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Background: A 36-year-old male with a history of cryptorchidism of the right side, treated with orchidopexy at the age of 4, presented with bilateral testicular swelling. Investigations: Investigations included laboratory workup, ultrasound of both testes, as well as CT-scan of the chest, abdomen, and pelvis. Initial treatment was bilateral orchiectomy. Results: Scrotal examination revealed a mass on the left side and a small right testis with a hard mass at the lower pole. One markedly enlarged right inguinal lymph node was palpable. LDH, ßHCG, and AFP were significantly elevated. Scrotal ultrasound revealed a homogeneous hypoechoic right testis without a mass and a heterogeneous mass containing multiple inhomogeneous cystic areas on the left side. A hypoechoic mass was visualized in the right groin. CT evaluation revealed an enlarged retroperitoneal lymph node on the left side. Diagnosis: Histopathological evaluation revealed seminoma of the right testis, nonseminomatous germ cell tumor of the left testis, and metastatic seminoma in the right groin postoperatively. Conclusions: Due to improved diagnostic tools as well as the establishment of various adjuvant treatment options, the mortality of testicular cancer generally decreased in the last decades. However, metastatic bilateral testicular cancer of different histology is a challenging situation for the urologist, which warrants further discussion. Adjuvant treatment as well as postoperative follow-up should be chosen carefully. [ABSTRACT FROM AUTHOR]

Context.—: Quality communication between clinicians and pathologists is required for optimal cancer care. The College of American Pathologists provides anatomic site-specific cancer protocols that facilitate synoptic reporting for efficient communication, contributing to accuracy and completeness of cancer staging., Objective.—: To evaluate synoptic cancer pathology reporting across the Department of Veterans Affairs (VA), the largest integrated health system in the United States, for 4 common cancers: melanoma and colon, bladder, and kidney cancer., Design.—: For each cancer type, we investigated at least 200 biopsy and 200 resection reports from 2019 to 2021. In each report, we determined whether a synoptic format was used. The reports were selected using random sampling across all VA health care facilities. We also identified a set of core elements that were underdocumented., Results.—: Among 1618 pathology reports, 778 (48%; 95% CI, 46%-50%) were synoptic reports. Synoptic reporting was much more common among resections (621 of 811; 77%; 95% CI, 74%-79%) than among biopsies (157 of 807; 19%; 95% CI, 17%-22%). It was most common in colorectal resections (200 of 206; 97%; 95% CI, 94%-99%) and least common in colon biopsy reports (1 of 200; 0.5%; 95% CI, 0%-3%). Core elements that were underdocumented included procedure and regional lymph nodes for resections of bladder and kidney cancer and of melanoma., Conclusions.—: Synoptic reporting was used about three-quarters of the time for resections and about 1 in 5 times for biopsies. Future work should develop implementation strategies to improve synoptic reporting, especially for biopsy specimens and core elements that were relatively underdocumented., (© 2024 College of American Pathologists.)

Competing Interests: Declaration of Competing Interest This information will be kept confidential. The Editor will discuss the method of disclosure of any potential conflict of interest with the corresponding author on an individual basis. Florian R. Schroeck receives research funding from the Department of Veterans Affairs, the National Institutes of Health, Pacific Edge, Nucleix, and Cepheid.

Background: The National Cancer Institute SEER Program regularly publishes bladder-cancer specific survival statistics. However, this data is for all bladder cancers, and information for non-muscle invasive bladder cancer (NMIBC) is difficult to obtain., Objective: To quantify 5-year overall and bladder cancer-specific survival in a cohort of Department of Veterans Affairs (VA) patients diagnosed with NMIBC., Methods: We identified VA patients diagnosed with NMIBC who underwent a transurethral resection from 2003-2013. The patient demographics and Charlson Comorbidity Index were categorized. We acquired the patients' date of death from the Veterans Health Administration's Death Ascertainment File and their cause of death from the Mortality Data Repository. We calculated Kaplan Meier estimates of survival., Results: A total of 27,008 patients were included; median age was 69 and almost all were male (99%). The median comorbidity score was 4. The most prevalent comorbidity indicators included Chronic Pulmonary Disease (48%), cancer other than Bladder (41%), and diabetes (40%). This cohort was found to have a 5-year overall survival of 68% (99% CI 67% -69%) and a 5-year bladder cancer-specific survival of 93% (99% CI 92% -94%)., Conclusions: The 5-year bladder cancer-specific survival in patients diagnosed with non-muscle invasive bladder cancer is substantially higher than the 5-year overall survival. This difference may be related to the severity and number of comorbidities that patients in this population must manage. This warrants further research into the necessity of currently recommended high-intensity cancer surveillance for individuals with NMIBC., Competing Interests: Kathryn McGonagle, Ellen J. Dematt, Zhibao Mi, and Kousick Biswas report no relevant conflicts of interest. Florian R. Schroeck reports research funding from the National Cancer Institute, Pacific Edge Ltd., Cepheid, and Nucleix., (© 2024 – The authors. Published by IOS Press.)

"Replace Cysto" is a multisite randomized phase 2 trial including 240 participants with low-grade intermediate-risk non-muscle-invasive bladder cancer, in which participants will be randomized 1:1:1 to one of two urine marker-based approaches alternating a urine marker test (Xpert Bladder Cancer Monitor or Bladder EpiCheck) with cystoscopy or to frequent scheduled cystoscopy. The primary objective is to determine whether urinary quality of life after surveillance is significantly improved in the urine marker arms. The primary outcome will be the patient-reported urinary quality of life domain score of the validated QLQ-NMIBC24 instrument, measured 1-3 d after surveillance. Exploratory outcomes include discomfort after surveillance, the number of invasive procedures that participants undergo per 1000 person years, complications from these procedures per 1000 person years, nonurinary quality of life, acceptability of surveillance, and bladder cancer recurrence and progression. Comparators include surveillance using (1) the Xpert Bladder Cancer Monitor test, (2) the Bladder EpiCheck urinary marker, or (3) frequent cystoscopy alone. After a negative cystoscopy ≤4 mo following bladder tumor resection, all the participants will undergo surveillance at 6, 12, 18, and 24 mo (with time zero defined as the date of the most recent bladder tumor resection). In the urine marker arms, surveillance at 6 and 18 mo will be performed with the marker. Regardless of the arm, participants will undergo cystoscopy at 12 and 24 mo. End of study for each participant will be their 24-mo cystoscopy. Overall trial duration is estimated at 5 yr from when the study opens to enrollment until completion of data analyses. The trial is registered at clinicaltrials.gov (NCT05796375).

Objective: To determine if accurate documentation of bladder cancer risk was associated with a clinician surveillance recommendation that is concordant with AUA guidelines among patients with nonmuscle invasive bladder cancer (NMIBC)., Methods: We prospectively collected data from cystoscopy encounter notes from four Department of Veterans Affairs (VA) sites to ascertain whether they included accurate documentation of bladder cancer risk and a recommendation for a guideline-concordant surveillance interval. Accurate documentation was a clinician-recorded risk classification matching a gold standard assigned by the research team. Clinician recommendations were guideline-concordant if the clinician recorded a surveillance interval that was in line with the AUA guideline., Results: Among 296 encounters, 75 were for low-, 98 for intermediate-, and 123 for high-risk NMIBC. 52% of encounters had accurate documentation of NMIBC risk. Accurate documentation of risk was less common among encounters for low-risk bladder cancer (36% vs 52% for intermediate- and 62% for high-risk, P < .05). Guideline-concordant surveillance recommendations were also less common in patients with low-risk bladder cancer (67% vs 89% for intermediate- and 94% for high-risk, P < .05). Accurate documentation was associated with a 29% and 15% increase in guideline-concordant surveillance recommendations for low- and intermediate-risk disease, respectively (P < .05)., Conclusion: Accurate risk documentation was associated with more guideline-concordant surveillance recommendations among low- and intermediate-risk patients. Implementation strategies facilitating assessment and documentation of risk may be useful to reduce overuse of surveillance in this group and to prevent unnecessary cost, anxiety, and procedural harms., Competing Interests: Declaration of Competing Interest Florian R. Schroeck reports research funding from Pacific Edge, Ltd., (Published by Elsevier Inc.)

