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J Natl Cancer Inst. 2009 Apr 15;101(8):571-80. doi: 10.1093/jnci/djp039. Epub 2009 Apr 7.

Provider treatment intensity and outcomes for patients with early-stage bladder cancer.

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Division of Oncology, Department of Urology, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.



Bladder cancer is among the most prevalent and expensive to treat cancers in the United States. In the absence of high-level evidence to guide the optimal management of bladder cancer, urologists may vary widely in how aggressively they treat early-stage disease. We examined associations between initial treatment intensity and subsequent outcomes.


We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients who were diagnosed with early-stage bladder cancer from January 1, 1992, through December 31, 2002 (n = 20 713), and the physician primarily responsible for providing care to each patient (n = 940). We ranked the providers according to the intensity of treatment they delivered to their patients (as measured by their average bladder cancer expenditures reported to Medicare in the first 2 years after a diagnosis) and then grouped them into quartiles that contained approximately equal numbers of patients. We assessed associations between treatment intensity and outcomes, including survival through December 31, 2005, and the need for subsequent major interventions by using Cox proportional hazards models. All statistical tests were two-sided.


The average Medicare expenditure per patient for providers in the highest quartile of treatment intensity was more than twice that for providers in the lowest quartile of treatment intensity ($7131 vs $2830, respectively). High-treatment intensity providers more commonly performed endoscopic surveillance and used more intravesical therapy and imaging studies than low-treatment intensity providers. However, the intensity of initial treatment was not associated with a lower risk of mortality (adjusted hazard ratio of death from any cause for patients of low- vs high-treatment intensity providers = 1.03, 95% confidence interval 0.97 to 1.09). Initial intensive management did not obviate the need for later interventions. In fact, a higher proportion of patients treated by high-treatment intensity providers than by low-treatment intensity providers subsequently underwent a major medical intervention (11.0% vs 6.4%, P = .02).


Providers vary widely in how aggressively they manage early-stage bladder cancer. Patients treated by high-treatment intensity providers do not appear to benefit in terms of survival or in avoidance of subsequent major medical interventions.

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