the initial treatment of non-muscle invasive bladder cancer: Retrospective study in a French peripheral hospital

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ORIGINAL ARTICLE

Factors affecting guideline adherence in

the initial treatment of non-muscle invasive bladder cancer: Retrospective study in a French peripheral hospital

Facteurs inﬂuenc ¸ant l’application des référentiels de traitement dans la prise en charge initiale des tumeurs de vessie n’envahissant pas le muscle : étude rétrospective d’un centre hospitalier régional franc ¸ais

S. Jeglinschi

^a^,^b^,∗

, A. Schirmann

^b

, M. Durand

^a

, S. Sanchez

^c

, S. Larré

^b

, P. Léon

^b^,^d

aServiced’urologie,CHUNice,06000Nice,France

bServiced’urologie,CHUReims,51100Reims,France

cDépartmentd’informationmédicale,centrehospitalier,10000Troyes,France

dServiced’urologie,cliniquePasteur,17200Royan,France

Received7June2019;accepted7November2019 Availableonline6December2019

KEYWORDS Clinicalpractice guidelines;

Treatment adherence;

Non-muscleinvasive bladdercancer;

Intravesicaltherapy;

BCGtherapy;

cystectomy

Summary

Objectives.—Toassesswhethertheinitial treatmentofnon-muscleinvasivebladdercancer (NMIBC)wasperformedaccordingtotheguidelines,andtodeterminethereasonswhyinitial treatmentwasnotprovidedinnonadherencecases.

Materialsandmethods.—WeretrospectivelyreviewedallpatientswithNMIBCwhounderwent theirfirsttransurethralresectionofbladdertumor(TURBT)ataperipheralhospital,between 2007and2016.ThetreatmentofferedtothepatientwascomparedtotheEuropeanAssociation ofUrologyguidelinesaccordingtoriskstratification.Foreachpatientwhodidnotreceivethe treatmentaccordingtotheguidelines,oneofthefollowingreasonswasidentified:poorpatient compliance,poorpatientgeneralhealthstatus,urologist’sdecision,lackofresources.

Results.—Onehundredﬁfty-ninepatientswereincludedwithameanageof72.2yearsatthe timeofNMIBC diagnosis.Thelow-riskpatients werestrictlytreatedaccordingtotheguide- lines.Amongtheintermediate-riskpatients,14%receivedmitomycinC.Amongthehigh-risk

∗Correspondingauthor.Serviced’urologie,CHUNice,30,avenueRomaine,06000Nice,France.

E-mailaddress:csj360@gmail.com(S.Jeglinschi).

https://doi.org/10.1016/j.purol.2019.11.003

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patients,39%receivedintravesicalBacillusCalmette-Guerin.Inthenonadherencecases(61%), thereasonswererelatedtothepatientin44%ofcases(poorcompliance,21%;poorpatient generalhealthstatus,23%),urologist’sdecisionin54%ofcases,andlackofresourcesin2%of cases.Thirty-sevenpercentofthehigh-riskpatientsunderwentre-resection.

Conclusions.—Overall,adherencetoNMIBCguidelineswaslowinalltreatmenttypes(intravesical therapy,re-resection,orcystectomyfor very high-riskpatients),butthisﬁnding was similartothatinpreviousstudies.Reasonsweremainlyrelatedtotheurologist’sdecisionor tothepatientcondition(poorcomplianceorpoorgeneralhealthstatus).

Levelofevidence.—3.

MOTSCLÉS Référentielsde traitement; Adhésionaux recommandations; Tumeurdevessienon inﬁltrante;

Instillations intra-vésicales; BCGthérapie; Cystectomie

Résumé ObjectifÉvaluersiletraitementinitialdestumeursdevessienoninﬁltrantlemuscle (TVNIM)étaitconformeauxrecommandationsdessociétéssavantesetlorsqueletraitement nel’étaitpas,d’enévaluerlescauses.

Méthodes.—L’ensembledesdossiersdeTVNIMreséquéepourla1^refoisdansuncentrehospi- talierrégionalpériphériquefrançais,entre2007et2016,ontétérevusrétrospectivement.Le traitementreçuaétécomparéauxréférentielseuropéens.Pourchaquepatientquinerecevait pasletraitementconformémentauréférentiel,undesmotifssuivantsétaitidentifié:mauvaise compliance,terraindéfavorable,décisiondel’urologueoumanquederessources.

