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Optimización del tratamiento del cáncer de vejiga no músculo invasivo mediante una app
Optimizing treatment for non muscle-invasive bladder cancer with an app
P. Beardoa,
Autor para correspondencia
Beardo.pastora@gmail.com

Autor para correspondencia.
, R. Pintob, H. Ayerrab, J. Agüeraa, S. Armijosc, J.L. Álvarez-Ossorioa
a UGC Urología, Hospital Universitario Puerta del Mar, Cádiz, España
b Servicio de Urología, Hospital Universitario de Álava, Vitoria-Gasteiz, España
c e-processmed, Vitoria-Gasteiz, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">En Espa&#241;a se estima que en 2020 se diagnosticaron un total de 20&#46;254 nuevos casos de c&#225;ncer de vejiga&#44; 18&#46;071 en hombres y 4&#46;279 en mujeres&#46; En los hombres ocup&#243; la tercera posici&#243;n detr&#225;s del c&#225;ncer de pr&#243;stata y de pulm&#243;n y&#44; en las mujeres&#44; la quinta posici&#243;n<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El c&#225;ncer de vejiga se divide en 2<span class="elsevierStyleHsp" style=""></span>grupos con distinto pron&#243;stico y tratamiento&#44; en funci&#243;n de la afectaci&#243;n de la capa muscular de la vejiga&#58; el c&#225;ncer no m&#250;sculo-infiltrante &#40;NMIBC&#41; y el c&#225;ncer m&#250;sculo-infiltrante &#40;MIBC&#41;&#46; El patr&#243;n est&#225;ndar de tratamiento del MIBC es la quimioterapia sist&#233;mica basada en platino &#40;neoadyuvante&#41; y la cistectom&#237;a radical&#44; mientras que en el caso del NMIBC es la resecci&#243;n transuretral del tumor &#40;RTUv&#41; y un tratamiento complementario intravesical con inmunoterapia con bacilo Calmette-Guerin &#40;BCG&#41; o quimioterapia pos-RTU<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La tasa de supervivencia a los 5 a&#241;os del NMIBC es superior al 80&#37;&#44; mientras que en el MIBC es inferior al 40&#37;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a>&#46; Entre un 70 y un 75&#37; de los tumores primarios de vejiga son NMIBC &#40;pTa&#44;T1 y carcinoma <span class="elsevierStyleItalic">in situ</span> &#91;Cis&#93;&#41;&#44; pero tienen un alto porcentaje de recidiva &#40;73-84&#37;&#41; y progresi&#243;n a MIBC &#40;35-55&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a>&#46; O&#44; dicho de otro modo&#44; el 75&#37; de los pacientes con c&#225;ncer vesical infiltrante tienen antecedentes de NMIBC&#46; Por tanto&#44; el correcto control y tratamiento del NMIBC es una medida de prevenci&#243;n secundaria con una importante ganancia potencial en t&#233;rminos de supervivencia y calidad de vida&#46; La elecci&#243;n del tratamiento complementario y los sucesivos controles depender&#225;n del paciente y&#44; fundamentalmente&#44; del grupo de riesgo de recidiva y progresi&#243;n<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4-6</span></a>&#44; que viene definido por una serie de variables anatomocl&#237;nicas&#58; sexo&#44; g&#233;nero&#44; estadio y grado tumoral&#44; n&#250;mero de tumores&#44; tumor primario o recidiva&#44; &#237;ndice de recidiva tumoral&#44; tama&#241;o tumoral &#40;entendido como m&#225;ximo di&#225;metro tumoral en cm&#41;&#44; y existencia o no de Cis asociado&#46; En funci&#243;n de estas variables anatomocl&#237;nicas&#44; las tablas <span class="elsevierStyleItalic">Bladder EORTC risk</span><a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> y el <span class="elsevierStyleItalic">CUETO scoring system</span><a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a>&#44; basados en el an&#225;lisis de datos de varios ensayos cl&#237;nicos&#44; definen distintos grupos de riesgo con diferente probabilidad de recurrencia y progresi&#243;n al a&#241;o y a los 5 a&#241;os&#46; As&#237;&#44; el tratamiento complementario intravesical es variable en funci&#243;n de las distintas caracter&#237;sticas anatomocl&#237;nicas&#44; lo que supone que la elecci&#243;n del tratamiento sea a menudo compleja<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">9&#44;10</span></a>&#46; A esto hay que sumar las caracter&#237;sticas individuales de cada paciente &#40;estado funcional&#44; expectativa de vida y comorbilidad&#41; que&#44; en &#250;ltima