Medical–surgical integration ‘boosts neoadjuvant chemotherapy use for bladder cancer’

Research from the USA indicates that a multidisciplinary approach and coordination between medical and surgical oncology services can help optimize the use of neoadjuvant chemotherapy for bladder cancer.

However, patient-related factors, such as comorbidities, were the main reason patients did not receive perioperative chemotherapy, which has failed to become the standard of care despite being shown to improve outcomes, including risk for recurrence and mortality.

Khurshid Guru (Roswell Park Cancer Institute, Buffalo, New York) and colleagues studied two sets of data on patients undergoing robot-assisted radical cystectomy (RARC). In phase I, 148 patients treated at their institution between 2005 and 2011 had cT2-stage disease or higher and were deemed eligible for neoadjuvant chemotherapy, while136 had at least T2 disease or nodal involvement and were considered candidates for adjuvant chemotherapy. In phase II, after the implementation of a practice-based learning and improvement approach, 42 patients underwent RARC during a single year.

In phase I, 44 (29.7%) patients underwent consultation for neoadjuvant chemotherapy, of whom 16 received it, three refused, 14 were recommended for immediate radical cystectomy, and 11 were not deemed candidates.

In phase II of the study, the institution adopted a more stringent algorithm for patient treatment, in which every new patient with T2 or higher disease was seen by both surgical and medical services, all patients scheduled for radical cystectomy were discussed at the multidisciplinary tumor board conference, and patients with upstaged disease on review were referred for a medical oncology consult.

By contrast with the first phase of the study, 21 (77.7%) of 27 eligible patients now received a medical oncology consultation for neoadjuvant chemotherapy, of whom 15 received the treatment, two refused the treatment, and four patients were deemed unsuitable candidates. This gave a utilization rate of 55.6% compared with 10.8% in phase I of the study.

However, the approach did not significantly affect rates of referral for adjuvant chemotherapy, with 79% of eligible patients referred for medical oncology in phase I versus 56% in phase II.

The team notes that the primary reason for not receiving neoadjuvant chemotherapy was patient comorbidities, such as renal disease.

Nevertheless, they suggest their results indicate that “[a] practice-based learning and improvement approach could improve the use of [neoadjuvant chemotherapy] by a collaborative effort between urologic oncology and medical oncology practices.”

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