Objective: To quantify the short-term burden associated with continent diversion relative to ileal conduit creation., Methods: Bladder cancer patients who underwent radical cystectomy in 2019 and 2020 were identified in the American College of Surgeons National Surgical Improvement Program database using current procedural terminology codes and pathology reports. Patients were grouped by urinary diversion performed: ileal conduit versus continent diversion (neobladder or cutaneous reservoir). Multiple logistic regression was used to examine the association between type of urinary diversion and 30-day outcomes, including postoperative complications, all-cause readmissions, and mortality, adjusting for baseline differences., Results: Of 4,755 patients who underwent radical cystectomy, 677 underwent continent diversion (14.2%). These patients were significantly younger (median 62 vs 71 years, P <.01) and less likely to have diabetes (13.6% vs 20.1%, P <.01), COPD (3.7% vs 7.1%, P<0.01), and prior pelvic radiation (5.5% vs 13.1%, P <.01). A greater proportion of continent diversion patients experienced a postoperative complication (56.0% vs 48.9%, P <.01) and all-cause readmission (30.3% vs 20.4%, P <.0). After adjustment, continent diversion patients had 1.4 (95% CI: 1.1-1.7) and 1.7 (95% CI: 1.4-2.1) times the odds of experiencing a postoperative complication or all-cause readmission, respectively. There was no statistically significant difference in mortality (OR 1.2, 95% CI: 0.5-2.9)., Conclusion: Compared to ileal conduit creation, continent urinary diversion is associated with increased odds of postoperative complications and readmission to the hospital within 30 days of surgery. Bladder cancer patients undergoing cystectomy and seeking continent diversion should be counseled on the increased short-term morbidity associated with this specific type of diversion., (Copyright © 2022. Published by Elsevier Inc.)

Background: Implementation Mapping is an organized method to select implementation strategies. However, there are 73 Expert Recommendations for Implementing Change (ERIC) strategies. Thus, it is difficult for implementation scientists to map all potential strategies to the determinants of their chosen implementation science framework. Prior work using Implementation Mapping employed advisory panels to select implementation strategies. This article presents a data-driven approach to implementation mapping, in which we systematically evaluated all 73 ERIC strategies using the Tailored Implementation for Chronic Diseases (TICD) framework. We illustrate our approach using implementation of risk-aligned bladder cancer surveillance as a case example., Methods: We developed objectives based on previously collected qualitative data organized by TICD determinants, i.e., what needs to be changed to achieve more risk-aligned surveillance. Next, we evaluated all 73 ERIC strategies, excluding those that were not applicable to our clinical setting. The remaining strategies were mapped to the objectives using data visualization techniques to make sense of the large matrices. Finally, we selected strategies with high impact, based on (1) broad scope, defined as a strategy addressing more than the median number of objectives, (2) requiring low or moderate time commitment from clinical teams, and (3) evidence of effectiveness from the literature., Results: We identified 63 unique objectives. Of the 73 ERIC strategies, 45 were excluded because they were not applicable to our clinical setting (e.g., not feasible within the confines of the setting, not appropriate for the context). Thus, 28 ERIC strategies were mapped to the 63 objectives. Strategies addressed 0 to 26 objectives (median 10.5). Of the 28 ERIC strategies, 10 required low and 8 moderate time commitments from clinical teams. We selected 9 strategies based on high impact, each with a clearly documented rationale for selection., Conclusions: We enhanced Implementation Mapping via a data-driven approach to the selection of implementation strategies. Our approach provides a practical method for other implementation scientists to use when selecting implementation strategies and has the advantage of favoring data-driven strategy selection over expert opinion., (© 2022. The Author(s).)

Background: Healthcare providers are often targeted as research participants, especially for implementation science studies evaluating provider- or system-level issues. Frequently, provider eligibility is based on both provider and patient factors. Manual chart review and self-report are common provider screening strategies but require substantial time, effort, and resources. The automated use of electronic health record (EHR) data may streamline provider identification for implementation science research. Here, we describe an approach to provider screening for a Veterans Health Administration (VHA)-funded study focused on implementing risk-aligned surveillance for bladder cancer patients., Methods: Our goal was to identify providers at 6 pre-specified facilities who performed ≥10 surveillance cystoscopy procedures among bladder cancer patients in the 12 months prior to recruitment start on January 16, 2020, and who were currently practicing at 1 of 6 pre-specified facilities. Using VHA EHR data (using CPT, ICD10 procedure, and ICD10 diagnosis codes), we identified cystoscopy procedures performed after an initial bladder cancer diagnosis (i.e., surveillance procedures). Procedures were linked to VHA staff data to determine the provider of record, the number of cystoscopies they performed, and their current location of practice. To validate this approach, we performed a chart review of 105 procedures performed by a random sample of identified providers. The proportion of correctly identified procedures was calculated (Positive Predictive Value (PPV)), along with binomial 95% confidence intervals (CI)., Findings: We identified 1,917,856 cystoscopies performed on 703,324 patients from October 1, 1999-January 16, 2020, across the nationwide VHA. Of those procedures, 40% were done on patients who had a prior record of bladder cancer and were completed by 15,065 distinct providers. Of those, 61 performed ≥ 10 procedures and were currently practicing at 1 of the 6 facilities of interest in the 1 year prior to study recruitment. The random chart review of 7 providers found 101 of 105 procedures (PPV: 96%; 95% CI: 91% to 99%) were surveillance procedures and were performed by the selected provider on the recorded date., Implications: These results show that EHR data can be used for accurate identification of healthcare providers as research participants when inclusion criteria consist of both patient- (temporal relationship between diagnosis and procedure) and provider-level (frequency of procedure and location of current practice) factors. As administrative codes and provider identifiers are collected in most, if not all, EHRs for billing purposes this approach can be translated from provider recruitment in VHA to other healthcare systems. Implementation studies should consider this method of screening providers., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Mortality from bladder cancer (BC) increases exponentially once it invades the muscle, with inherent challenges delineating at the population level. We sought to develop and validate a natural language processing (NLP) model for automatically identifying patients with muscle-invasive bladder cancer (MIBC)., Methods: All patients with a Current Procedural Terminology code for transurethral resection of bladder tumor (TURBT; n = 76,060) were selected from the Department of Veterans Affairs (VA) database. A sample of 600 patients (with 2,337 full-text notes) who had TURBT and confirmed pathology results were selected for NLP model development and validation. The NLP performance was assessed by calculating the sensitivity, specificity, positive predictive value, negative predictive value, F1 score, and overall accuracy at the individual note and patient levels., Results: In the validation cohort, the NLP model had average overall accuracies of 94% and 96% at the note and patient levels. Specifically, the F1 score and overall accuracy for predicting muscle invasion at the patient level were 0.87% and 96%, respectively. The model classified nonmuscle-invasive bladder cancer (NMIBC) with overall accuracies of 90% and 93% at the note and patient levels. When applying the model to 71,200 patients VA-wide, the model classified 13,642 (19%) as having MIBC and 47,595 (66%) as NMIBC and was able to identify invasion status for 96% of patients with TURBT at the population level. Inherent limitations include a relatively small training set, given the size of the VA population., Conclusion: This NLP model, with high accuracy, may be a practical tool for efficiently identifying BC invasion status and aid in population-based BC research., Competing Interests: Ruixin YangResearch Funding: Janssen, Merck Lauren E. HowardResearch Funding: Bayer (Inst), Merck (Inst), Ferring (Inst), MDxHealth (Inst), Sanofi (Inst), Diasorin (Inst), Myriad Genetics (Inst), LungLife AI (Inst) Amanda De HoedtStock and Other Ownership Interests: Myovant SciencesResearch Funding: Bayer (Inst), Ferring (Inst), Merck (Inst), Janssen (Inst), MDxHealth (Inst), Sanofi (Inst), Diasorin (Inst), Myriad Genetics (Inst), LungLife AI (Inst), Pfizer (Inst), Blue Earth Diagnostics (Inst) Florian R. SchroeckOther Relationship: Sesen Bio Zachary KlaassenHonoraria: Pfizer/Astellas, BayerConsulting or Advisory Role: Sesen Bio Stephen J. FreedlandEmployment: Genomic Health (I)Consulting or Advisory Role: Astellas Pharma, Janssen Biotech, Dendreon, Bayer, Pfizer, Ferring, AstraZeneca, Sanofi, Myovant Sciences, Clovis Oncology, Merck, Exact SciencesSpeakers' Bureau: Sanofi, AstraZenecaResearch Funding: Bayer (Inst), Janssen Biotech (Inst), Myriad Genetics (Inst), GenomeDx (Inst), Progenika (Inst), MDxHealth (Inst), OPKO Diagnostics (Inst), Diasorin, MerckTravel, Accommodations, Expenses: Sanofi Stephen B. WilliamsConsulting or Advisory Role: Taris BioMedical (Inst), Photocure, UroTodayTravel, Accommodations, Expenses: JanssenNo other potential conflicts of interest were reported.