Résultats.—Auﬁnal,159patientsontétéinclusavecunâgemoyende72,2ansaudiagnostic.

Touslespatientsàfaiblerisqueontététraitésselonleréférentiel.Parmilespatientsàrisque intermédiaire,14%avaientrec¸udel’Amétycine.Parmilespatientsàrisqueélevé,39%ont eudesinstillationsparBCG.Chezlesautres(61%),lesmotifsétaientliésaupatientdans44% descas(mauvaise compliance[21%]etterraindéfavorable[23%]),etliésàla décisionde l’urologuedans54%descas,etauxressourcesdans2%descas.Autotal,37%despatientsà hautrisqueonteuunere-résection.

Conclusion.—L’adhésionautraitementderéférencedanslapriseenchargeinitialedesTVNIM étaitfaiblequelquesoitletraitement(instillations,re-résectionsoucystectomiesitrès-haut risque),maissimilaireauxétudesprécédentes.Lesmotifsprincipauxétaientmajoritairement liésàladécisiondel’urologueouaupatient(mauvaisecomplianceouterraindéfavorable).

Niveaudepreuve.— 3.

Introduction

Non-muscleinvasivebladdercancer(NMIBC)guidelinesoffer the highest level of evidence regarding the treatment of non-muscleinvasive diseaseandareintended tooptimize patient care [1—3]. Therefore, it would be expected to observe a high level of similarity between the guidelines anddailyclinicalpractice[4].

Nostudyhasmainlyinvestigatedthereasonswhyadher- ence to the guidelines was hindered in NMIBC. However, the importance of those reasons has been highlighted by many studies [3—6]. A few studies regarding NMIBC guidelineadherencehaveusedsurveystoinvestigateurol- ogists’ treatment patterns [4,7—9]. Other studies have investigated the rate of adherence to NMIBC treatments (instillationsandre-resections)[6,10—13].Knowingtherea- sons implied with nonadherence to the guidelines would allowhealthcareprofessionalstotakeactiononthemod- iﬁable factors in order to improve the rate of NMIBC adherence.

Theobjectivesofthisstudyweretoevaluateiftheini- tial treatment of NMIBC was performed according to the NMIBCguidelines,andtodeterminethereasonswhyinitial treatmentwasnotprovidedinthecasesofnonadherence.

Patients and methods

We conducted a retrospective study of all consecutive charts of patients with NMIBC who underwent their ﬁrst transurethral resection of bladder tumor (TURBT) at a single community hospital in France from January 2007 to May 2016. Patients with missing data; those who had undergone their initial TURBT outside of the community hospital; and those who had a pathology report of a condition other than NMIBC were excluded. Over that timeframe, the patients were operated by nine senior urologists.

Atbaseline,thefollowinginformationwasrecorded:age atdiagnosis,CharlsonComorbidityIndex,Charlson10-year

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survivalprobability,andtumorcharacteristicsaccordingto thesurgicalandpathologicalreports.

Classiﬁcation of patients

Patientsweredividedintofourriskgroupsaccordingtothe EAUNMIBCguidelines[2].

Patients were stratiﬁed as low risk if the tumor was pTa,lowgrade,<3cm;intermediateriskifpTa,lowgrade, multifocal, or>3cm; high risk if pT1 and/or high grade and/or carcinoma in situ (CIS); and very high risk if pT1 andhighgrade,verylargeontheﬁrstTURBTorpersistent onre-resection,pT1G3andCIS,oranaggressivepathologic subtype.

Thetumorwasconsidered>3cmormultipleifdescribed assuchintheoperativereportwritteninthepatient’smedi- cal record, or if it was described as very large or to be multipletumors.