instancia&#44; van a condicionar la aplicabilidad de las recomendaciones en el NMIBC<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">11-14</span></a>&#46; Todo ello se traduce en una alta variabilidad en el tratamiento<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">15-19</span></a> y seguimiento de estos pacientes<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#44;11&#44;20&#44;21</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Las aplicaciones &#40;apps&#41; desarrolladas para tel&#233;fonos inteligentes y tabletas&#44; dirigidas tanto a pacientes como a profesionales&#44; se utilizan cada vez m&#225;s en la atenci&#243;n m&#233;dica&#46; El desarrollo de esta tecnolog&#237;a se est&#225; aplicando a m&#250;ltiples campos de la atenci&#243;n m&#233;dica urol&#243;gica&#58; informaci&#243;n m&#233;dica para pacientes y profesionales&#44; cribado&#44; diagn&#243;stico&#44; tratamiento&#44; pron&#243;stico&#44; apoyo remoto al paciente y promoci&#243;n del autocuidado&#46; Entre las apps con aplicabilidad en el campo espec&#237;fico de c&#225;ncer de vejiga&#44; encontramos&#58; <span class="elsevierStyleItalic">Bladder-cancer</span> y <span class="elsevierStyleItalic">Bladder cancer treatment</span> &#40;informaci&#243;n gen&#233;rica para pacientes&#41;&#44; <span class="elsevierStyleItalic">Bladder cancer risk assessment tool</span> &#40;evaluaci&#243;n de factores de riesgo para cribado&#41;&#44; <span class="elsevierStyleItalic">EORTC risk tables</span> &#40;c&#225;lculo del riesgo de recidiva&#41;&#44; la calculadora Blappder &#40;propuesta de tratamiento en el NMIBC en funci&#243;n del grupo de riesgo EORTC&#41;&#44; <span class="elsevierStyleItalic">BCG treatment</span> &#40;informaci&#243;n y recomendaciones para pacientes en tratamiento con BCG&#41;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a>&#46; Sin embargo&#44; no se ha desarrollado ninguna app de seguimiento y tratamiento para el NMIBC que incluya los principales datos incluidos en el &#225;rbol de decisi&#243;n para el tratamiento del NMIBC y que&#44; adem&#225;s&#44; cumpla los requisitos de validaci&#243;n metodol&#243;gica<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">23&#44;24</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">En este estudio presentamos los resultados de validaci&#243;n de una app &#40;APPv&#41; que incluye todos los par&#225;metros cl&#237;nico-patol&#243;gicos que proporcionan una propuesta individualizada y en consonancia con las gu&#237;as de pr&#225;ctica cl&#237;nica &#40;GPC&#41; de tratamiento y seguimiento para los pacientes con NMIBC&#46; El objetivo principal es evaluar la concordancia global y ajustada por tasa de recidiva-progresi&#243;n de la prescripci&#243;n tratamiento en el NMIBC mediante la APPv basada en la mejor evidencia cient&#237;fica disponible y en la opini&#243;n del ur&#243;logo&#46; El objetivo secundario es evaluar la supervivencia global y la supervivencia c&#225;ncer espec&#237;fica &#40;CSS&#41; en los grupos con acuerdo en la propuesta de tratamiento y sin acuerdo&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todo</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">1&#46;<span class="elsevierStyleSup">a</span> fase&#58; Fase de desarrollo de APPv</span><p id="par0030" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Revisi&#243;n del protocolo de tratamiento y seguimiento para en NMIBC en funci&#243;n de la MEB en 2018&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Elaboraci&#243;n de la arquitectura de la APPv para el algoritmo de decisi&#243;n informatizado en funci&#243;n del protocolo de tratamiento y seguimiento dise&#241;ado&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Desarrollo de la aplicaci&#243;n inform&#225;tica&#46;</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">A trav&#233;s de una serie de variables de entrada se generan las siguientes variables de salida relativas a los siguientes conceptos &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#58;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Grupo de riesgo de recidiva y progresi&#243;n y el riesgo de ambos a 1 y 5 a&#241;os&#44; basado en las tablas de <span