Objective: To evaluate the degree of discomfort among patients with bladder cancer undergoing office-based cystoscopy and identify factors and interventions that influence discomfort and anxiety., Methods: We conducted a survey of the Bladder Cancer Advocacy Network Patient Survey Network (BCAN PSN) to investigate the degree of discomfort associated with office-based cystoscopy and prevalence of interventions used to reduce discomfort. All patients had undergone at least one previous cystoscopy. Bivariable and multivariable logistic regression were used to identify factors associated with moderate-to-severe cystoscopy discomfort., Results: Among 488 BCAN PSN respondents (50% response rate), 392 responded with demographic data and discomfort score. Cystoscopy was associated with moderate-to-severe discomfort in 52% of patients. Respondents who reported moderate-to-severe discomfort were more likely to describe their most recent cystoscopy discomfort as worse than prior (P<0.001) and to be interested in planning discomfort mitigation for cystoscopy (P<0.001). On multivariable analysis, gender was the only factor independently associated with discomfort, with women reporting less discomfort than men (OR 0.59, 95%CI 0.37-0.95,P=0.03). Patients reported a wide variety of cystoscopy-specific interventions with differing perceived effectiveness, the most common being intraurethral lidocaine., Conclusions: Over half of patients undergoing office-based cystoscopy for bladder cancer report moderate-to-severe discomfort, constituting a substantial problem among patients undergoing the procedure. Future large pragmatic comparative effectiveness trials are needed to better understand which interventions work most effectively to reduce discomfort associated with cystoscopy., Competing Interests: Conflict of Interest JBK: Arquer and Photocure Medical Advisor; YL: Consultant C2I genomics, Photocure, Astra-Zeneca, Merck, Fergene, Abbvie, Cleveland Diagnostic, BMS, Nucleix, Investigaor for Photocure, Abbott, Cepheid, Pacific Edge, FKD, MDxHealth, Biocancell, Storz, Leadership in Vessi Medical and CAPs Medical; JG: Investigator for FerGene; AS: Investigator for Urogen, Consultant for FerGene, Urogen, Merck;, (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: For many patients with cancer, the frequency of surveillance after primary treatment depends on the risk for cancer recurrence or progression. Lack of risk-aligned surveillance means too many unnecessary surveillance procedures for low-risk patients and not enough for high-risk patients. Using bladder cancer as an example, we examined whether practice determinants differ between Department of Veterans Affairs sites where risk-aligned surveillance was more (risk-aligned sites) or less common (need improvement sites)., Methods: We used our prior quantitative data to identify two risk-aligned sites and four need improvement sites. We performed semistructured interviews with 40 Veterans Affairs staff guided by the Tailored Implementation for Chronic Diseases framework that were deductively coded. We integrated quantitative data (risk-aligned site v need improvement site) and qualitative data from interviews, cross-tabulating salient determinants by site type., Results: There were 14 participants from risk-aligned sites and 26 participants from need improvement sites. Irrespective of site type, we found a lack of knowledge on guideline recommendations. Additional salient determinants at need improvement sites were a lack of resources ("the next available without overbooking is probably seven to eight weeks out") and an absence of routines to incorporate risk-aligned surveillance ("I have my own guidelines that I've been using for 35 years")., Conclusion: Knowledge, resources, and lack of routines were salient barriers to risk-aligned bladder cancer surveillance. Implementation strategies addressing knowledge and resources can likely contribute to more risk-aligned surveillance. In addition, reminders for providers to incorporate risk into their surveillance plans may improve their routines., Competing Interests: Florian R. SchroeckOther Relationship: Sesen BioNo other potential conflicts of interest were reported.

Objective: To evaluate the effect of a preexisting posttraumatic stress disorder (PTSD) diagnosis on suicide and non-suicide mortalities among men with newly diagnosed prostate cancer, and examine potential mediating factors for the relationship between PTSD and suicide., Methods: We used patient-level data from Veterans Health Administration electronic medical records to identify men (age ≥40 years) diagnosed with prostate cancer between 2004 and 2014. We used Fine and Gray regression model to estimate the risk for competing mortality outcomes (suicide, non-suicide, and alive). We used structural equation models to evaluate the mediating factors., Results: Our cohort comprised 214,649 men with prostate cancer, of whom 12,208 (5.7%) had a preexisting PTSD diagnosis. Patients with PTSD compared to those without utilized more healthcare services and had lower risk cancer at diagnosis. Additionally, they experienced more suicide deaths (N = 26, 0.21% vs. N = 269, 0.13%) and fewer non-suicide deaths (N = 1399, 11.5% vs. N = 45,625, 22.5%). On multivariable analysis, PTSD was an independent suicide risk factor (HR = 2.35; 95% CI: 1.16, 4.78). Depression, substance use disorder, and any definitive prostate cancer treatment were partial mediators. However, PTSD was associated with lower non-suicide mortality risk (HR = 0.86; 95% CI: 0.77, 0.96)., Conclusion: Patients with PTSD experienced greater suicide risk even after adjusting for important mediators. They may have experienced lower non-suicide mortality risk due to favorable physical health resulting from greater healthcare service use and early diagnosis of lower risk cancer. Our findings highlight the importance of considering psychiatric illnesses when treating patients with prostate cancer and the need for interventions to ameliorate suicide risk., (Published 2020. This article is a U.S. Government work and is in the public domain in the USA.)

Background: It is important to understand the implications of reduced bacillus Calmette-Guérin (BCG) treatment intensity, given global shortages and early termination of the NIMBUS trial., Objective: To assess the association of partial versus complete BCG induction with outcomes., Design Setting and Participants: This is a retrospective cohort study of veterans diagnosed with high-risk non-muscle-invasive bladder cancer (NMIBC; high grade [HG] Ta, T1, or carcinoma in situ) between 2005 and 2011 with follow-up through 2014., Intervention: Patients were categorized into partial versus complete BCG induction (one to five vs five or more instillations). Partial BCG induction subgroups were defined for comparison with the NIMBUS trial., Outcome Measurements and Statistical Analysis: Propensity score-adjusted regression models were used to assess the association of partial BCG induction with risk of recurrence and bladder cancer death., Results and Limitations: Among 540 patients, 114 (21.1%) underwent partial BCG induction. Partial versus complete BCG induction was not significantly associated with the risk of recurrence in HG Ta (cumulative incidence [CIn] 46.6% vs 53.9% at 5 yr, p  =  0.38) or T1 (CIn 47.1% vs 56.7 at 5 yr, p  = 0.19) disease. Similarly, we found no increased risk of bladder cancer death (HG Ta: CIn 4.7%7vs 5.4% at 5 yr, p  = 0.87; T1: CIn 10.0% vs 11.4% at 5 yr, p  =  0.77). NIMBUS-like induction was associated with an increased risk of recurrence in patients with HG Ta disease, although not statistically significant. Unmeasured confounding is a limitation., Conclusions: Cancer outcomes were similar among high-risk NMIBC patients who underwent partial versus complete BCG induction, suggesting that future research is needed to determine how to optimize BCG delivery for the greatest number of patients, especially during global shortages., Patient Summary: Outcomes were similar between patients receiving partial and complete courses of bacillus Calmette-Guérin (BCG) therapy. Future research is needed to determine how to best deliver BCG to the greatest number of patients, particularly during medication shortages.

Efforts to improve cancer care primarily come from two fields: improvement science and implementation science. The two fields have developed independently, yet they have potential for synergy. Leveraging that synergy to enhance alignment could both reduce duplication and, more importantly, enhance the potential of both fields to improve care. To better understand potential for alignment, we examined 20 highly cited cancer-related improvement science and implementation science studies published in the past 5 years, characterizing and comparing their objectives, methods, and approaches to practice change. We categorized studies as improvement science or implementation science based on authors' descriptions when possible; otherwise, we categorized studies as improvement science if they evaluated efforts to improve the quality, value, or safety of care, or implementation science if they evaluated efforts to promote the implementation of evidence-based interventions into practice. All implementation studies (10/10) and most improvement science studies (6/10) sought to improve uptake of evidence-based interventions. Improvement science and implementation science studies employed similar approaches to change practice. For example, training was employed in 8/10 implementation science studies and 4/10 improvement science studies. However, improvement science and implementation science studies used different terminology to describe similar concepts and emphasized different methodological aspects in reporting. Only 4/20 studies (2 from each category) described using a formal theory or conceptual framework to guide program development. Most studies were multi-site (10/10 implementation science and 6/10 improvement science) and a minority (2 from each category) used a randomized design. Based on our review, cancer-related improvement science and implementation science studies use different terminology and emphasize different methodological aspects in reporting but share similarities in purpose, scope, and methods, and are at similar levels of scientific development. The fields are well-positioned for alignment. We propose that next steps include harmonizing language and cross-fertilizing methods of program development and evaluation.

