A Google Trends™ Analysis of Bladder Cancer: Determining Awareness Campaign Success, and Patients' Needs in Clinical Management.

OBJECTIVE: We aimed to determine the interest and changing trends over time in the diagnosis and treatment of bladder cancer and its awareness campaign by examining the Google Trends application as an indicator of people's interest globally. METHODS: Using the Google Trends application, we determined the yearly and country-based relative search volumes of the term "bladder tumor" and of the methods used in the diagnosis and treatment of bladder cancer in the period from January 2004 to December 2019. We compared the median relative search volumes found in the period 2004-2011 (Period 1) with those found in the period 2012-2019 (Period 2). RESULTS: We found that the median relative search volume for bladder cancer decreased in period 2 and this was parallel to the decrease in the incidence rates in North America and Australia (p<0.001). We found that the bladder cancer awareness month did not cause an increase in the online interest (p>0.05). We found that the median relative search volumes of diagnostic cystoscopy and cytology were higher than those of molecular markers and imaging methods in line with guidelines (p<0.001). Also, TURBT was the most sought-term among treatment methods with increasing popularity in the second period (p<0.001). CONCLUSION: People use the internet intensively to search for information about bladder cancer. We think that several types of web-based applications such as "Google Trends" can help determine the behavioural patterns and tendencies of bladder cancer patients and affect the clinical decision-making processes, as well as readily determining the impact of cancer awareness campaigns to bring about an increased awareness in the society for the recognition of the importance of an early diagnosis.

Urology Residency Training in Medically Underserved Areas Through the Integration of a Federally Qualified Health Center Rotation.

OBJECTIVE: To identify workforce related barriers to urologic care in Medically Underserved Areas (MUA) and Health Professional Shortage Areas (HPSA). Federally Qualified Health Centers (FQHC) are community-based organizations that aim to close gaps, but little is known about exposure to underserved areas during residency training. METHODS: The objective of this study was to characterize the experiences of urology residents who participated in a rotation within a FQHC. The study consisted of: (1) 12-item post-rotation self-assessment (2) review of career paths of former graduates who completed the rotation, and (3) retrospective review of patients treated at FQHC from 2016 to 2018. RESULTS: There were a total of 1735 patient visits, 97 were for cystoscopy, 76.36% of patients had Medicaid or no insurance. There were 1092 unique patients seen and 281 (25.73%) were referred for surgery. A majority of residents (100%) stated they had a better appreciation of treating patients in underserved areas. A majority of residents (71.6%) of residents said they were more likely to practice in an underserved area after residency. Among former graduates who rotated through the clinic, 100% (n = 4) were practicing in a MUA or HPSA. CONCLUSION: The integration of an FQHC during urology residency training was associated with highly favorable satisfaction by trainees. Given persistent workforce related shortages in urology, these findings support exposure to medically underserved areas during training.

Management of benign prostatic hyperplasia in the 21st century: temporal trends in Australian population-based data.

OBJECTIVE: To examine national trends in the medical and surgical treatment of benign prostatic hyperplasia (BPH) using Australian Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) population data from 2000 to 2018. PATIENTS AND METHODS: Annual data was extracted from the MBS, PBS and Australian Institute of Health and Welfare databases for the years 2000-2018. Population-adjusted rates of BPH procedures and medical therapies were calculated and compared in relation to age. Cost analysis was performed to estimate financial burden due to BPH. RESULTS: Overall national hospital admissions due to BPH declined between 2000 and 2018, despite an increased proportion of admissions due to private procedures (42% vs 77%). Longitudinal trends in the medical management of BPH showed an increased prescription rate of dutasteride/tamsulosin combined therapy (111 vs 7649 per 100 000 men) and dutasteride monotherapy (149 vs 336 per 100 000 men) since their introduction to the PBS in 2011. Trends in BPH surgery showed an overall progressive increase in rate of total procedures between 2000 and 2018 (92 vs 133 per 100 000 men). Transurethral resection of the prostate (TURP) remained the most commonly performed surgical procedure, despite reduced utilisation since 2009 (118 vs 89 per 100 000 men), offset by a higher uptake of photoselective vaporisation of prostate, holmium:YAG laser enucleation of prostate, and later likely due to minimally invasive surgical therapies including prostatic urethral lift and ablative technologies (including Rezum™). Financial burden due to BPH surgery has remained steady since 2009, whilst the burden due to medical therapy has risen sharply. CONCLUSION: Despite reduced national BPH-related hospitalisations, overall treatment for BPH has increased due to medical therapy and surgical alternatives to TURP. Further exploration into motivators for particular therapies and effect of medical therapy on BPH progression in clinical practice outside of clinical trials is warranted.