class="elsevierStyleItalic">EORTC risk</span><a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> y en el <span class="elsevierStyleItalic">CUETO scoring system</span><a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> &#40;para pacientes con tratamiento previo con BCG&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Tratamiento de elecci&#243;n &#40;variable principal del estudio&#41;&#58; el programa genera la variable de tratamiento m&#225;s adecuada en cada caso&#44; adem&#225;s de opciones de tratamiento alternativo&#44; si las hubiera&#44; por orden de recomendaci&#243;n&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Seguimiento&#58; el programa proporciona el esquema de seguimiento individualizado para cada paciente&#44; que incluye el n&#250;mero de cistoscopias&#44; citolog&#237;as&#44; tomograf&#237;as y biopsias anuales&#44; su cadencia y la duraci&#243;n del seguimiento&#46;</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Fase de prueba y mejora de la APPv&#46;</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">Se realizaron pruebas de la aplicaci&#243;n inform&#225;tica mediante supuestos pr&#225;cticos con cada posible combinaci&#243;n de las variables de entrada&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">2&#46;&#170; Fase&#58; Validaci&#243;n de APPv</span><p id="par0090" class="elsevierStylePara elsevierViewall">Poblaci&#243;n objeto de estudio</p><p id="par0095" class="elsevierStylePara elsevierViewall">Estudio de concordancia observacional prospectivo de muestras relacionadas a doble ciego en 100 pacientes con primero o sucesivo diagn&#243;stico histol&#243;gico de c&#225;ncer vesical urotelial no m&#250;sculo infiltrante tratados mediante resecci&#243;n transuretral &#40;RTU&#41; desde enero hasta octubre de 2019&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Criterios de inclusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Pacientes con edad mayor o igual a 18 a&#241;os&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">Diagn&#243;stico histol&#243;gico <span class="elsevierStyleItalic">de novo</span> o sucesivo de NMIBC &#40;pTa&#44; pT1 o Cis&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">ECOG 0-2&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">Paciente que haya otorgado su consentimiento por escrito para participar en el estudio&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Criterios de exclusi&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Antecedente de MIBC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Carcinoma vesical no urotelial o histolog&#237;as mixtas&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Ausencia de capa muscular en la muestra histol&#243;gica de RTUv o re-RTUv&#44; que impida la correcta estadificaci&#243;n del tumor&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Tratamiento con radioterapia&#44; quimioterapia intravenosa o inmunosupresores durante el periodo de estudio&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">Infecci&#243;n del tracto urinario sin tratar&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Infecci&#243;n sist&#233;mica grave&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Otras neoplasias durante los 5 a&#241;os previos a la inclusi&#243;n en el estudio &#40;excepto carcinoma basocelular&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Embarazo&#46;</p></li></ul></p></span></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">M&#233;todo</span><p id="par0170" class="elsevierStylePara elsevierViewall">Simulaci&#243;n de APPv&#58; propuesta de tratamiento complementario seg&#250;n la APPv objeto de estudio&#44; adem&#225;s de la informaci&#243;n adicional relativa al seguimiento propuesto y el grupo de riesgo de recidiva y progresi&#243;n seg&#250;n las tablas de <span class="elsevierStyleItalic">EORTC risk</span> o el <span class="elsevierStyleItalic">CUETO scoring system&#44;</span> si el paciente ha recibido tratamiento previo con BCG &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">Consulta presencial de prescripci&#243;n&#58; visita posquir&#250;rgica con la prescripci&#243;n de tratamiento complementario&#44; en su caso&#44; por parte del ur&#243;logo &#40;2 