Objective: To examine three aspects of urologist practice structure that may affect quality of prostate cancer care: practice size, ownership of an intensity modulated radiation therapy (IMRT) device, participation within a multi-specialty group (MSG). Health care reforms focused on improving quality are particularly relevant for prostate cancer given its prevalence and concerns for overdiagnosis and overtreatment., Methods: Using data from the Surveillance, Epidemiology and End-Results (SEER)-Medicare linked registry, we examined quality of prostate cancer treatment according to each treating urologist's practice size, type (single-specialty vs. MSG) and ownership of IMRT. Mixed models were used to adjust for patient differences., Results: We identified 22,412 men with newly diagnosed prostate cancer treated by 2,199 urologists during the study. We observed minimal differences for most quality metrics according to practice size, type, and ownership of IMRT. Adherence to all eligible quality metrics was better among MSGs compared to single specialty groups (20.0% adherence versus 18.2%, p=0.01) whereas there was no significant difference by ownership of IMRT (17.1% adherence in owners versus 18.9% non-owners, p=0.09)., Conclusion: Differences in quality across practice size, type and ownership of IMRT were modest, with substantial room for improvement regardless of practice structure., Competing Interests: Disclosures:The authors have no conflicts of interest related to this work.

Purpose: Many patients living with bladder cancer do not undergo surveillance that is aligned with their risk for recurrence or progression, which exposes them to unnecessary risk and burden of procedures. To implement risk-aligned surveillance as recommended by multiple guidelines, we need to understand patient-, provider-, and system-level factors contributing to the delivery of risk-aligned surveillance. In this study, we sought to systematically assess patient-level factors., Participants and Methods: Guided by the Tailored Implementation for Chronic Diseases framework, we conducted semistructured interviews with 22 patients with bladder cancer undergoing surveillance cystoscopy procedures at three facilities within the Department of Veterans Affairs. Patients were sampled using quantitative data on bladder cancer risk category (low v high) and on surveillance category (aligned v not aligned with cancer risk). Interview transcripts were analyzed using a priori codes from the Tailored Implementation for Chronic Diseases framework. Quantitative and qualitative data were integrated by cross-tabulating determinants across risk and surveillance categories., Results: Participants included seven low-risk and 15 high-risk patients; 10 underwent risk-aligned surveillance and 12 did not. In mixed-methods analyses, perception of risk appropriately differed by risk but not by surveillance category. Participants understood the recommended surveillance schedule according to their risk category. Participants emphatically expressed that adhering to providers' recommendations is prudent; intentions to adhere did not vary across risk and surveillance categories., Conclusion: Participants intended to adhere to providers' recommendations and strongly endorsed the importance of adherence. These findings suggest implementation strategies to improve risk-aligned surveillance may be most effective when targeting provider- and system-level factors rather than patient-level factors.

Purpose: To assess the association of low- vs. guideline-recommended high-intensity cystoscopic surveillance with outcomes among patients with high-risk non-muscle invasive bladder cancer (NMIBC)., Materials & Methods: A retrospective cohort study of Veterans Affairs patients diagnosed with high-risk NMIBC between 2005 and 2011 with follow-up through 2014. Patients were categorized by number of surveillance cystoscopies over two years following diagnosis: low- (1-5) vs. high-intensity (6 or more) surveillance. Propensity score adjusted regression models were used to assess the association of low-intensity cystoscopic surveillance with frequency of transurethral resections, and risk of progression to invasive disease and bladder cancer death., Results: Among 1,542 patients, 520 (33.7%) underwent low-intensity cystoscopic surveillance. Patients undergoing low-intensity surveillance had fewer transurethral resections (37 vs. 99 per 100 person-years; p<0.001). Risk of death from bladder cancer did not differ significantly by low (cumulative incidence [CIn] 8.4% [95% CI 6.5-10.9) at 5 years) vs. high-intensity surveillance (CIn 9.1% [95% CI 7.4-11.2) at 5 years, p = 0.61). Low vs. high-intensity surveillance was not associated with increased risk of bladder cancer death among patients with Ta (CIn 5.7% vs. 8.2% at 5 years p = 0.24) or T1 disease at diagnosis (CIn 10.2% vs. 9.1% at 5 years, p = 0.58). Among patients with Ta disease, low-intensity surveillance was associated with decreased risk of progression to invasive disease (T1 or T2) or bladder cancer death (CIn 19.3% vs. 31.3% at 5 years, p = 0.002)., Conclusions: Patients with high-risk NMIBC undergoing low- vs. high-intensity cystoscopic surveillance underwent fewer transurethral resections, but did not experience an increased risk of progression or bladder cancer death. These findings provide a strong rationale for a clinical trial to determine whether low-intensity surveillance is comparable to high-intensity surveillance for cancer control in high-risk NMIBC., Competing Interests: The authors have declared that no competing interests exist.

Background: Longer time intervals from presentation with hematuria to bladder cancer diagnosis have been reported among women compared with men. Despite women being the fastest growing cohort within the Department of Veterans Affairs, little is known about women veterans with bladder cancer. Our objectives were to quantify the time from hematuria to bladder cancer diagnosis in Department of Veterans Affairs and assess differences between sexes., Methods: This was a retrospective cohort study of patients diagnosed with bladder cancer from 2001 to 2016. Included were patients with hematuria for fewer than 365 days before a bladder cancer diagnosis and who had a record of diagnostic cystoscopy after hematuria but before diagnosis. We evaluated the number of days from hematuria to diagnostic cystoscopy (clinical appraisal), cystoscopy to bladder cancer diagnosis (surgical appraisal), and hematuria to bladder cancer diagnosis (total diagnostic appraisal). We used quantile regression models to separately evaluate the effect of sex on the three appraisal intervals., Results: Data from 213 women and 24,295 men were analyzed. The median clinical appraisal time was 78 days for women and 72 for men (p = .49). The median surgical appraisal time was 32 days for women and 33 for men (p = .74). The median total diagnostic appraisal time was 135 days for women and 130 for men (p = .71). Multivariable analyses showed no differences between men and women for any of the three appraisal intervals., Conclusions: The majority of time from hematuria to bladder cancer diagnosis is spent in clinical appraisal, but little difference was observed between men and women in Department of Veterans Affairs., (Published by Elsevier Inc.)

Background: Surveillance recommendations for patients with low-risk, non-muscle-invasive bladder cancer (NMIBC) are based on limited evidence. The objective of this study was to add to the evidence by assessing outcomes after frequent versus recommended cystoscopic surveillance., Methods: This was a retrospective cohort study of patients diagnosed with low-risk (low-grade Ta (AJCC)) NMIBC from 2005 to 2011 with follow-up through 2014 from the Department of Veterans Affairs. Patients were classified as having undergone frequent versus recommended cystoscopic surveillance (>3 vs 1-3 cystoscopies in the first 2 years after diagnosis). By using propensity score-adjusted models, the authors estimated the impact of frequent cystoscopy on the number of transurethral resections, the number of resections without cancer in the specimen, and the risk of progression to muscle-invasive cancer or bladder cancer death., Results: Among 1042 patients, 798 (77%) had more frequent cystoscopy than recommended. In adjusted analyses, the frequent cystoscopy group had twice as many transurethral resections (55 vs 26 per 100 person-years; P < .001) and more than 3 times as many resections without cancer in the specimen (5.7 vs 1.6 per 100 person-years; P < .001). Frequent cystoscopy was not associated with time to progression or bladder cancer death (3% at 5 years in both groups; P = .990)., Conclusions: Frequent cystoscopy among patients with low-risk NMIBC was associated with twice as many transurethral resections and did not decrease the risk for bladder cancer progression or death, supporting current guidelines., (© 2019 American Cancer Society.)

Objective: To understand cystoscopic surveillance practices among patients with low-risk non-muscle-invasive bladder cancer (NMIBC) within the Department of Veterans Affairs (VA)., Methods: Using a validated natural language processing algorithm, we included patients newly diagnosed with low-risk (ie low-grade Ta) NMIBC from 2005 to 2011 in the VA. Patients were followed until cancer recurrence, death, last contact, or 2 years after diagnosis. Based on guidelines, surveillance overuse was defined as >1 cystoscopy if followed <1 year, >2 cystoscopies if followed 1 to <2 years, or >3 cystoscopies if followed for 2 years. We identified patient, provider, and facility factors associated with overuse using multilevel logistic regression., Results: Overuse occurred in 75% of patients (852/1135) - with an excess of 1846 more cystoscopies performed than recommended. Adjusting for 14 factors, overuse was associated with patient race (odds ratio [OR] 0.49, 95% confidence interval [CI]: 0.28, 0.85 unlisted race vs White), having 2 comorbidities (OR 1.60, 95% CI: 1.00, 2.55 vs no comorbidities), and earlier year of diagnosis (OR 2.50, 95% CI: 1.29, 4.83 for 2005 vs 2011, and OR 2.03, 95% CI: 1.11, 3.69 for 2006 vs 2011). On sensitivity analyses assuming all patients were diagnosed with multifocal or large low-grade tumors (ie, intermediate-risk), overuse would have still occurred in 45% of patients., Conclusion: Overuse of cystoscopy among patients with low-risk NMIBC was common, raising concerns about bladder cancer surveillance cost and quality. However, few factors were associated with overuse. Further qualitative research is needed to identify other determinants of overuse not readily captured in administrative data., (Published by Elsevier Inc.)