Treatments received

Ifthepatientwasinthelow-riskgroup,therewasnoindi- cationfor re-resection, intravesicaltherapy,induction, or maintenancetherapy.Immediatepostoperativeinstillation was not analyzed in our study. If the patient was in the intermediategroup,therewasanindicationforintravesical therapywithinduction by eitherBacillus Calmette-Guerin (BCG)ormitomycinC.IfmitomycinCwaschosen,therewas an indicationfor a minimumof eightinstillations withno mandatorymaintenance,sincemaintenanceisnotrequired bytheguidelines.IfBCGwaschosen,therewasanindica- tionforsixinductioninstillationsfollowedbymaintenance composedof threeinstillations for3 months,followed by threeinstillationsevery6monthsforaminimumof1year.

Ifthepatientwasinthehigh-riskgroup,therewasanindica- tionforintravesicalBCGwithinductionidenticaltothatin theintermediategroup,followedbythesamemaintenance protocolusedintheintermediategroupbutforaduration of3years,asrecommendedbytheEuropeanAssociationof Urology(EAU)[2].Regarding thepatients whowere eligi- bleforintravesicaltherapy,weconsideredthatintravesical therapywasstartedifthepatienthadreceivedatleastone instillation.Ifthepatientwasinthe veryhigh-riskgroup, therewasanindicationforcystectomy[2].

Assessment and classiﬁcation of protocol deviations

Eachcasewasanalyzedtodetermineifre-resectionorinstil- lationswereindicated.Theindicationforre-resectionwas presentifoneofthefollowingcriteriawasmet:incomplete resection,pT1and/orhigh-gradetumor,andnomusclevis- ibleonthe pathological report,except for low-grade pTa when the lamina propria was seen. For patients treated before2013, according to the previous French guidelines regardingre-resection,thecriteriawereasfollows:incom- pleteresection,pT1andhigh-gradetumor[14].

Foreachpatient,wenotedifthetreatmentappliedwas according to his/her risk group, asrecommended by the EAUguidelines.Whenthetreatmentguidelines(intravesical therapy [started and ﬁnished], re-resection, and cystectomy)werenotapplied,wereviewedthecharttodetermine

the main reason for which the patient was not treated accordingtotheguideline.Poorpatientgeneralhealthsta- tus wasconsidered themain reasonifthe patienthadan advanced age (>80 years),major comorbidities (Charlson ComorbidityIndex),apoorestimatedCharlson10-yearsur- vivalprobabilitydefinedaslessthan10%,andifthechart indicated a known intolerance to the treatment. ‘‘Poor patient health status’’wasalso considered themain rea- sonifthepatientstoppedmaintenanceBCGforintolerance issues. Another main reasonwas considered poor patient compliance ifthe patient refused the treatment, did not showupfor treatment,or waslosttofollow-up. Thelack ofresources wasconsidered themainreasoniftheguide- line treatment couldnot be applied becauseof a lack in resources.This situationwasonlyencounteredbecauseof thelackofsupplyofBCG.Incaseswhentheurologistspec- ifiedinhisconsultnotesthathepreferredanon-guideline treatmentforreasonsnotrelatedtothepatients’health;his complianceorforlackofresources,thereasonwasclassi- fiedastheurologist’sdecision.Whenthepatienthadagood generalhealthstatus,wascompliant,resourceswereavail- ableandstilltherecommendedtreatmentwasnotprovided, thereasonwasalsoclassifiedastheurologist’sdecisionby default.

Statistical analysis

Ourmainpurposewastoprovideadetaileddescriptiveanal- ysis of the treated population. Categorical variables are described using frequency tables. Cross tabulations were performed to describe our variables. For the descriptive analysis,quantitativevariablesareexpressedasmeanand standarddeviations; qualitativevariablesareexpressedas percentages. The Chi² test with the Yates correction for comparisonwasusedtocomparereresection for high risk at differenttimeperiods.We usedSPSSsoftware,version 12.0(IBMCorp.)toperformthestatisticalanalysis.

Ethical statement

All legal conditions for epidemiological surveys were respected, and the French national commission govern- ingtheapplicationofdataprivacylaws(the‘‘Commission Nationale Informatique et Libertés’’) issued approval for both projects. Since the study was strictly observational andusedanonymousdata,inaccordancetothelaws that regulate‘‘non-interventionalclinical research’’inFrance, namelyarticlesL.1121-1andR.1121-2ofthePublicHealth Code,wedidnotrequirethewritteninformedconsentfrom theparticipantsortheauthorizationfromanyotherethics committeetoconductthissurvey.

