladder. It is used to remove cancerous cells from the bladder, check for recurrence, and as a means of infusing chemotherapy directly into the bladder. Cystoscopy carries a small risk of urinary tract infection and can find abnormalities that require further intensive investigations that ultimately prove to be benign, explained Dr. Hollenbeck, citing two reasons why doctors would not want to overuse this procedure.

When asked how a newly diagnosed patient can identify overly aggressive surveillance and treatment, Dr. Hollenbeck offered this advice. “The real issue of this disease is figuring out whether the cancer is a pussy cat or a tiger. For the majority, you will know very early on—in about three months—whether it’s a pussy cat,” said Dr. Hollenbeck, referring to the chronic, slow-growing form of bladder cancer (80% of all).

The physician will know this after surgically removing the tumor and in some cases, going back and removing cells in the section of the bladder where the tumor had been, Dr. Hollenbeck explained. The idea is to make sure that the cancer did not invade the muscle of the bladder wall. “Then, the three-month evaluation with cystoscopy, will more than likely let you will know whether you’re dealing with a pussy cat, and if so, the physician doesn’t have to be nearly as aggressive from then on. Surveillance should gradually be spaced out thereafter. The optimal intervals are unclear. We are trying to get a better handle on this as part of our ongoing effort.”

Maryann Napoli, Center for Medical Consumers© May 2009

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