ur&#243;logos especializados en c&#225;ncer de vejiga&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Las propuestas de tratamiento y seguimiento de la APPv y el ur&#243;logo son realizadas por profesionales diferentes &#40;doble ciego&#41;&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">An&#225;lisis</span><p id="par0185" class="elsevierStylePara elsevierViewall">La variable dependiente principal es la concordancia entre el tratamiento prescrito por la aplicaci&#243;n &#40;incluye la primera opci&#243;n y la alternativa de tratamiento&#41; y por el ur&#243;logo &#40;s&#237;&#47;no&#41;&#44; tanto referido a la re-RTU como al tratamiento complementario&#44; global y ajustada por la tasa de recidiva-progresi&#243;n&#46; Como variables secundarias se analizan la supervivencia global y la CSS en ambos grupos &#40;con y sin acuerdo en el tratamiento propuesto entre APPv y ur&#243;logo&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Todo el an&#225;lisis estad&#237;stico se realizar&#225; con el paquete estad&#237;stico SPSS 21&#46;0 &#40;SPSS Inc&#46; Headquarters&#44; Chicago&#44; Illinois&#44; Estados Unidos&#41;&#46; Todos los test se calcular&#225;n con un nivel de significaci&#243;n a<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05 y los intervalos de confianza se calcular&#225;n con el nivel de confianza 1-a<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;95&#46; Se estima el &#237;ndice de concordancia &#40;&#237;ndice kappa&#41; para la evaluaci&#243;n del objetivo principal &#40;se acepta la hip&#243;tesis del estudio si c-index &#8805; 0&#44;7&#41;&#46; Se eval&#250;a el riesgo de recidiva&#44; progresi&#243;n tumoral&#44; supervivencia global y CSS en el grupo de coincidencia de tratamiento ur&#243;logo-APPv y en el de no coincidencia mediante <span class="elsevierStyleItalic">log-rank test</span>&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Este estudio tiene la aprobaci&#243;n del Comit&#233; de &#201;tica del Pa&#237;s Vasco &#40;c&#243;digo interno PS2018004&#41; de fecha 12 de abril de 2018&#46; Todos los pacientes incluidos en el estudio han dado su consentimiento por escrito&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Este proyecto ha sido en parte financiado por el Departamento de Salud del Pa&#237;s Vasco &#40;N&#46;&#176; de expediente 2017111087&#44; BOPV n&#46;&#176; 133&#44; de 13 de julio de 2017&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Resultados</span><p id="par0205" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas cl&#237;nico-patol&#243;gicas de la serie global y en ambos grupos &#40;coincide tratamiento ur&#243;logo-APPv y no coincide&#41; se recogen en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Objetivo principal</span><p id="par0210" class="elsevierStylePara elsevierViewall">El tratamiento complementario intravesical prescrito por el ur&#243;logo coincide con el propuesto por la APPv en el 64&#37; de los casos &#40;&#237;ndice kappa 0&#44;55&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; un 31&#37; son infratratados y un 5&#37; sobretratados&#44; tomando el tratamiento propuesto por la APPv como referencia &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; En funci&#243;n del grupo de riesgo&#44; el tratamiento coincide para el bajo riesgo en un 77&#37; &#40;kappa 0&#44;55&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#44; en un 63&#37; &#40;kappa 0&#44;52&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;0001<span class="elsevierStyleItalic">&#41;</span> para el riesgo intermedio&#44; en un 17&#37; &#40;kappa 0&#44;143&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;014&#41; para alto riesgo y en un 66&#37; &#40;kappa 0&#44;71&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; para muy alto riesgo&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">El 25&#37; de los pacientes recidivan durante el seguimiento &#40;52&#37; pTa&#59; 20&#37; pT1&#59; 16&#37; pT2&#59; 12&#37; Cis&#44; 64&#37; de alto grado y 36&#37; de bajo grado&#41;&#46; En funci&#243;n del acuerdo APPv-ur&#243;logo y no acuerdo en el tratamiento&#44; la recidiva por grupo de riesgo es del 0&#37; vs&#46; 3&#44;8&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;23&#41; en