Regional Differences in Early Stage Bladder Cancer Care and Outcomes

Abstract

In part because of its protracted natural history, bladder cancer is among the most expensive malignancies from diagnosis to death. In light of the uncertainty surrounding the optimal care, we evaluated regional differences in initial treatment intensity and outcomes among patients with early stage (ie, superficial) bladder cancer. We identified 20,328 patients diagnosed with early stage bladder cancer between 1992 and 2002 using SEER-Medicare data. Patients were assigned to a hospital service area (HSA) according to their ZIP code and followed longitudinally through 2005. Next, HSAs were sorted into equally sized groups according to their average treatment intensity, as measured by all Medicare payments for bladder cancer in the first 2 years after diagnosis. We assessed relationships between regional treatment intensity and patient outcomes, including the use of major interventions and survival. Medicare payments were nearly $4000 USD per capita more in high vs. low treatment intensity regions ($5594 to $9554 USD). High-spending regions used more bladder cancer-related services and major interventions than low-spending regions (all P < .001). However, greater spending did not improve survival. In fact, patients in lower spending regions had superior cancer-specific survival (adjusted hazard ratio, low vs. high 0.83; 95% CI .71-.97). Among patients with early stage bladder cancer, those in high-intensity regions do not benefit in terms of survival or in the avoidance of major interventions. Although the cause is unclear, patients residing in low-spending regions are less likely to die of their disease, while avoiding potentially unnecessary and costly care.