Results Patient cohort

FourhundredelevenNMIBCﬁleswerereviewed.The ﬁnal cohortincluded 159patients(130[82%] menand29[18%]

women). Patients’mean ageat the timeofdiagnosis was 72.2years.ThemeanCharlsonComorbidityIndexwas1.2, and the mean Charlson 10-year survival probability was

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Table1 Patientcharacteristics.

All Low-riskgroup Intermediate-risk group

High-risk group

Veryhigh-risk group

Numberofpatients(n) 159 49 28 70 12

Sex,n(%)

Men 130(82) 37(76) 24(85) 61(87) 8(67)

Women 29(18) 12(24) 4(15) 9(13) 4(33)

Generalhealthstatus

Meanageatdiagnosis 72.2 68.3 70 75.7 72.9

Comorbidities(meanCharlson ComorbidityIndex)

1.2 1.2 1.3 1.1 1.7

Survivalprobability(mean Charlson10-yearsurvival probability)

36.4 44.2 43.5 29.7 20.5

Typeoftumorn,(%)

pTa,lowgrade,single,<3cm 49(31) 49(100) 0 0 0

pTa,multiple,and/or>3cm 28(18) 0 28(100) 0 0

pTa,highgradeonly 31(19) 0 0 31(44) 0

pTa,highgrade,andCIS 3(2) 0 0 3(4) 0

CISonly 6(4) 0 0 6(9) 0

pT1,lowgrade 12(8) 0 0 12(17) 0

pT1,lowgrade,andCIS 0 0 0 0 0

pT1,highgradeonly 18(11) 0 0 18(26) 0

pT1,highgrade,andCIS 2(1) 0 0 0 2(17)

pT1,highgrade,verylarge 8(5) 0 0 0 8(67)

pT1andaggressivepathologic subtype

2(1) 0 0 0 2(17)

36.4%.Thedistributionofthetumortypeswasasfollows:

70%,pTa;26%,pT1;and4%,CIS.The mostfrequenttumor typewasasingle,<3cm,pTa,low-gradeurothelialcarci- noma (49 patients [31%]). Table 1 shows the clinical and pathologicalcharacteristicsofthecohortanddifferentrisk groups.

Classiﬁcation of patients

The159patientswerestratiﬁedaccordingtotheirEAUrisk group: 49 (30%) were low risk, 28 (18%) were intermedi- aterisk,70(44%)werehighrisk,and12(8%)veryhighrisk (Fig.1).

Treatments received

Among the low-risk patients, all underwent surveillance.

Nonereceivedintravesicaltherapyorre-resection.Among the intermediate-risk patients, 14% started intravesical therapy,all withmitomycinC; none receivedBCG.In the high-riskgroup,39%ofpatientsstartedintravesicaltherapy, allwithBCG;nonereceivedmitomycinC.Ofthehigh-risk patientsthatstartedBCG,15%(4/27)ﬁnishedmaintenance.

Concerningthehigh-riskpatientsthatstartedBCG,theaver- ageinstillations/perpatientwas8.1(219intravesicalBCG for27patients).Inthehigh-riskgroup,37%ofpatientswho had an indication for re-resection, underwent this proce- dure. In the very high-risk group, all thepatients had an indicationforradicalcystectomy.Inthissubgroup,8%(1/12) underwentradicalcystectomy(Table2).

Protocol deviation

Amongthosewhodidnotstartintravesicaltherapy inthe intermediategroup,thereasonswererelatedtothepatient in21.0%ofcases(poorcompliance)andurologist’sdecision in79.0%ofcases.

Among thosewhodid notstart intravesicalBCGin the high-riskgroup,thereasonswererelatedtothepatientin 44.2%ofcases(poorcompliance,20.9%;poorgeneralhealth status,23.3%), urologist’s decision in 53.5% of cases,and lackofresourcesin2.3%ofcases.