el bajo riesgo&#44; 14&#44;6&#37; vs&#46; 50&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;002&#41; para el riesgo intermedio&#44; del 0&#37; vs&#46; 80&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;02&#41; para el alto riesgo y del 0&#37; vs&#46; 50&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;51&#41; para el muy alto riesgo&#46; Cuando ajustamos el an&#225;lisis de acuerdo del tratamiento ur&#243;logo-APPv&#44; el &#237;ndice kappa es de 0&#44;7 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; para los pacientes sin recidiva&#46; El 89&#44;1&#37; de los pacientes que reciben el tratamiento complementario intravesical acorde con la propuesta de la APPv contin&#250;an libres de recidiva&#44; frente al 61&#44;1&#37; en los que no hay acuerdo &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;0004&#41;&#44; con un RR 0&#44;46 &#40;IC&#160;95&#37;&#58; 0&#44;25-0&#44;86&#41; vs&#46; RR 2&#44;4 &#40;IC&#160;95&#37;&#58; 1&#44;5-3&#44;8&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; El 100&#37; de los pacientes estaban libres de progresi&#243;n en el grupo de acuerdo y el 88&#44;9&#37; en el grupo sin acuerdo &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41;&#44; con un RR 1 vs&#46; RR 1&#44;125 &#40;IC&#160;95&#37;&#58; 1-1&#44;26&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;004&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">La APPv propone completar el tratamiento local con re-RTU en el 46&#37; de los pacientes frente al 20&#37; propuesto por el ur&#243;logo &#40;kappa 0&#44;41&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; El 40&#37; de los pacientes en los que la APPv indica re-RTU y esta no se lleva a cabo recidivan&#44; frente al 18&#44;7&#37; de recidivas en el grupo en que s&#237; se realiza &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;031&#41;&#44; con un RR 0&#44;34 &#40;IC 95&#37;&#58; 02&#44;-0&#44;91&#41; vs&#46; RR 1&#44;4 &#40;IC 95&#37;&#58; 0&#44;97-1&#44;9&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;058&#41;&#46; Si aplicamos ambos criterios conjuntamente&#44; tratamiento complementario y re-RTU de prescripci&#243;n por ur&#243;logo y lo que propone la APPv&#44; el 92&#37; de los pacientes contin&#250;a libre de recidiva en el grupo de acuerdo frente al 66&#37; en el que no lo hay &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; con un RR 0&#44;23 &#40;IC 95&#37;&#58; 0&#44;08-0&#44;65&#41; vs&#46; RR 1&#44;4 &#40;IC 95&#37;&#58; 1&#44;12-1&#44;73&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; En este caso el porcentaje libre de progresi&#243;n en el grupo de acuerdo es del 100&#37; y del 92&#37; en el grupos sin acuerdo &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41;&#44; con un RR 1 vs&#46; RR 1&#44;09 &#40;IC&#160;95&#37;&#58; 1-1&#44;18&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;017&#41;<span class="elsevierStyleItalic">&#46;</span></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Objetivos secundarios</span><p id="par0225" class="elsevierStylePara elsevierViewall">La supervivencia global y la CSS en funci&#243;n del tratamiento recibido de acuerdo y no de acuerdo con la prescripci&#243;n de la APPv es del 96&#44;9&#37; vs&#46; 88&#44;9&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;153&#41; y del 100&#37; vs&#46; 91&#44;4&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;028&#41;&#44; respectivamente &#40;<a class="elsevierStyleCrossRef" href="#fig0020">fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">El 52&#37; de los pacientes completa el tratamiento complementario intravesical prescrito&#44; el 57&#37; en el grupo de acuerdo y el 39&#37; en el grupo sin acuerdo &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;273&#41;&#46; Los motivos de interrupci&#243;n del tratamiento son recidiva &#40;14&#37;&#41;&#44; efecto adverso &#40;10&#44;2&#37;&#41;&#44; problemas de suministro del f&#225;rmaco &#40;7&#44;2&#37;&#41;&#44; comorbilidad &#40;7&#44;2&#37;&#41;&#44; criterio facultativo &#40;7&#44;2&#37;&#41; y negativa del paciente &#40;3&#37;&#41;&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discusi&#243;n</span><p id="par0235" class="elsevierStylePara