ASCO GU 2023: A SEER-Medicare Based Quality Score for Patients with Synchronous and Metachronous Metastatic Upper Tract Urothelial Carcinoma and Its Association with Cost of Care and Survival

( On the second day of the American Society for Clinical Oncology (ASCO) Genitourinary Cancer Symposium 2023 focussing on urothelial cancer, the Poster Session B: Prostate Cancer and Urothelial Carcinoma included a presentation from Dr. Daniel Joyce presented a SEER-Medicare based analysis to determine a quality score for patients with both synchronous and metachronous metastatic upper tract urothelial carcinoma (mUTUC) and the association with both patient survival outcomes and treatment costs.

Given the scarcity of UTUC, and particularly mUTUC, there is a limited literature base of population-based studies evaluating outcomes exclusively for metastatic upper tract urothelial carcinoma (mUTUC). The available literature is further limited by only capturing patients with de novo (synchronous) metastases as opposed to those who progress to metastatic disease (metachronous). Given these limitations to the literature, these authors sought to evaluate the outcomes and costs associated with mUTUC and employ a novel methodology to identify both synchronous and metachronous mUTUC patients using claims data. Building off of this, they developed a guideline-based quality score to improve quality of care in this space.

To do so, the authors used the SEER-Medicare database to identify patients aged 66 years and older diagnosed with mUTUC between 2004 and 2012. They defined a number of quality criteria including:

 1) cancer-specific survival greater than 12 months;
 2) receipt of systemic therapy;
 3) receipt of hospice/palliative care.

They used Kaplan-Meier survival curves and Cox proportional hazard models to compare overall survival between quality scores (0 vs. ≥1) and synchronous vs. metachronous mUTUC. Additionally, they examined total healthcare and Medicare Part D out-of-pocket costs within two years of diagnosis. Finally, the authors used regression analyses to assess characteristics associated with quality criteria and total healthcare costs.

Among 1,223 identified patients, 381 (31.2%) and 842 (68.8%) had synchronous and metachronous mUTUC, respectively. At least one quality criterion was met in 40.2% of patients. Notably, only 54 patients (4.4%) received palliative care services.


On multivariable analysis, patients with synchronous mUTUC (OR:0.55, 95%CI:0.41–0.72), and at least 3 comorbidities (OR:0.68, 95%CI:0.47–0.98), were less likely to achieve at least one quality criterion. Patients meeting quality criteria had longer survival compared with patients who did not meet criteria (HR:0.52, 95%CI: 0.46–0.59). Meeting at least one quality criterion was independently associated with increased costs ($94,677, 95%CI: 87702–101652 vs. $63575, 95%CI: 59598–67552) on multivariable regression analysis.


In conclusion, the authors noted that less than half of mUTUC patients met at least one of the quality criteria that were proposed in this analysis. However, quality score achievement was associated with longer overall survival at a modest increase in total healthcare spending. These findings not only provide guidance for future study of rare diseases using secondary data, but also highlight inadequacies in the current management of mUTUC.

Presented by: Daniel D. Joyce, MD, Mayo Clinic, Rochester, MN

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A SEER-Medicare Based Quality Score for Patients with Both Synchronous and Metachronous Metastatic Upper Tract Urothelial Carcinoma - Daniel Joyce