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Delays in radical cystectomy linked to shorter bladder cancer survival
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Delays in radical cystectomy appeared associated with increased mortality among patients with muscle-invasive bladder cancer, regardless of whether they received neoadjuvant chemotherapy, according to study results published in Cancer.
Those more likely to experience delays when going directly to radical cystectomy without neoadjuvant chemotherapy included men, residents of high-poverty or rural areas, and patients who transferred care to another provider after transurethral resection of the bladder tumor.
“Timely surgery is fundamental to the optimal management of [muscle-invasive bladder cancer], and this necessitates attention to the impact of health disparities on timely access to complex surgical care and care coordination, especially for patients requiring provider transfers between [transurethral resection] and [radical cystectomy],” Alice T. Chu, BS, research assistant in the department of urology at University of Washington, and colleagues wrote.
Chu and colleagues sought to determine whether delays in performing radical cystectomy after unsuccessful treatment with transurethral resection of a bladder tumor had any effect on health outcomes.
The researchers used the SEER-Medicare linked database to identify 1,509 patients with confirmed stage II urothelial carcinoma of the bladder who underwent radical cystectomy between 2004 and 2012.
The study population included 1,238 patients (mean age, 75.2 years; 73% men; 88.8% white non-Hispanic) who underwent radical cystectomy after transurethral resection and 271 patients (mean age, 72.9 years; 73.4% men; 84.9% non-Hispanic white) who received neoadjuvant chemotherapy before radical cystectomy.
Results showed delays beyond 12 weeks from transurethral resection to radical cystectomy resulted in increased mortality, both without neoadjuvant chemotherapy use (HR = 1.34; 95% CI 1.03-1.76) and after neoadjuvant chemotherapy (HR = 1.63; 95% CI 1.06-2.52).
Patients who did not receive chemotherapy before radical cystectomy most often experienced delays in surgery if they were men (OR = 2.22; 95% CI, 1.25-4) or lived in high-poverty (OR = 1.37; 95% CI, 1.01-2.08) or nonmetropolitan areas (OR = 1.61; 95% CI, 1.01-2.55).
Patients who required a transfer in care to a different provider also appeared more likely to face delays in radical cystectomy (OR = 1.82; 95% CI, 1.1-3.03).
“These factors may be surrogates for challenges accessing providers who manage complex cancers,” Chu and colleagues wrote. “Patients who had different providers perform [transurethral resection] and [radical cystectomy] were more likely to experience delays in definitive local treatment.”
This study was limited by its retrospective design and the use of database-linked national registry data, which can be susceptible to coding inaccuracies and changes. The investigators noted their inability to determine disease progression at the time of radical cystectomy from its initial entry into the SEER database, which could influence the survival models they produced.
“Mechanisms to improve transitions from [neoadjuvant chemotherapy to radical cystectomy]are critical; ensuring that high-volume centers are aware of [neoadjuvant chemotherapy] patients before its completion can help to avert [radical cystectomy] delays,” Chu and colleagues wrote. “Investments in interventions that augment natural health services processes, such as secondary referrals, could streamline care for patients with complex cancer to reduce delays in appropriate and necessary expert care and ultimately optimize patient-centered outcomes.”
Heightened regionalization and specialization of surgical procedures, such as radical cystectomy, are primary factors in the delay to surgery experienced by patients with bladder cancer, Selma Masic, MD, and Marc C. Smaldone, MD, both of the division of urology and urologic oncology at Fox Chase Cancer Center, wrote in an accompanying editorial.
“As an increasing proportion of patients transition their care to high-volume centers, opportunities for delay will undoubtedly present themselves because strategies for optimizing care transitions have only recently become a priority of contemporary health care reform efforts,” they wrote. “Because of the large body of evidence supporting the importance of timely oncologic treatment, minimizing treatment delays has become a central focus for contemporary health care reform and is more relevant than ever in the setting of increasing regionalization.”
Masic and Smaldone wrote that the study provides evidence of the socioeconomic disparities that can lead to delays in care and agreed with Chu and colleagues that providing streamlined health care services to patients with complex cancers, such as muscle-invasive bladder cancer, is crucial to improving outcomes.
“As policies addressing the problematic consequences of regionalization are implemented, special consideration for worsening access disparities will be of the utmost importance,” Masic and Smaldone wrote. “As we continue to treat patients with muscle-invasive bladder cancer in an ever-evolving health care system, we must remain focused on implementing sound policies that benefit patients on an individual and national level, minimize treatment delays, and do not leave out the most vulnerable members of society, who are already the most likely to be affected by untoward consequences of reform.” – by Drew Amorosi
Disclosure: University of Washington School of Medicine and the Howard J. Cohen Bladder Cancer Foundation supported this study. Chu reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Masic and Smaldone report no relevant financial disclosures.
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Chu AT, et al. Cancer. 2019;doi:10.1002/cncr.32048.
Masic S and Smaldone MC. Cancer. 2019;doi:10.1002/cncr.32047.
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