elsevierViewall">Existe un alto porcentaje de discordancia entre la propuesta que hace la APPv basada en las gu&#237;as de pr&#225;ctica cl&#237;nica y la que hace el ur&#243;logo &#40;36&#37;&#41;&#46; Esta diferencia en el tratamiento del NMIBC es similar a las documentadas en estudios previos&#44; que reportan entre un 47&#37; y un 64&#37; de prescripci&#243;n del tratamiento adecuado&#44; y que han sido explicadas por el hecho de que el ur&#243;logo basa sus decisiones&#44; adem&#225;s de en las gu&#237;as de pr&#225;ctica cl&#237;nica&#44; en datos subjetivos basados en su experiencia<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a>&#46; La baja adherencia a las recomendaciones de dichas gu&#237;as se traduce en un 15-20&#37; de los pacientes que no reciben ning&#250;n tratamiento complementario intravesical despu&#233;s de la RTU<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">16&#44;17</span></a>&#46; Estos pacientes se distribuyen por grupo de riesgo en 6-62&#37;&#44; 2-33&#37; y 1-35&#37; de los pacientes con bajo&#44; intermedio y alto o muy alto riesgo respectivamente<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">16&#44;17</span></a>&#46; Adem&#225;s de los pacientes que s&#237; reciben tratamiento complementario intravesical&#44; hasta un 53&#37; no reciben el tratamiento complementario de acuerdo con las recomendaciones de las gu&#237;as de pr&#225;ctica cl&#237;nica<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a>&#46; En concreto&#44; al 35-50&#37; de los pacientes con NMIBC de alto o muy alto riesgo se les prescribe el tratamiento intravesical pos-RTU con BCG durante menos de un a&#241;o o en un esquema de tratamiento diferente al recomendado<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a>&#46; Por otro lado&#44; el 65&#37; de las interrupciones del tratamiento no est&#225;n relacionadas con efectos adversos de la BCG<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">En nuestro estudio&#44; las mayores diferencias entre las recomendaciones de la APPv &#40;basadas en las gu&#237;as de pr&#225;ctica cl&#237;nica&#41; y la propuesta del ur&#243;logo se encuentran en el grupo de alto riesgo &#40;el 83&#37; de pacientes sin el tratamiento adecuado en nuestro estudio&#41; y en la realizaci&#243;n o no de re-RTU &#40;el 26&#37; de pacientes subsidiarios de re-RTU en nuestro estudio a quienes no se les realiza&#41;&#46; En cuanto al infratratamiento del NMIBC de alto riesgo&#44; es probable que indique una baja adherencia a los esquemas de tratamiento con BCG durante 3 a&#241;os<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">11&#44;17</span></a>&#44; a pesar de la superioridad en t&#233;rminos de recurrencia<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">25&#44;26</span></a>&#46; Este infratratamiento sucede especialmente en pacientes mayores &#40;&#8805;70 a&#241;os&#41;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a>&#46; Sin embargo&#44; esto no sucede con la APPv&#44; ya que en su algoritmo de decisi&#243;n aplica la escala de valoraci&#243;n geri&#225;trica de acuerdo con las recomendaciones actuales<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a>&#46; Respecto a la infrautilizaci&#243;n de la re-RTU&#44; estos datos est&#225;n en consonancia con lo documentado previamente&#44; ya que al 20-45&#37; de los pacientes con tumor de alto grado no se les realiza<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">15-17</span></a>&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Seg&#250;n nuestros resultados&#44; el incumplimiento de las recomendaciones en el tratamiento del NMIBC &#40;grupo sin acuerdo con la APPv&#41; se traduce en una mayor tasa de recidiva y progresi&#243;n y peor CSS&#46; Este dato no ha sido evaluado en los estudios de adherencia a las gu&#237;as&#44; ya que mayoritariamente se basan en encuestas sobre la pr&#225;ctica cl&#237;nica habitual&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">En la actualidad no podemos comparar los resultados propuestos por la APPv&#44; dado que no hay disponibilidad de otras aplicaciones de estas caracter&#237;sticas<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> que hayan sido