The initiation of a multidisciplinary bladder cancer clinic and the uptake of neoadjuvant chemotherapy: A time-series analysis

Abstract

Introduction: While level 1 evidence supports the use of neoadjuvant chemotherapy (NAC) for patients with muscle-invasive bladder cancer (MIBC), its uptake has been underwhelming, even in academic centres. Our aim was to determine if the initiation of a multidisciplinary bladder cancer clinic (MDBCC) in 2008 at our institution, where patients are assessed simultaneously by bladder cancer-focused urologists and radiation oncologists with easy access to a medical oncologist, was associated with an increased use of NAC. Methods: Patients with MIBC initiating treatment between July 2000 and June 2013 were identified and classified by academic year (July 1 to June 30). Time-series analyses using interventional autoregressive integrated moving average (ARIMA) models with ramp intervention functions were then conducted. A sensitivity analysis was performed on clinical N0 patients. Results: The cohort included 278 patients: 168 from 2000-2007 and 110 from 2008-2012 (academic years). Forty-two (15.1%) patients received NAC and 74 (26.6%) received adjuvant chemotherapy (AC). Overall the proportion of patients receiving NAC increased from 7.7% before the MDBCC to 47.6% in 2012 (Interventional ARIMA p=0.036). The results were similar when restricting to cN0 patients (p<0.001). NAC use gradually increased over time regardless of MDBCC attendance, although the proportion of patients receiving NAC appears to have risen more sharply among MDBCC attendees. Conclusions: At our institution, the initiation of the MDBCC was temporally associated with increased use of NAC. In addition to multidisciplinary collaboration, having a critical mass of NAC physician advocates and support from institutional leaders are essential to the uptake of NAC.

Perioperative chemotherapy for bladder cancer: A qualitative study of physician knowledge, attitudes, and behaviour

“…Consistent with other reports, our results suggest that a multidisciplinary approach to MIBC management is critical to increase referral and rates of chemotherapy uptake (16,18,28). Further, our results support the need for physician advocates and institutional support and policy to increase chemotherapy uptake (16,28).…”

Treatment of bladder cancer in the elderly

“…For instance in Toronto's MDBCC, a team of specialized oncologists can provide a thorough discussion with patients as to what the best care for them can be [ 16 ]. Through the MDBCC, MIBC patients can decide undergo trimodal bladder preservation treatments, with RadC as salvage therapy [ 70 ]. Trimodal therapy in elderly patients has been found to be well tolerated with outcomes similar to that of RadC [ 71 ].…”

Bladder Cancer Multidisciplinary Clinic (BCMC) Model Influences Disease Assessment and Impacts Treatment Recommendations

“…Reports on BCMC models and their impact on patient care are limited in the literature. Nayan et al documented an increase in NAC utilization after a BCMC model was adopted in their institution, from 8% to 48%, although a similar trend was also observed across the years, but to a lesser extent, in patients that did not attend their multidisciplinary clinic [8]. However, there was no data comparison with outside referring providers in that study.…”

“…Multidisciplinary clinics for genitourinary malignancies have emerged lately, predominantly around prostate cancer care [6,7] and more recently for bladder cancer (BC) care [8][9][10]. It has been suggested that multidisciplinary clinics are more likely to follow evidence-based practice recommendations compared to health care facilities without this integrative model [2].…”

“…It has been suggested that multidisciplinary clinics are more likely to follow evidence-based practice recommendations compared to health care facilities without this integrative model [2]. For BC in particular, an increase in administration of standard-of-care neoadjuvant chemotherapy (NAC) from 7.7% to 47.6% prior to radical cystectomy (RC) has been reported in a tertiary center, after the initiation of a bladder cancer multidisciplinary clinic (BCMC) [8], and referral to high volume tertiary institutions has been encouraged for BC care [11]. In addition, Kulkarni et al reported a significant change in BC staging after imaging and pathology review of outside records, in combination with additional imaging ordered during multidisciplinary evaluation, dictating vital treatment alterations [10].…”