Geographic Variation in Cystoscopy Rates for Suspected Bladder Cancer between Female and Male Medicare Beneficiaries.

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.

Variation in the Diagnostic Evaluation among Persons with Hematuria: Influence of Gender, Race and Risk Factors for Bladder Cancer.

PURPOSE: We sought to determine whether race, gender and number of bladder cancer risk factors are significant predictors of hematuria evaluation. MATERIALS AND METHODS: We used self-reported data from SCCS (Southern Community Cohort Study) linked to Medicare claims data. Evaluation of subjects diagnosed with incident hematuria was considered complete if imaging and cystoscopy were performed within 180 days of diagnosis. Exposures of interest were race, gender and risk factors for bladder cancer. RESULTS: Of the 1,412 patients evaluation was complete in 261 (18%). On our adjusted analyses African American patients were less likely than Caucasian patients to undergo any aspect of evaluation, including urology referral (OR 0.72, 95% CI 0.56-0.93), cystoscopy (OR 0.67, 95% CI 0.50-0.89) and imaging (OR 0.75, 95% CI 0.59-0.95). Women were less likely than men to be referred to a urologist (OR 0.59, 95% CI 0.46-0.76). Also, although all patients with 2 or 3 risk factors had 31% higher odds of urology referral (OR 1.31, 95% CI 1.02-1.69), adjusted analyses indicated that this effect was only apparent among men. CONCLUSIONS: Only 18% of patients with an incident hematuria diagnosis underwent complete hematuria evaluation. Gender had a substantial effect on referral to urology when controlling for socioeconomic factors but otherwise it had an unclear role on the quality of evaluation. African American patients had markedly lower rates of thorough evaluation than Caucasian patients. Number of risk factors predicted referral to urology among men but it was otherwise a poor predictor of evaluation. There is opportunity for improvement by increasing the completion of hematuria evaluations, particularly in patients at high risk and those who are vulnerable.

Budget impact of incorporating one instillation of hexaminolevulinate hydrochloride blue-light cytoscopy in transurethral bladder tumour resection for patients with non-muscle-invasive bladder cancer in Sweden.

OBJECTIVES: To explore the cost impact on Swedish healthcare of incorporating one instillation of hexaminolevulinate hydrochloride (HAL) blue-light cystoscopy into transurethral resection of bladder tumour (TURBT) in patients with suspected new or recurrent non-muscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS: A decision tree model was built based on European Association of Urology guidelines for the treatment and management of NMIBC. Input data were compiled from two recent studies comparing recurrence rates of bladder cancer in patients undergoing TURBT with either the current standard of care (SOC) of white-light cystoscopy, or with the SOC and HAL blue-light cystoscopy. Using these published data with clinical cost data for surgical and outpatient procedures and pharmaceutical costs, the model reported on the clinical and economic differences associated with the two treatment options. RESULTS: This model demonstrates the significant clinical benefits likely to be observed through the incorporation of HAL blue-light cystoscopy for TURBT in terms of reductions in recurrences of bladder cancer. Analysis of economic outputs of the model found that the use of one instillation of HAL for TURBT in all Swedish patients with NMIBC is likely to be cost-neutral or cost-saving over 5 years relative to the current SOC of white-light cystoscopy. CONCLUSIONS: The results of this analysis provide additional health economic rationale for the incorporation of a single instillation of HAL blue-light cystoscopy for TURBT in the treatment of patients with NMIBC in Sweden.

Racial Disparities in End-of-Life Care Among Patients With Prostate Cancer: A Population-Based Study.