desarrolladas seg&#250;n una metodolog&#237;a cient&#237;fica validada<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">22-24</span></a>&#46; Por tanto&#44; se requieren m&#225;s estudios multic&#233;ntricos de validaci&#243;n con la APPv&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Las principales limitaciones del estudio son ser unic&#233;ntrico y la existencia de un posible sesgo de informaci&#243;n en la medida del tama&#241;o tumoral&#44; que es subjetiva y&#44; aunque los observadores est&#225;n entrenados&#44; puede derivar en un sesgo de clasificaci&#243;n por grupo de riesgo&#44; probablemente no diferencial entre grupos&#46; Por otra parte&#44; el seguimiento medio inferior a 5 a&#241;os puede limitar los resultados debido a la baja ocurrencia de eventos &#40;recidiva y progresi&#243;n&#41; en ambos grupos&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusi&#243;n</span><p id="par0260" class="elsevierStylePara elsevierViewall">Este trabajo muestra como una app desarrollada seg&#250;n la metodolog&#237;a cient&#237;fica podr&#237;a contribuir a mejorar la adherencia a las recomendaciones de las gu&#237;as de pr&#225;ctica cl&#237;nica y&#44; por tanto&#44; los resultados en salud de los pacientes con NMIBC al disminuir la tasa de recidiva y progresi&#243;n y aumentar la CSS&#46; Si bien se necesitan m&#225;s estudios que confirmen la validez de esta APPv&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Financiaci&#243;n</span><p id="par0285" class="elsevierStylePara elsevierViewall">Este proyecto ha sido financiado por el Departamento de Salud del Gobierno Vasco &#40;n&#176; de expediente 2017111003&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicto de intereses</span><p id="par0265" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluar la concordancia global y ajustada por tasa de recidiva-progresi&#243;n de la prescripci&#243;n del tratamiento en el c&#225;ncer de vejiga no m&#250;sculo-invasivo &#40;NMIBC&#41; de una app basada en la mejor evidencia cient&#237;fica disponible y la opini&#243;n del ur&#243;logo&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Desarrollo de una app espec&#237;fica para el tratamiento y seguimiento del NMIBC &#40;APPv&#41; y validaci&#243;n de la variable de salida propuesta de tratamiento mediante un estudio de concordancia observacional prospectivo de muestras relacionadas a doble ciego en 100 pacientes con primer o sucesivo diagn&#243;stico histol&#243;gico de NMIBC&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El tratamiento prescrito por el ur&#243;logo coincide con el propuesto por la APPv en el 64&#37; de los casos &#40;&#237;ndice kappa 0&#44;55&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; La coincidencia para el bajo riesgo es del 77&#37; &#40;kappa 0&#44;55&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#44; 63&#37; &#40;kappa 0&#44;52&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; para el riesgo intermedio&#44; 17&#37; &#40;kappa 0&#44;143&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;014&#41; en alto riesgo y 66&#37; &#40;kappa 0&#44;71&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; para muy alto riesgo&#46; El 89&#44;1&#37; de los pacientes que reciben el tratamiento complementario intravesical acorde con la APPv contin&#250;an libres de recidiva&#44; frente al 61&#44;1&#37; en que no hay acuerdo &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0004&#41;&#44; con un RR de 0&#44;46 &#40;IC 95&#37;&#58; 0&#44;25-0&#44;86&#41; vs&#46; RR de 2&#44;4 &#40;IC 95&#37;&#58; 1&#44;5-3&#44;8&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; El 100&#37; de los pacientes est&#225;n libres de progresi&#243;n en el grupo de acuerdo y el 88&#44;9&#37; en el grupo sin acuerdo &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41; con un RR de 1 vs&#46; RR de 1&#44;125 &#40;IC 95&#37;&#58; 1-1&#44;26&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La APPv puede mejorar la adherencia a las recomendaciones de tratamiento seg&#250;n las gu&#237;as de pr&#225;ctica cl&#237;nica y los resultados en salud en el NMIBC&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To evaluate overall and recurrence-progression