Among the high-risk patients that started but did not ﬁnishBCG maintenance, the reasons were related tothe patientin56.5%ofcases(poorcompliance,34.8%;poorgen- eralhealthstatus, 21.7%),urologist’sdecision in34.8% of cases,andlackofresourcesin8.7%ofcases.

Among those who did not undergo re-resection in the high-risk group, the reasons were related to the patient in 45.0% of cases (poor compliance, 15.0%; poor general health status, 20.0% and urologist’s decision in 65.0% of cases(Table3).Whenstratifyingbytimeperiodbeforeand afterthe2010Frenchguidelines(thatmentionedclearlythe needfor re-resection),we foundaresectionratefor high risknot statisticallydifferentwhen comparing2007—2010 and2011—2016(27%vs.40%,P=0.54)(Table4).

Amongthosethatdidnotundergoradicalcystectomyin thevery high-risk group,the reasons were relatedtothe patientin81.8%ofcases(poorcompliance,18.2%;poorgen- eralhealthstatus,63.6%)andurologist’sdecisionin18.2%

ofcases(Table3).

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Figure1. Patientﬂowchart.

Table2 Treatmentsreceived.

Intravesicaltherapy Re-resection Cystectomy

Indicated,n Started,n(%

ofpatients whostarted MMCorBCG accordingto theguidelines)

Indicated,n Re-resected,n (%ofpatients re-resected accordingto theguidelines)

Indicated,n Cystectomized, n(%of

patients cystectomized accordingto theguidelines) Low-risk

group,n=49

0 0 0 0 0 0

Intermediate- riskgroup, n=28

28 4(14%) 1 0(0%) 0 0

High-risk group,n=70

70 27(39%) 63 23(37%) 0 0

Veryhigh-risk group,n=12

0 3(0%) 8 3(38%) 12 1(8%)

MMC:mitomycinC;BCG:BacillusCalmette-Guerin.

Discussion

Adherence tothe guidelines concerning the treatment of NMIBCwaslow for re-resection, intravesical therapy,and radical cystectomy for very high-risk cases. The reasons

were related tothe patient, urologist’s decision, or lack ofavailableresources.Whenstratifyingbyriskgroups,we observedahigherguidelineadherenceforlow-riskpatients andalowerguidelineadherenceforintermediate-risk,high- risk,andveryhigh-riskpatients.

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affectinginitialtreatmentofnonmuscleinvasivebladdercancer31

Table3 Treatmentdeviationincomparisontoguidelines.

Deviationfromguideline:Nointravesicaltherapy DeviationfromGuideline:Noreresection Deviationfromguideline:Nocystectomy Patientswithan

indicationfor intravesicaltherapy thatdidnotstart intravesicaltherapy

Proportionofeachreasonwhennotstarting intravesicaltherapy

Patientswith indicationfor re-resectionthat didnotundergo re-resection

Proportionofeachreasonfornot undergoingre-resection

Patientswith indicationfor cystectomywho didnotundergo cystectomy

Proportionofeachreasonfornot undergoingradicalcystectomy Poorpatient

compliance

Poorgeneral healthstatus

Urologist’s decision

Lackof resources

Poorpatient compliance

Urologist’s decision Low-riskgroup

n=49

0 0 0

Intermediate- riskgroup n=28

24(86%) 5(21.0%) 0(0.0%) 19(79.0%) 0(0.0%) 1(50%) 0(0.0%) 0(0.0%) 1(100.0%) 0

High-riskgroup n=70

43(61%) 9(20.9%) 10(23.3%) 23(53.5%) 1(2.3%) 40(63%) 6(15.0%) 8(20.0%) 26(65.0%) 0

Very-highrisk group n=12

0 5(42%) 2(40.0%) 3(60.0%) 0 11(92%) 2(18.2%) 7(63.6%) 2(18.2%)

Table4 Reresectionforhighriskbytimeperiods.