Objective: To investigate the impact of urologist practice structure on health care spending for men with prostate cancer. We hypothesize that 3 elements of urologist practice structure may influence spending for prostate cancer care: urologist participation within a multispecialty group (MSG), practice size among single specialty urology groups, and intensity-modulated radiation therapy (IMRT) ownership., Materials and Methods: We used a 20% sample of fee-for-service Medicare beneficiaries to identify men newly diagnosed with prostate cancer between 2011 and 2014. We identified each man's urologist and used data from the Healthcare Relational Spheres provider files to identify practice type, size, and IMRT ownership for each urologist. We then fit generalized linear mixed models to estimate the association between these practice features and Medicare payments in the year after diagnosis. All models were adjusted for patient and healthcare market characteristics., Results: We identified 35,929 men with newly diagnosed prostate cancer who were treated by 6381 urologists. Medicare payments for men with newly diagnosed prostate cancer were significantly lower in MSGs ($19,181 v. $22,366 large single specialty group, P < 0.001) and significantly higher among practices with IMRT ownership ($23,801 v. $20,162 for non-owners, P < 0.001). These differences persisted in sensitivity analyses including only men treated with radiotherapy and examining only prostate cancer-related claims., Conclusion: Urologist practice structure is associated with payments for prostate cancer care. MSGs had the lowest Medicare payments per episode of prostate cancer care while groups with IMRT ownership had the highest., (Copyright © 2019. Published by Elsevier Inc.)

Background and Objective: Hybrid operating room suites with intraoperative magnetic resonance imaging enable image guided surgery in a fully functional operating room environment. While this environment creates challenges to anesthetic care, the effects on anesthetic adverse events and outcomes are largely unknown. This systematic scoping review aims to map the existing knowledge about anesthetic care in advanced imaging hybrid operating rooms., Methods: A broad-based literature search was performed using the PubMed (Medline), Embase, Cochrane Library, Web of Science, and Google Scholar databases. References published in English between January 1994 and August 2017 were included. Quality of evidence was assessed using the GRADE guidelines., Results: Forty-seven manuscripts were eligible for data collection. Adverse events were heterogeneously defined across 17 manuscripts and occurred in 0 to 100% (quality of evidence mostly very low). Monitoring difficulty was reported in 4 manuscripts of very low data quality. Interference between the magnet and the electrocardiogram was investigated in 2 manuscripts (quality of evidence low and very low, respectively). None of the reported events appeared to result in long-term patient harm. Author recommendations or a narrative review of the literature were provided in 40 manuscripts. Common safety concerns included lower equipment reliability, inaccessibility of the patient and airway, and the relative isolation of the suite (in relationship to other anesthesia care areas). Most authors also emphasized the importance of safety checklists, protocols, and provider training., Discussion: While intraoperative magnetic resonance imaging hybrid operating rooms are increasingly utilized, the existing literature does not allow estimating adverse event rates in this location. Prospective studies quantifying the effect of the environment on anesthesia outcomes are lacking. Despite this, there is a broad consensus regarding the anesthetic and safety concerns. More research is needed to inform practice standards and training requirements for this challenging environment., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The high rate of non-muscle-invasive bladder cancer recurrence is a major challenge in patient management. miRNAs functionally regulate tumor cell proliferation and invasion, and have strong potential as biomarkers because they are robust to degradation. The objective of this project was to identify reproducible prognostic miRNAs in resected non-muscle-invasive bladder tumor tissue that are predictive of the recurrent tumor phenotype., Methods: We utilized patients diagnosed with primary non-muscle-invasive bladder cancer in three independent cohorts for a biomarker discovery/validation approach. Baseline tumor tissue from patients with the clinically challenging, non-muscle-invasive primary low stage (Ta), high grade, and T1 tumors (tumors extending into the lamina propria) comprised the discovery cohort ( n = 38). We isolated the tumor tissue RNA and assessed a panel of approximately 800 miRNAs., Results: miR-26b-5p was the top-ranking prognostic tumor tissue miRNA, with a time-to-recurrence HR 0.043 for levels above versus below median, ( P adj = 0.0003). miR-26b-5p was related to a dose-response reduction in tumor recurrence, and levels above the median were also associated with reduced time-to-progression ( P adj = 0.02). We used two independent longitudinal cohorts that included both low-grade and high-grade Ta and T1 tumors for validation and found a consistent relationship between miR-26b-5p and recurrence and progression., Conclusions: Our results suggest that miR-26b-5p levels may be prognostic for non-muscle-invasive bladder cancer recurrence, and can feasibly be assessed in baseline tumor tissue from a wide variety of clinical settings., Impact: Early identification of those non-muscle-invasive bladder tumor patients with refractory phenotypes would enable individualized treatment and surveillance., (©2019 American Association for Cancer Research.)

Objective: To assess geographic variation in cystoscopy rates among women vs men with suspected bladder cancer, lending insight into gender-specific differences in cystoscopic evaluation., Methods: We conducted a cross-sectional study of all fee-for-service Medicare beneficiaries within 306 Hospital Referral Regions (HRRs) who received care in 2014. For each HRR, we calculated the age- and race-adjusted cystoscopy rate for women and men as our primary outcome. The rate was the number of beneficiaries who underwent cystoscopy for bladder cancer symptoms (using procedure and ICD-9 diagnosis codes) divided by all beneficiaries in the HRR. We used the coefficient of variation to compare relative variability of cystoscopy rates., Results: Overall, 173,551 women (n = 14.8 million) and 286,090 men (n = 11.5 million) underwent cystoscopy in 2014. While women received less cystoscopies compared to men (mean 11.0 vs 23.5 per 1000, P < .001), there was greater variation in cystoscopy rates among women (coefficient of variation 27.5 vs 23.5, P = .010). When restricting to ICD-9 codes for hematuria only, women continued to demonstrate greater variation in cystoscopy rates (coefficient of variation 27.8 vs 24.2, P = .022). Findings were robust across larger HRR sizes-thereby removing some random variation seen in smaller HRRs-as well as across years 2010, 2011, 2012, and 2013., Conclusion: Cystoscopy rates are lower in women than men, likely due to their lower bladder cancer incidence. However, there is greater variation in cystoscopy rates among women with symptoms of bladder cancer. This may reflect increased provider uncertainty whether to refer and work-up women with suspected bladder cancer., (Copyright © 2018. Published by Elsevier Inc.)

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., Competing Interests: Conflict of Interest Disclosures: Dr Schroeck is site primary investigator (without compensation) for a clinical trial of Vicinium, sponsored by Eleven Biotherapeutics. Mr Seigne owns 100 common stock of Johnson & Johnson. No other disclosures were reported.

Objective: To determine if Accountable Care Organizations (ACOs) have the potential to accelerate the impact of prostate cancer screening recommendations., Methods: We performed a retrospective cohort study using Medicare data evaluating the rates of PSA testing and prostate biopsy among men without prostate cancer between 2011 and 2014. We assessed PSA testing and biopsy rates before and after policy implementation among patients of ACO and non-ACO-aligned physicians. To control for secular trends, difference-in-differences methods were used to determine the effects of ACO implementation., Results: We identified 1.1 million eligible men without prostate cancer. From 2011 to 2014, the rates of PSA testing and biopsy declined by 22.3% and 7.0%, respectively. PSA testing declined similarly regardless of ACO participation-from 618 to 530 tests per 1000 beneficiaries among ACO-aligned physicians and from 607 to 516 tests per 1000 beneficiaries among non-ACO-aligned physicians (difference-in-differences P = .11). Whereas rates of prostate biopsy remained constant for patients of non-ACO-aligned physicians at 12 biopsies per 1000 beneficiaries, these rates increased from 11.6 to 12.5 biopsies per 1000 beneficiaries of patients of ACO-aligned physicians (difference-in-differences P = .03)., Conclusion: PSA testing and prostate biopsy rates decreased significantly between 2011 and 2014. The rate of PSA testing was not differentially affected by ACO participation. Conversely, there was an increase in the rate of prostate biopsy among patients of ACO-aligned physicians. ACOs did not accelerate deimplementation of PSA testing for eligible Medicare beneficiaries without prostate cancer., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Implementation science is a rapidly developing field dedicated to the scientific investigation of strategies to facilitate improvements in healthcare delivery. These strategies have been shown in several settings to lead to more complete and sustained change. In this essay, we discuss how refined surveillance recommendations for non-muscle-invasive bladder cancer, which involve a complex interplay between providers, healthcare facilities, and patients, could benefit from use of implementation strategies derived from the growing literature of implementation science. These surveillance recommendations are based on international consensus and indicate that the frequency of surveillance cystoscopy should be aligned with each patient's risk for recurrence and progression of disease. Risk-aligned surveillance entails cystoscopy at 3 and 12 months followed by annual surveillance for low-risk cancers, with surveillance every 3 months reserved for high-risk cancers. However, risk-aligned care is not the norm. Implementing risk-aligned surveillance could curtail overuse among low-risk patients, while curbing underuse among high-risk patients. Despite clear direction from respected and readily available clinical guidelines, there are multiple challenges to implementing risk-aligned surveillance in a busy clinical setting. Here, we describe how implementation science methods can be systematically used to understand determinants of care and to develop strategies to improve care. We discuss how the tailored implementation for chronic diseases framework can facilitate systematic assessment and how intervention mapping can be used to develop implementation strategies to improve care. Taken together, these implementation science methods can help facilitate practice transformation to improve risk-aligned surveillance for bladder cancer., (Published by Elsevier Inc.)