rate-adjusted concordance of treatment prescription in non-muscle-invasive bladder cancer &#40;NMIBC&#41; of an app based on the best available scientific evidence and the urologist&#39;s opinion&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Development of an app &#40;APPv&#41; specifically designed for the treatment and follow-up of NMIBC and validation of the proposed APPv treatment endpoint by means of a prospective double-blind observational concordance study of related samples in 100 patients with initial or successive histological diagnosis of NMIBC&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The treatment prescribed by the urologist agrees with that proposed by the APPv in 64&#37; of cases &#40;kappa index 0&#46;55&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Regarding low risk&#44; the agreement is 77&#37; &#40;kappa 0&#46;55&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#44; 63&#37; &#40;kappa 0&#46;52&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; for intermediate risk&#44; 17&#37; &#40;kappa 0&#46;143&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41; in high risk and 66&#37; &#40;kappa 0&#46;71&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; for very high risk&#46; Of patients receiving adjuvant intravesical treatment according to APPv&#44; 89&#46;1&#37; remain free of recurrence vs&#46; 61&#46;1&#37; of those with disagreement &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0004&#41;&#44; with a RR 0&#46;46 &#40;95&#37;CI&#58; 0&#46;25-0&#46;86&#41; vs&#46; RR 2&#46;4 &#40;95&#37;CI&#58; 1&#46;5-3&#46;8&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; In the APPv-urologist agreement group&#44; 100&#37; of patients are free of progression and 88&#46;9&#37; in the disagreement group &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41; with a RR 1 vs&#46; RR 1&#46;125 &#40;95&#37;CI&#58; 1-1&#46;26&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">APPv can improve adherence to treatment recommendations according to clinical practice guidelines and health outcomes at NMIBC&#46;</p></span>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Charlson &#40;rango&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&#44;5 &#40;2-13&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Muscular en muestra RTU diagn&#243;stica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intermedio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alto&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Muy alto&nbsp;\t\t\t\t\t\t\n
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                  """
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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas cl&#237;nico-patol&#243;gicas en ambos grupos de tratamiento &#40;grupo acuerdo ur&#243;logo-APPv&#44; grupo no acuerdo ur&#243;logo-APPv&#41; y en la serie global</p>"
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        "etiqueta" => "Tabla 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Tabla "
            "rol" => "short"
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                0 => """
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tratamiento propuesto por la APPv</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BCG 1 a&#241;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BCG 3 a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cistectom&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Tipos de tratamiento pos-RTU propuesto por el ur&#243;logo y tratamiento propuesto por la APPv</p>"
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                  "referenciaCompleta" => "Estimaciones de la incidencia de c&#225;ncer en Espa&#241;a&#44; 2020&#46; Red Espa&#241;ola de Registros de C&#225;ncer &#40;REDECAN&#41;&#44; Enero 2020 &#91;consultado 15 Sept 2021&#93;&#46; Disponible en&#58; https&#58;&#47;&#47;redecan&#46;org&#47;redecan&#46;org&#47;es&#47;Informe&#95;incidencia&#95;REDECAN&#95;2020&#46;pdf"
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                            0 => "M&#46; Burger"
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es en pt

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