OBJECTIVE: To examine racial disparities in end-of-life (EOL) care among black and white patients dying of prostate cancer (PCa). METHODS: Relying on the SEER-Medicare database, 3789 patients who died of metastatic PCa between 1999 and 2009 were identified. Information was assessed regarding diagnostic care, therapeutic interventions, hospitalizations, intensive care unit (ICU) admissions, and emergency department visits in the last 12 months, 3 months, and 1 month of life. Logistic regression tested the relationship between race and the receipt of diagnostic care, therapeutic interventions, and high-intensity EOL care. RESULTS: Overall, 729 patients (19.24%) were black. In the 12-months preceding death, laboratory tests (odds ratio [OR], 0.51; 95% CI, 0.36-0.72), prostate-specific antigen test (OR, 0.54; 95% CI, 0.43-0.67), cystourethroscopy (OR, 0.71; 95% CI, 0.56-0.90), imaging procedure (OR, 0.58; 95% CI, 0.41-0.81), hormonal therapy (OR, 0.53; 95% CI, 0.44-0.65), chemotherapy (OR, 0.59; 95% CI, 0.48-0.72), radiotherapy (OR, 0.74; 95% CI, 0.61-0.90), and office visit (OR, 0.38; 95% CI, 0.28-0.50) were less frequent in black versus white patients. Conversely, high-intensity EOL care, such as ICU admission (OR, 1.27; 95% CI, 1.04-1.58), inpatient admission (OR, 1.49; 95% CI, 1.09-2.05), and cardiopulmonary resuscitation (OR, 1.72; 95% CI, 1.40-2.11), was more frequent in black versus white patients. Similar trends for EOL care were observed at 3-month and 1-month end points. CONCLUSIONS: Although diagnostic and therapeutic interventions are less frequent in black patients with end-stage PCa, the rate of high-intensity and aggressive EOL care is higher in these individuals. These disparities may indicate that race plays an important role in the quality of care for men with end-stage PCa.

FGFR3 mutation analysis in voided urine samples to decrease cystoscopies and cost in nonmuscle invasive bladder cancer surveillance: a comparison of 3 strategies.

PURPOSE: We determined whether FGFR3 mutation analysis of voided urine samples would be cost-effective to partly replace cystoscopy in the surveillance of patients treated for nonmuscle invasive urothelial carcinoma. MATERIALS AND METHODS: In this decision analytical study we analyzed data on 70 Dutch patients with FGFR3 positive primary tumors and a median followup of 8.8 years. Surveillance strategies were compared in a Markov model. Modified surveillance consisted of FGFR3 mutation analysis of voided urine samples every 3 months, and cystoscopy at 3, 12 and 24 months. Standard surveillance was defined as cystoscopy every 3 months and minimal surveillance was defined as cystoscopy at 3, 12 and 24 months. Analysis was stratified for 3 risk profiles, including surveillance after 1) the primary tumor, 2) the first to third recurrence and 3) the fourth recurrence or more. Sensitivity analysis was performed to evaluate the impact of variations in cost, sensitivity and specificity. RESULTS: The probability of no recurrence after 2 years of surveillance after a primary tumor was higher for modified surveillance than for standard and minimal surveillance, eg after primary tumors (95.7% vs 95.0% and 93.9%, respectively). The total cost of surveillance after the primary tumor was lower for minimal and modified surveillance (€2,254 and €2,558, respectively) than for standard surveillance (€5,861). Results were robust to changing inputs over plausible ranges and consistent for each of the 3 risk profiles. CONCLUSIONS: Surveillance in which cystoscopy is partly replaced by FGFR3 mutation analysis of urine seems a safe, effective and cost-effective surveillance strategy. Further validation in larger cohorts is required.

The role of preoperative testing on outcomes after sling surgery for stress urinary incontinence.