Patientsn Re- resection indicatedn

Re-resected,n (%ofpatients re-resected accordingto theguidelines)

DeviationfromGuideline:Nore-resection Patientswith

indicationfor re-resectionthat didnotundergo re-resection

P Poor

patient compliance

Poor general health status

2007—2010 17 15 4(27%) 11(73%)

0.54 2(18.0%) 2(18.0%) 7(64.0%)

2011—2016 53 48 19(40%) 29(60%) 4(13.7%) 6(20.7%) 19(65.5%)

2007—2016 70 63 23(37%) 40(63%) 6(15.0%) 8(20.0%) 26(65.0%)

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Ourresultscorroboratethoseinnationalstudieswhere only36%ofurologistsreportedconstantlyfollowingNMIBC guidelines [7]. Adherence to guidelines has been shown toalsobelow in Europe,Canada, theUnited States,and Brazil [3,4,6]. Additionally, low guideline adherence has beenencounteredinother specialties,suchasgynecology (e.g.,concerningthetreatmentofovariancancer)[15].To ourknowledge,thisistheﬁrstworldwidestudythatmainly assessed the reasons for nonadherence to NMIBC guidelines.Oneof thestrengthsof ourstudy wastheinclusion ofallthepatientsdiagnosedashavingNMIBC,whichruled outurologist selectionbiasthatwasfoundinother survey studies that tended to overestimate guideline adherence [5,7—9,16].

Poor general health status

In ourcohort, the poor general health status contributed toalargepartofthelackofguidelineadherence,whichis notsurprisingsincebladdercancertendstoaffectelderly individuals [17].The ‘‘poor general health status’’ factor explainswhyBCGwasnotstartedin23.3%ofthehigh-risk patientsandwhycystectomieswerenotperformedin63.6%

oftheveryhigh-riskpatients(Table3).

Ageover75—80yearshasalreadybeenconsideredafac- torfor BCG underuse[10,18,19]. Agemore than 70 years andcomorbiditieshavebeenalsofoundtobeafactorhin- deringguidelineadherenceingynecologicaloncology[15].A multidisciplinaryapproachinvolvingtheonco-gerontologist is essential in order to obtain the best outcomes for the elderlypopulation[20].

Patient compliance

Poorcompliancewasalsoamajorcauseofnonadherence, accountingfor 20.9% of cases when intravesical BCG was notstartedand34.8%ofcaseswhenBCGwasnotﬁnished.

Sincethehigh-riskpatientsinourseriesthatstartedBCG, receivedanaverageof8.1instillationsperpatient(there- foreslightlymorethan6instillationswhichcorrespondsto a BCG induction), it shows that our cohort received BCG inductionfollowedbyonlyafewmaintenanceinstillations.

According toLamm et al., thepatients’ poor compliance couldhavebeenrelatedtotheirreluctancetosideeffects aswellastheirunderestimationofitsbenefits[21].Physi- ciansshouldhavebetter communicationwiththe patient, firstconcerning the benefits of BCG and second concern- ingthepossibilitytopreventtheminorsideeffectsortreat them if they occur [7,21,22]. Psycho-educational support couldalsoimprovepatients’compliancetotreatmentand wouldreducetheirfears[23].

Unfortunately, the managementof side effects of BCG is not optimal among urologists because of inadequate prescription of antibiotics and premature protocol ter- mination for minor side effects [7,22]. Complementary training on the side effects of BCG as well as regu- lar updates on the free available best practice European andFrench guidelinesconcerningthe prevention ofthese side effects could be the key to alleviating this problem [1,2].

Urologist’s decision

Only 39% of our patients started BCG, which is low but similartoaresultfoundinaSwedishstudywithoutanyurol- ogist selection bias [10]. Lenis et al. reported that some urologists waited for multiple recurrences of an initially high-risk tumor beforeoffering intravesicalBCG,contrary totheguidelines,whichcorroborateswithourﬁndingsthat inmorethanhalfofthecaseswhenBCGisnotgivenforhigh- riskpatients,itis becauseoftheurologist’sdecision[18].

Furthermore,urologistsconsidermaintenanceBCGasdifﬁ- culttoorganize;therefore,theyoftendivergefromLamm etal.’s3-yearprotocol[4,7].

We also found that underuse of mitomycin C mainly because of the urologist’s decision accounts for approxi- mately 80% of cases, which corroborates withﬁndings of other studies where more than half of the intermediate- risk patients did notreceive any intravesical therapy [5].

