Epidemiology

selective

INTRODUCTION AND OBJECTIVE: Hematuria is a cardinal symptom of urinary tract cancer and is used to advocate selective screening in this patient cohort. Guidelines vary on who should be investigated following a presentation of hematuria. We report the external validation of the Hematuria Cancer Risk Score (HCRS), a risk assessment tool, to better selective patients who should receive hematuria investigations.
METHODS: The HCRS was developed previously using a prospective cohort of 3,539 patients investigated for hematuria across 40 UK hospitals (DETECT 1; ClinicalTrials.gov: NCT02676180). The external validation cohort consisted of 500 consecutive patients referred to secondary care under an accelerated access pathway for hematuria investigations. Patients included received cystoscopy and upper tract imaging. A diagnosis of cancer was based on histological confirmation. A predetermined cut-off was determined for the validation cohort.
RESULTS: Of 500 patients in the validation cohort, 471 patients were included for analysis. Overall, 36 patients had a diagnosis of urinary tract cancer (33 [7.0%] bladder cancers, 3 [0.6%] upper tract cancers). Median HCRS was higher in patients diagnosed with bladder cancer compared to non-cancer patients (6.118 (IQR: 5.741-6.601) versus 5.265 (IQR: 4.423-6.142) p<0.001). Validation of the HCRS achieved a good discrimination with an AUC of 0.727 (95% CI 0.650e0.804) in the validation cohort. Utilizing a cut-off score of 4.015 allowed identification of 35 tumours (97%) while simultaneously reducing the number of patients undergoing investigation by 72 patients (15%). This includes all three patients with upper tract tumours (1 RCC, 2 UTUC). Only a G1 Ta bladder cancer was missed.
CONCLUSIONS: We report the HCRS offers good discriminatory ability in identifying patients who would benefit from investigation for hematuria. As many as 15% of patients referred for hematuria investigations could be spared from invasive procedures safely, leading to healthcare cost savings. The simplicity of the model allows for easy clinical adoption and can aid both patient and physician decision making. is a complex oncological surgical procedure and population studies of routine surgical care have suggested suboptimal results compared to high-volume centers of excellence. A previous Canadian bladder cancer quality-of-care consensus led to adoption of multiple key quality-of-care indicators with associated benchmarks created utilizing available evidence and expert opinion to inform and measure future performance. Herein we report real-life benchmark performance for the management of muscle invasive bladder cancer (MIBC) relative to expert opinion guidance.

Source of
METHODS: This is a population-based, retrospective, cohort study that used the Ontario Cancer Registry (OCR) to identify all incident patients who underwent RC from 2009 and 2013. Electronic records of treatment from 1,573 patients were linked to OCR; pathology records were obtained for all cases and reviewed by a team of trained data abstractors. The primary objective was to describe benchmarks for identified indicators first as median values obtained across hospitals or providers as well as a "pared-mean" approach to identify a benchmark population of "top performance" as defined as the best outcome accomplished for at least 10 percent of the population.
RESULTS: Overall, performance in Ontario across all indicators fell short of expert-opinion determined benchmarks. Annual surgical volume by each surgeon performing a RC (benchmark>6, percent of institutions meeting benchmark [20%), percent of patients with MIBC referred pre-operatively to Medical Oncology (MO; benchmark >90%, percent of institutions meeting benchmark [2%) and Radiation Oncology (RO; benchmark >50%, percent of institutions meeting benchmark [0%), time to cystectomy within 6 weeks of TURBT in patients without neoadjuvant chemotherapy (benchmark <6 weeks, percent of institutions meeting benchmark [0%), percent of patients with adequate lymph node dissection (defined as >14 nodes, benchmark >85%, percent of institutions meeting benchmark [0%), percent of patients with positive margins post RC (benchmark <10%, percent of institutions meeting benchmark [46%), and 90 day mortality (benchmark <5%, percent of institutions meeting benchmark [37%) fell considerably short. Simply evaluating benchmarks across the province as median performance significantly under-estimated benchmarks that were possible by top-performing hospitals.
CONCLUSIONS: Performance through the majority of BC quality of care indicators fall short of benchmarks proposed by expertopinion. Different methodologies such as a pared-mean approach of top performers may provide more realistic benchmarking.