Background: Prostate cancer treatment is a significant source of morbidity and spending. Some men with prostate cancer, particularly those with significant health problems, are unlikely to benefit from treatment., Objective: To assess relationships between financial incentives associated with urologist ownership of radiation facilities and treatment for prostate cancer., Design, Setting, and Participants: A retrospective cohort of Medicare beneficiaries with prostate cancer diagnosed between 2010 and 2012. Patients were further classified by their risk of dying from noncancer causes in the 10 yr following their cancer diagnosis by using a mortality model derived from comparable patients known to be cancer-free., Intervention: Urologists were categorized by their practice affiliation (single-specialty groups by size, multispecialty group) and ownership of a radiation facility., Outcome Measurements and Analysis: Use of intensity-modulated radiation therapy (IMRT) and use of any treatment within 1 yr of diagnosis. Generalized estimating equations were used to adjust for patient differences., Results: Among men with newly diagnosed prostate cancer, use of IMRT ranged from 24% in multispecialty groups to 37% in large urology groups (p<0.001). Patients managed in groups with IMRT ownership (n=5133) were more likely to receive IMRT than those managed by single-specialty groups without ownership (43% vs 30%, p<0.001), regardless of group size. Among patients with a very high risk (> 75%) of noncancer mortality within 10 yr of diagnosis, both IMRT use (42% vs 26%, p<0.001) and overall treatment (53% vs 44%, p<0.001) were more likely in groups with ownership than in those without, respectively., Conclusions: Urologists practicing in single-specialty groups with an ownership interest in radiation therapy are more likely to treat men with prostate cancer, including those with a high risk of noncancer mortality., Patient Summary: We assessed treatment for prostate cancer among urologists with varying levels of financial incentives favoring intervention. Those with stronger incentives, as determined by ownership interest in a radiation facility, were more likely to treat prostate cancer, even when treatment was unlikely to provide a survival benefit to the patient., (Copyright © 2017 European Association of Urology. All rights reserved.)

Importance: While computed tomography (CT) represents a tremendous advance in diagnostic imaging, it also creates the problem of incidental detection-the identification of tumors unrelated to the clinical symptoms that initiate the test., Objective: To determine the geographic variation in the United States in CT imaging and the corresponding association with one of the most consequential sequelae of incidental detection: nephrectomy., Design, Setting, and Participants: This study is a cross-sectional analysis of age-, sex-, and race-adjusted Medicare data (January 2010-December 2014) from 306 hospital referral regions (HRRs) in the United States and includes information from 15 million fee-for-service Medicare beneficiaries age 65 to 85 years., Exposures: Regional CT risk (ie, the proportion of the population receiving either a chest or abdominal CT over 5 years)., Main Outcomes and Measures: Five-year risk of nephrectomy (partial or total)., Results: Data from 15 million fee-for-service Medicare beneficiaries age 65 to 85 years were gathered and illustrate that 43% of Medicare beneficiaries age 65 to 85 years received either a chest or abdominal CT from January 2010 to December 2014. This risk varied across the HRRs, ranging from 31% in Santa Cruz, California, to 52% in Sun City, Arizona. Increased regional CT risk was associated with a higher nephrectomy risk (r = 0.38; 95% CI, 0.28-0.47), particularly among HRRs with more than 50 000 beneficiaries (r = 0.47; 95% CI, 0.31-0.61). After controlling for HRR adult smoking rates, imaging an additional 1000 beneficiaries was associated with 4 additional nephrectomies (95% CI, 3-5). Case-fatality rates for those who underwent nephrectomy were 2.1% at 30 days and 4.3% at 90 days., Conclusions and Relevance: Fee-for-service Medicare beneficiaries are commonly exposed to CT imaging. Those residing in high-scanning regions face a higher risk of nephrectomy, presumably reflecting the incidental detection of renal masses. Additional surgery should be considered one of the risks of excessive CT imaging.

Objective: To take the first step toward assembling population-based cohorts of patients with bladder cancer with longitudinal pathology data, we developed and validated a natural language processing (NLP) engine that abstracts pathology data from full-text pathology reports., Methods: Using 600 bladder pathology reports randomly selected from the Department of Veterans Affairs, we developed and validated an NLP engine to abstract data on histology, invasion (presence vs absence and depth), grade, the presence of muscularis propria, and the presence of carcinoma in situ. Our gold standard was based on an independent review of reports by 2 urologists, followed by adjudication. We assessed the NLP performance by calculating the accuracy, the positive predictive value, and the sensitivity. We subsequently applied the NLP engine to pathology reports from 10,725 patients with bladder cancer., Results: When comparing the NLP output to the gold standard, NLP achieved the highest accuracy (0.98) for the presence vs the absence of carcinoma in situ. Accuracy for histology, invasion (presence vs absence), grade, and the presence of muscularis propria ranged from 0.83 to 0.96. The most challenging variable was depth of invasion (accuracy 0.68), with an acceptable positive predictive value for lamina propria (0.82) and for muscularis propria (0.87) invasion. The validated engine was capable of abstracting pathologic characteristics for 99% of the patients with bladder cancer., Conclusion: NLP had high accuracy for 5 of 6 variables and abstracted data for the vast majority of the patients. This now allows for the assembly of population-based cohorts with longitudinal pathology data., (Published by Elsevier Inc.)

Context: Some of the high costs of robot-assisted radical prostatectomy (RARP), intensity-modulated radiotherapy (IMRT), and proton beam therapy may be offset by better outcomes or less resource use during the treatment episode., Objective: To systematically review the literature to identify the key economic trade-offs implicit in a particular treatment choice for prostate cancer., Evidence Acquisition: We systematically reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement and protocol. We searched Medline, Embase, and Web of Science for articles published between January 2001 and July 2016, which compared the treatment costs of RARP, IMRT, or proton beam therapy to the standard treatment. We identified 37, nine, and three studies, respectively., Evidence Synthesis: RARP is costlier than radical retropubic prostatectomy for hospitals and payers. However, RARP has the potential for a moderate cost advantage for payers and society over a longer time horizon when optimal cancer and quality-of-life outcomes are achieved. IMRT is more expensive from a payer's perspective compared with three-dimensional conformal radiotherapy, but also more cost effective when defined by an incremental cost effectiveness ratio <$50 000 per quality-adjusted life year. Proton beam therapy is costlier than IMRT and its cost effectiveness remains unclear given the limited comparative data on outcomes. Using the Grades of Recommendation, Assessment, Development and Evaluation approach, the quality of evidence was low for RARP and IMRT, and very low for proton beam therapy., Conclusions: Treatment with new versus traditional technologies is costlier. However, given the low quality of evidence and the inconsistencies across studies, the precise difference in costs remains unclear. Attempts to estimate whether this increased cost is worth the expense are hampered by the uncertainty surrounding improvements in outcomes, such as cancer control and side effects of treatment. If the new technologies can consistently achieve better outcomes, then they may be cost effective., Patient Summary: We review the cost and cost effectiveness of robot-assisted radical prostatectomy, intensity-modulated radiotherapy, and proton beam therapy in prostate cancer treatment. These technologies are costlier than their traditional counterparts. It remains unclear whether their use is associated with improved cure and reduced morbidity, and whether the increased cost is worth the expense., (Published by Elsevier B.V.)

