PD12-05 IMPROVING RATES OF INTRAVESICAL CHEMOTHERAPY FOR LOW GRADE BLADDER CANCER

Abstract

INTRODUCTION AND OBJECTIVE: Despite advances in urologic research, there is often a disconnect with real-world practice. AUA guidelines recommend consideration of an immediate postoperative instillation of intravesical chemotherapy (IVC) for low grade urothelial cancers, which has been shown to reduce tumor recurrence up to ∼40%. However, rates of postoperative IVC use remains low due to high costs, low availability, and side effects. While Mitomycin C is the standard of care, recent data demonstrates that gemcitabine (Gem) has similar efficacy in reducing tumor recurrences, while being more tolerable and less expensive. We created an implementation protocol to improve usage rates of immediate post-operative Gem. Because histology is not available to the surgeon prior to ordering IVC, the accuracy of visual grading during cystoscopy was determined for our group of surgeons. METHODS: Pre-intervention audits were performed at two hospitals to determine for baseline rates of appropriate use of immediate post-operative IVC in patients with low grade (LG) non-muscle invasive (NMI) urothelial carcinoma (UC) undergoing resection of bladder tumors (TURBT) over a 3-month period. Needs assessment was performed to recognize key stakeholders and identify barriers to use. An intervention protocol was designed and implemented, which included new EMR order sets, education of providers and staff, and establishment of communication checkpoints. A 4 month post-intervention audit was performed. RESULTS: Prior to knowing histology, LG histology was accurately predicted with a PPV of 80%. Pre-intervention rates of appropriate intravesical chemotherapy use were 9% at hospital A and 39% at hospital B. Post-intervention rates were 81% at hospital A and 84% at hospital B. CONCLUSIONS: Prior to knowing histology, our urologists can accurately predict LG histology and thus patients who will require IVC after TURBT. There was a significant improvement in the rates of immediate postoperative Gem at both hospitals. Continued refinement of the protocol will be necessary to further improve and sustain these improved rates. This success indicates that our intervention may be used as a model for other institutions.Source of Funding: Urology Care Foundation Resident Research Award; Kahlert Foundation