Barocas et al. suggested that in orderto reduce the gap betweenintravesicaltherapyandtheguidelines,urologists mustadheremoretotheguidelines[24].

We found a relatively low re-resection rate for high- risktumors(37%)mainlybecauseoftheurologist’sdecision (65.0%), but this ﬁnding wassimilar tothat in other retrospective studies (22—35%)[6,13,25—27]. Even though it was not statistically signiﬁcant, we noted an increase in reresectionratesforhighriskafter2010,whentheFrench guidelinesmentioningreresection werepublished(27%vs.

40%,P=0.54).Thelack ofstatisticalsigniﬁcancemightbe due tothe smallsample size and thus thelack ofpower.

Larger studies might benecessary inordertoexplore our ﬁndings.Gottoetal.foundthatregionalhospitalstendto re-resectlesshigh-risktumorsthanacademiccenters,which couldbe thecase in ourregional hospital[6].In Canada, meetingstodiscussbestpracticeandreviewguidelineswere organized,buttherateofparticipationofurologistswork- inginaregionalbackgroundwaslow[6].Ithasbeenshown thatdiscussinganoncologycase inanuro-oncologymulti- disciplinarymeeting(MDM)majorlyaltersthetreatmentin 26.7%ofcases[13,27].Itshouldbenotedthatsomecases ofNMIBCthatweanalyzedlackedanMDMreport.

Lack of resources

Wefoundthat8.7%(2/23)ofhigh-riskpatientsthatstarted BCGwereunabletocompleteBCGmaintenancebecauseof theworldwideBCGshortage.Bothpatientswerediagnosed in2013,whichcorrespondstotheperiodofBCGshortagein France.Foroneofthepatients,maintenancewasnotdone, for theother itwasdone usingmitomycinC.Gates etal.

found a similarrate of 5% (2/41) for BCG not completed becauseoftheworldwideshortage[12].Weonlyfoundone reportof a high-riskpatient wherethe urologistspeciﬁed that hechose not tostart BCGbecause of BCGshortage.

ThepreventionofBCGshortageisobviouslynecessary.

Limitations

Since the study is performed at a single community cen- ter, we did not have any possibility of follow up for patientstreatedinitiallyattheinstitutionthatlatersought

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careelsewhere, whichmight have overestimatedthe rate of ‘non-compliance’. Another limitation is the retrospective nature of the study therefore making difficult to determine the exact reason for guideline deviation. Fur- thermore,the category‘‘urologist’sdecision’’ mighthave been overestimated, sinceif the urologist applied a non- guideline treatmentwithout specifying thereason(health counter-indication,lackofresources,patient’spreference for a non-guideline treatment), the reason was classified erroneously as the urologist’s decision. We also possible wrongfullyclassifiedas‘‘urologist’sdecision’’incaseswhen noconsultnoteswerefound bytheinvestigatorreviewing the filesin order tofindthe real reasonbehind the non- guidelinetreatment.Weremind thatitisfundamentalfor aurologist optingfor a non-guidelinetreatment toassure thatthepatient’schartcontainstheelementsofjustifica- tion (patient’s decision, cardiologist’s counter indication, lack of BCG,etc). Other pitfalls of thisstudy include the relativelysmallsamplesizeduetothefactthatthestudyis performedinalow-volumeperipheralhospital.

Conclusions

Theguidelinesarerightfullyestablishedinordertooptimize treatment, avoid protocol deviations, and favor optimal evidence-basedhealthcareforpatients.Someofthemea- sures to improve guideline adherence include a better onco-geriatricevaluation,improveddoctor-patientcommu- nication, the use of a multidisciplinary team involving a psycho-educationalapproach,andpreventionofthelackof resources.Allurologistsshouldbeencouragedto(1)consult theguidelinesfreelyavailableontheofﬁcialEAUwebsites, (2) participate in uro-oncology MDMs, and (3) participate in meetingsthat discuss best practice and review guidelines [3]. Futuremulticentric studies shouldfocus on the efﬁcacyoftheimplementationofthesemeasuresinimprov- ingguidelineadherencefortreatingNMIBC.

Acknowledgments

None.

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

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