Objective: To examine discomfort, anxiety, and preferences for decision making in patients undergoing surveillance cystoscopy for non-muscle-invasive bladder cancer (NMIBC)., Methods: Veterans with a prior diagnosis of NMIBC completed validated survey instruments assessing procedural discomfort, worry, and satisfaction, and were invited to participate in semistructured focus groups about their experience and desire to be involved in surveillance decision making. Focus group transcripts were analyzed qualitatively, using (1) systematic iterative coding, (2) triangulation involving multiple perspectives from urologists and an implementation scientist, and (3) searching and accounting for disconfirming evidence., Results: Twelve patients participated in 3 focus groups. Median number of lifetime cystoscopy procedures was 6.5 (interquartile range 4-10). Based on survey responses, two-thirds of participants (64%) experienced some degree of procedural discomfort or worry, and all participants reported improvement in at least 2 dimensions of overall well-being following cystoscopy. Qualitative analysis of the focus groups indicated that participants experience preprocedural anxiety and worry about their disease. Although many participants did not perceive themselves as having a defined role in decision making surrounding their surveillance care, their preferences to be involved in decision making varied widely, ranging from acceptance of the physician's recommendation, to uncertainty, to dissatisfaction with not being involved more in determining the intensity of surveillance care., Conclusion: Many patients with NMIBC experience discomfort, anxiety, and worry related to disease progression and not only cystoscopy. Although some patients are content to defer surveillance decisions to their physicians, others prefer to be more involved. Future work should focus on defining patient-centered approaches to surveillance decision making., (Published by Elsevier Inc.)

Background: Despite the high prevalence of bladder cancer, research on optimal bladder cancer care is limited. One way to advance observational research on care is to use linked data from multiple sources. Such big data research can provide real-world details of care and outcomes across a large number of patients. We assembled and validated such data including (1) administrative data from the Department of Veterans Affairs (VA), (2) Medicare claims, (3) data abstracted by tumor registrars, (4) data abstracted via chart review from the national electronic health record, and (5) full text pathology reports., Methods: Based on these combined data, we used administrative data to identify patients with newly diagnosed bladder cancer who received care in the VA. To validate these data, we first compared the diagnosis date from the administrative data to that from the tumor registry. Second, we measured accuracy of identifying bladder cancer care in VA administrative data, using a random chart review (n = 100) as gold standard. Lastly, we compared the proportion of patients who received bladder cancer care among those who did versus did not have full text bladder pathology reports available, expecting that those with reports are significantly more likely to receive care in VA., Results: Out of 26,675 patients, 11,323 (42%) had tumor registry data available. 90% of these patients had a difference of 90 days or less between the diagnosis dates from administrative and registry data. Among 100 patients selected for chart review, 59 received bladder cancer care in VA, 58 of which were correctly identified using administrative data (sensitivity 98%, specificity 90%). Receipt of bladder cancer care was substantially more common among those who did versus did not have bladder pathology available (96% vs. 43%, p < 0.001)., Conclusion: Merging administrative with electronic health record and pathology data offers new possibilities to validate the use of administrative data in bladder cancer research.

Background: Several new prostate cancer treatments have emerged since 2000, including 2 radiotherapies with similar efficacy at the time of their introduction: intensity-modulated radiotherapy (IMRT) and stereotactic body radiation therapy (SBRT). The objectives of this study were to compare their early adoption patterns and identify factors associated with their use., Methods: By using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, patients who received radiation therapy during the 5 years after IMRT introduction (2001-2005) and the 5 years after SBRT introduction (2007-2011) were identified. The outcome of interest was the receipt of new radiation therapy (ie, IMRT or SBRT) compared with the existing standard radiation therapies at that time. The authors fit a series of multivariable, hierarchical logistic regression models accounting for patients nested within health service areas to examine the factors associated with the receipt of new radiation therapy., Results: During 2001 to 2005, 5680 men (21%) received IMRT compared with standard radiation (n = 21,555). Men who received IMRT were older, had higher grade tumors, and lived in more populated areas (P < .05). During 2007 through 2011, 595 men (2%) received SBRT compared with standard radiation (n = 28,255). Men who received ng SBRT were more likely to be white, had lower grade tumors, lived in more populated areas, and were more likely to live in the Northeast (P < .05). Adjusting for cohort demographic and clinical factors, the early adoption rate for IMRT was substantially higher than that for SBRT (44% vs 4%; P < .01)., Conclusions: There is a stark contrast in the adoption rates of IMRT and SBRT at the time of their introduction. Further investigation of the nonclinical factors associated with this difference is warranted. Cancer 2017;123:2945-54. © 2017 American Cancer Society., (© 2017 American Cancer Society.)

Introduction: Evidence-based guidelines are published by the AUA (American Urological Association) to improve the quality and consistency of urological care. The 2014 AUA Census reported a unique field regarding provider utilization of AUA Guidelines. We sought to identify factors associated with nonuse of AUA Guidelines to understand how education and dissemination of these guidelines might be improved., Methods: Using 2014 AUA Census data providers were stratified based on self-reported use or nonuse of AUA Guidelines. Bivariate analyses and multivariable logistic regression analysis were performed to identify factors associated with nonuse. Post-stratification weights were applied to calculate national estimates with SAS®, version 9.4., Results: The 2,202 survey respondents represented 11,680 practicing urologists. AUA guideline use was reported by 95.0% of the weighted population. There was no significant difference in utilization based on gender, race, country of origin, practice type or fellowship completion. After controlling for other variables urologists who reported practicing in a rural area were more likely to be nonusers (OR 1.06, 95% CI 1.03-1.09). Additionally, urologists who had been practicing longer were less likely to utilize guidelines compared with those earlier in the career (practicing 10 to 20 years OR 1.15, 95% CI 1.10-1.21 and more than 20 years OR 1.13, 95% CI 1.09-1.18, p <0.05)., Conclusions: Despite continued publication and dissemination of AUA Guidelines about 5% of urologists do not utilize guidelines. Later career status and rural geography were associated with nonuse. These data may inform efforts to improve dissemination and education regarding evidence-based practice.

Purpose: The delivery of high quality prostate cancer care is increasingly important for health systems, physicians and patients. Integrated delivery systems may have the greatest ability to deliver high quality, efficient care. We sought to understand the association between health care integration and quality of prostate cancer care., Materials and Methods: We used SEER-Medicare data to perform a retrospective cohort study of men older than age 65 with prostate cancer diagnosed between 2007 and 2011. We defined integration within a health care market based on the number of discharges from a top 100 integrated delivery system, and compared rates of adherence to well accepted prostate cancer quality measures in markets with no integration vs full integration (greater than 90% of discharges from an integrated system)., Results: The average man treated in a fully integrated market was more likely to receive pretreatment counseling by a urologist and radiation oncologist (62.6% vs 60.3%, p=0.03), avoid inappropriate imaging (72.2% avoided vs 60.6%, p <0.001), avoid treatment when life expectancy was less than 10 years (23.7% vs 17.3%, p <0.001) and avoid multiple hospitalizations in the last 30 days of life (50.2% vs 43.6%, p=0.001) than when treated in markets with no integration. Additionally, patients treated in fully integrated markets were more likely to have complete adherence to all eligible quality measures (OR 1.38, 95% CI 1.27-1.50)., Conclusions: Integrated systems are associated with improved adherence to several prostate cancer quality measures. Expansion of the integrated health care model may facilitate greater delivery of high quality prostate cancer care., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To assess a large national sample of bladder cancer pathology reports to determine if they contained the components necessary for clinical decision-making., Methods: We examined a random sample of 507 bladder cancer pathology reports from the national Department of Veterans Affairs Corporate Data Warehouse to assess whether each included information on the 4 report components explicitly recommended by the College of American Pathologists' protocol for the examination of such specimens: histology, grade, presence vs absence of muscularis propria in the specimen, and microscopic extent. We then assessed variation in the proportion of reports lacking at least 1 component across Department of Veterans Affairs facilities., Results: One hundred eight of 507 reports (21%) lacked at least 1 of the 4 components, with microscopic extent and presence vs absence of muscularis propria in the specimen most commonly missing (each in 11% of reports). There was wide variation across facilities in the proportion of reports lacking at least 1 component, ranging from 0% to 80%., Conclusion: One-fifth of bladder cancer pathology reports lack information needed for clinical decision-making. The wide variation in incomplete report rates across facilities implies that some facilities already have implemented best practices assuring complete reporting whereas others have room for improvement. Future work to better understand barriers and facilitators of complete reporting may lead to interventions that improve bladder cancer care., (Published by Elsevier Inc.)

