Setting benchmarks in the treatment of invasive bladder cancer

The comparison of outcomes to some reference standard is known as benchmarking [1]. This well-established business tool is recognized as a strategy that can improve process, performance, and efficiency. Although several methods for improving performance have been developed primarily for manufacturing organizations [2], benchmarking has been used with increasing frequency in the health care industry to improve treatment practice and related quality of care. These early medical directives have primarily targeted screening efforts, disease prevention, and the treatment of common adult and pediatric medical conditions [3]. A growing interest in improving treatment processes for common malignancies exists, paving the way for establishing benchmarks, improving treatment efficiency, and, perhaps, impacting disease survival. In recent years, we have been unable to improve substantially the survival of muscle invasive bladder cancer. Although this may result from a lack of innovative treatment strategies, another contributing factor may be an inefficient application of existing therapies. It is likely that both play a role. Certainly, it is worthwhile to examine current treatment practices and processes to identify areas in which improvements can be made. In manufacturing, if a process is underperforming, attempts are made to diminish production variation, reduce errors, and establish subsequent benchmarks that will improve the process and its output. Although patient care is certainly more complex than assembly work, our medical “workforce” can still use aspects of this strategy to improve efficiency and outcomes of treatment for muscle invasive bladder cancer. To appreciate successfully the impact of established benchmarks, there must be a willingness by the provider to adhere to specialty directed standards. This issue is timely because federal regulatory efforts to ensure quality of medical care has led to the creation of benchmarks for several areas of medicine, and, not surprisingly, Medicare reimbursement is being linked to adherence to these standards [4]. Recently, the American Urological Association has been developing quality indicators for common urologic conditions, and the American Board of Urology has defined urologic standards of care necessary for Maintenance of Certification. With this in mind, it is incumbent upon the Society of Urologic Oncology to review accepted standards of care for urologic malignancies critically and, when necessary, establish reasonable benchmarks that focus on improved patient functional and survival outcome, closing the gap between treatment that patients should receive and treatment that they do receive. In this Seminars issue, authors from varying areas of oncologic care discuss aspects of treatment that must be considered in the creation of benchmarks for muscle invasive bladder cancer. Available evidence for proposed standards is provided for radiation, chemotherapy, and radical surgery. The first article outlines the concept of benchmarking, discusses its use in aspects of the health care industry, and provides a rationale for its application in bladder cancer treatment. The article by Skinner et al. reviews and suggests important surgical techniques and strategies to consider when developing operative benchmarks. It also underscores the lack of systematic and rigorous evidence associated with long accepted surgical techniques. Dr. Dreicer provides a reasonable argument for the use of systemic chemotherapy in the neoadjuvant and, perhaps, perioperative setting in patients with muscle invasive disease. Finally, Coen et al. provide a comprehensive review of technologic applications and treatment strategies in radiation therapy. They then describe established standards and current technology that will support contemporary benchmarks. This issue of the Seminars will hopefully frame a dialogue in developing multidisciplinary benchmarks for the treatment of muscle invasive bladder cancer.