PURPOSE: In this study we analyzed Medicare claims data to measure the effect of preoperative urodynamics and cystoscopy on outcomes after sling surgery. MATERIALS AND METHODS: We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of beneficiaries. Women who underwent sling procedures between July 1, 1999 and December 31, 2000 were identified on the basis of the presence of CPT-4 code 57288 (sling operation for stress incontinence). Subjects were tracked for 6 months before surgery to identify type of preoperative studies performed (urodynamics and cystoscopy) and for 12 months after surgery to assess short-term complications. RESULTS: Of 1,356 subjects 24.8% underwent preoperative cystoscopy and 27.4% underwent preoperative urodynamic testing. In postoperative year 1, 32.4% of subjects underwent cystoscopy and 30.5% underwent urodynamics. Patients who underwent preoperative urodynamics were more likely to be newly diagnosed with urge incontinence after surgery (21.9% vs 12.7%, p <0.0001). Those who underwent preoperative cystoscopy were significantly more likely to be diagnosed with (9.4% vs 6.1%, p <0.043) or treated for (10.6% vs 7.2%, p <0.047) outlet obstruction postoperatively than those who did not. Multivariate analysis revealed that subjects who underwent preoperative urodynamics were significantly less likely to undergo postoperative urodynamics than those who did not (OR 0.34, 95% CI 0.24-0.48). CONCLUSIONS: Our findings of worse outcomes among women who underwent preoperative testing may be due in part to case selection. Our finding that women who underwent preoperative urodynamics were only a third as likely to undergo postoperative urodynamics as those who did not supports the use of urodynamics in the preoperative setting. However, the true effect of urodynamics on sling outcomes remains controversial.

Monitoring trends in waiting periods in Canada for elective surgery: validation of a method using administrative data.

BACKGROUND: Provincial governments require timely, economical methods to monitor surgical waiting periods. Although use of prospective procedure-specific registers would be the ideal method, a less elaborate system has been proposed that is based on physician billing data. This study assessed the validity of using the date of the last service billed prior to surgery as a proxy for the beginning of the post-referral, pre-surgical waiting period. METHOD: We examined charts for 31,824 elective surgical encounters between 1992 and 1996 at an Ontario teaching hospital. The date of the last service before surgery (the last billing date) was compared with the date of the consultant's letter indicating a decision to book surgery (i.e., to begin waiting). RESULTS: Several surgical specialties (but excluding cardiac, orthopedic and gynecologic) had a close correlation between the dates of the last pre-surgery visit and those of the actual decision to place the patient on the waiting list. Similar results were found for 12 of 15 individually studied procedures, including some orthopedic and gynecological procedures. CONCLUSION: Used judiciously, billing data is a timely, inexpensive and generally accurate method by which provincial governments could monitor trends in waiting times for appropriately selected surgical procedures.

Routine cystoscopy before radical prostatectomy: is it justified?

OBJECTIVES: The extent of the required preoperative workup of patients who are candidates for radical prostatectomy is still controversial. Traditionally, cystoscopy has been reserved only for those patients who present with hematuria. However, several investigators have reported significant incidental cystoscopic findings among these patients and advocated the routine use of cystoscopy before radical prostatectomy. In view of the conflicting recommendations, we elected to assess the role of routine cystoscopy in a series of patients with prostate cancer at our institute. METHODS: We retrospectively reviewed the cystoscopic findings of 225 consecutive patients with organ-confined prostate carcinoma scheduled for radical prostatectomy. Rigid cystoscopy was performed before surgery either in an outpatient setting or on the operating table just before the operation. RESULTS: Significant cystoscopic findings were noted in 3 (1.3%) of 225 patients. These included a bladder stone in 1 patient, superficial bladder tumor in 1 patient, and a post-sphincteric urethral polyp containing prostatic adenocarcinoma in a third patient. This polyp was resected transurethrally and the patient was treated thereafter with irradiation because of local extension. None of the 3 patients had microscopic hematuria on urinalysis to suggest the findings. Cystoscopy was uneventful in all patients, apart from occasional mild hematuria. CONCLUSIONS: These results show that the treatment of patients who were candidates for radical prostatectomy was affected by the findings of preoperative cystoscopy in less than 1% of the cases. We believe that in view of the low yield of cystoscopic findings in these patients, in an era in which cost effectiveness is a major issue, the routine use of cystoscopy before radical prostatectomy is not justified.