Purpose: Hospital readmissions after radical cystectomy vary with respect to intensity in terms of impact on patients and health care systems. Therefore, we conducted a population based study to examine factors associated with increasing readmission intensity after radical cystectomy for bladder cancer., Materials and Methods: Using SEER (Surveillance, Epidemiology, and End Results)-Medicare data we identified 1,782 patients who underwent radical cystectomy from 2003 to 2009. We defined readmission intensity in terms of length of stay (days) divided into quartiles of less than 3 (lowest), 3 to 4, 5 to 7 and more than 7 (highest). We used logistic regression to examine factors associated with readmission intensity., Results: More than half of the patients with the highest intensity readmissions were readmitted within the first week and 77% were readmitted within 2 weeks of discharge. Patients with the highest intensity readmissions were similar in age, gender, race, socioeconomic status, pathological stage, comorbidity, neoadjuvant chemotherapy use and urinary diversion type compared to patients with the lowest intensity readmissions. After multivariable adjustment, complications during the index cystectomy admission (p <0.001), readmission week (p=0.04), and the interaction between index length of stay and discharge to a skilled nursing facility (p=0.04) were associated with the highest readmission intensity., Conclusions: Readmission intensity differs widely after discharge following radical cystectomy. As postoperative efforts to minimize the readmission burden increase, a better understanding of the factors that contribute to the highest intensity readmissions will help direct limited resources (eg telephone calls, office visits) toward high yield areas., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We evaluated whether patients with prostate cancer who received best care according to a set of 5 nationally endorsed quality measures had decreased treatment related morbidity and improved cancer control., Materials and Methods: In this retrospective cohort study we included 38,055 men from the SEER (Surveillance, Epidemiology and End Results)-Medicare database treated for localized prostate cancer between 2004 and 2010. We determined whether each patient received best care, defined as care adherent to all applicable measures. We measured associations of best care with the need for interventions, addressing treatment related morbidity, and with the need for secondary cancer therapy using Cox proportional hazards models., Results: Only 3,412 men (9.0%) received best care. Five years after treatment these men and men who did not receive best care had a similar likelihood of undergoing procedures for urinary morbidity (prostatectomy subset 10.7% vs 12.9%, p = 0.338) and secondary cancer therapy (prostatectomy for high risk prostate cancer subset 40.9% vs 37.3%, p = 0.522). However, they were more likely to be treated with a procedure for sexual morbidity (prostatectomy 17.3% vs 10.8%, p <0.001). Similar trends were observed in men treated with radiotherapy., Conclusions: Overall men who received best care did not fare better in regard to treatment related morbidity or cancer control. Collectively our findings suggest that the current process of care measures are not tightly linked to outcomes and further research is needed to identify better measures that are meaningful and important to patients., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Robotic prostatectomy has rapidly disseminated over the past decade. How managed care, thought by many to be a barrier to new technology, influences the dissemination of robotics is unknown. We sought to better understand the relationship between a market's managed-care penetration and the dissemination of robotic prostatectomy., Methods: We used SEER-Medicare data from 2003 through 2007 to identify men ≥66 years of age treated with radical prostatectomy for prostate cancer. We categorized Health Service Areas (HSAs) according to the degree of managed-care penetration (ie, low vs high). We assessed adoption of robotic prostatectomy and utilization among adopting HSAs using Cox proportional-hazards and Poisson regression models, respectively., Results: Compared with markets with little managed care, highly penetrated markets had more racial diversity (24% vs 15% nonwhite, P < .01), higher population densities (1987 vs 422 people/square mile, P < .01), and higher median incomes ($49 374 vs $36 236, P < .01). Robotic prostatectomy adoption and utilization increased over time in both HSA categories. Compared with low managed-care markets, those with high managed care adopted robotic prostatectomy more rapidly (eg, probability 0.37 [low] vs 0.52 [high] in 2007; P < .01). However, the postadoption utilization of robotic prostatectomy was constrained in these highly penetrated markets (eg, probability 0.66 [low] vs 0.52 [high] in 2007; P < .01)., Conclusions: High managed-care penetration was associated with more rapid robotic prostatectomy adoption. However, once adopted, utilization increased more slowly in these markets. Understanding this paradox is important as more technologies are unveiled in an increasingly cost-conscious health care environment., (© The Author(s) 2014.)

Objective: To evaluate the association of technological capacity with prostate cancer quality of care. Technological capacity was conceptualized as a market's ability to provide prostate cancer treatment with new technology, including robotic prostatectomy and intensity-modulated radiotherapy (IMRT)., Methods: In this retrospective cohort study, we used data from the Surveillance, Epidemiology, and End Results-Medicare linked database from 2004 to 2009 to identify men with newly diagnosed prostate cancer (n = 46,274). We measured technological capacity as the number of providers performing robotic prostatectomy or IMRT per population in a health care market. We used multilevel logistic regression analysis to assess the association of technological capacity with receiving quality care according to a set of nationally endorsed quality measures, while adjusting for patient and market characteristics., Results: Overall, our findings were mixed with only subtle differences in quality of care comparing high-tech with low-tech markets. High robotic prostatectomy capacity was associated with better adherence to some quality measures, such as avoiding unnecessary bone scans (79.8% vs 73.0%; P = .003) and having follow-up with urologists (67.7% vs 62.6%; P = .023). However, for most measures, neither high robotic prostatectomy nor high-IMRT capacity was associated with significant increases in adherence rates. In fact, for 1 measure (treatment by a high-volume provider), high-IMRT capacity was associated with lower performance (23.4% vs 28.5%; P <.001)., Conclusion: Our findings suggest that new technology is not clearly associated with higher quality of care. To improve quality, more specific efforts will be needed., (Published by Elsevier Inc.)

Purpose: We assessed the relationship between health care system performance on nationally endorsed prostate cancer quality of care measures and prostate cancer treatment outcomes., Materials and Methods: This retrospective cohort study included 48,050 men from SEER-Medicare linked data diagnosed with localized prostate cancer between 2004 and 2009, and followed through 2010. Based on a composite quality measure we categorized the health care systems in which these men were treated into 1-star (bottom 20%), 2-star (middle 60%) and 3-star (top 20%) systems. We then examined the association of health care system level quality of care with outcomes using multivariable logistic and Cox regression., Results: Patients who underwent prostatectomy in 3-star vs 1-star health care systems were at lower risk for perioperative complications (OR 0.80, 95% CI 0.64-1.00). However, they were more likely to undergo a procedure addressing treatment related morbidity, eg for sexual morbidity (11.3% vs 7.8%, p = 0.043). In patients who received radiotherapy star ranking was not associated with treatment related morbidity. In all patients star ranking was not significantly associated with all-cause mortality (HR 0.99, 95% CI 0.84-1.15) or secondary cancer therapy (HR 1.04, 95% CI 0.91-1.20)., Conclusions: We found no consistent association between health care system quality and outcomes, which questions how meaningful these measures ultimately are for patients. Thus, future studies should focus on developing more discriminative quality measures., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We examined variation in active surveillance use in Medicare eligible men undergoing expectant treatment for early stage prostate cancer., Materials and Methods: Using SEER (Surveillance, Epidemiology and End Results) and Medicare data we identified 49,192 men diagnosed with localized prostate cancer from 2004 through 2007. Of 7,347 patients who did not receive treatment (ie expectant management) within 12 months of diagnosis we assessed the prevalence of active surveillance (ie repeat prostate biopsy and prostate specific antigen measurement) vs watchful waiting across health care markets. We fit multivariable logistic regression models to examine associations of active surveillance with patient demographics, cancer severity and health care market characteristics., Results: During the study interval use of active surveillance vs watchful waiting increased significantly in patients treated expectantly from 9.7% in 2004 to 15.3% in 2007 (p <0.001). Active surveillance was less common in older patients, those with high risk tumors and those with more comorbidities (each p <0.001). Patients who were white and had higher socioeconomic status were more likely to receive active surveillance (each p <0.05). After adjusting for patient and tumor characteristics significant differences in the predicted probability of active surveillance persisted across health care markets (range 2.4% to 30.1%). No significant variation in active surveillance use was associated with specific health care market characteristics, including intensity of end of life care, Medicare reimbursement or provider density., Conclusions: Active surveillance has been relatively uncommon in Medicare beneficiaries with localized prostate cancer. Its use relative to watchful waiting varies based on patient demographics, tumor severity and geographic location., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Despite the endorsement of several quality measures for prostate cancer by the National Quality Forum and the Physician Consortium for Performance Improvement, how consistently physicians adhere to these measures has not been examined. We evaluated regional variation in adherence to these quality measures to identify targets for future quality improvement., Materials and Methods: For this retrospective cohort study we used SEER (Surveillance, Epidemiology, and End Results)-Medicare data for 2001 to 2007 to identify 53,614 patients with newly diagnosed prostate cancer. Patients were assigned to 661 regions (Hospital Service Areas). Hierarchical generalized linear models were used to examine reliability adjusted regional adherence to the endorsed quality measures., Results: Adherence at the patient level was highly variable, ranging from 33% for treatment by a high volume provider to 76% for receipt of adjuvant androgen deprivation therapy while undergoing radiotherapy for high risk cancer. In addition, there was considerable regional variation in adherence to several measures, including pretreatment counseling by a urologist and radiation oncologist (range 9% to 89%, p <0.001), avoiding overuse of bone scans in low risk cancer (range 16% to 96%, p <0.001), treatment by a high volume provider (range 1% to 90%, p <0.001) and followup with radiation oncologists (range 14% to 86%, p <0.001)., Conclusions: We found low adherence rates for most established prostate cancer quality of care measures. Within most measures regional variation in adherence was pronounced. Measures with low adherence and a large amount of regional variation may be important low hanging targets for quality improvement., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)