QuickScan Reviews in Urology, March 15 2009

Objective: Test the impact of delay in time to cystectomy and mortality in a national database. Participants/Methods: Using a linked Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset, 441 patients were indentified who underwent radical cystectomy for stage II bladder cancer within 4 to 52 weeks of diagnosis and who did not receive preoperative chemotherapy. Survival models were constructed to test the potential association between time from diagnosis to cystectomy and mortality. Results: Compared to patients who received a cystectomy within 8 weeks, those whose cystectomy was delayed beyond 12 weeks from time of diagnosis at endoscopic resection had worse overall and disease-specific mortality. Other variables associated with worse overall survival included increasing age and increasing comorbidities. Conclusions: Delaying radical cystectomy beyond 12 weeks from the time of diagnosis is associated with worse overall and disease-specific mortality. Reviewer's Comments: Muscle-invasive bladder cancer can present one of the biggest challenges to urologists. We know it is a lethal disease, and the best option for management involves radical cystectomy. We also know that this is a potentially morbid operation, made more complex by advanced age and comorbidities of the typical bladder cancer patient. Therefore, it can be difficult to get a patient from diagnosis of muscle invasive bladder cancer to the point of getting their cystectomy. Several studies from single institutions have shown an association between delays in this process and worse outcomes. In the present study, the authors sought to ask the same question but at the national level to account for potential differences across regional and institution-specific variations in practice. Their results again confirm that it is important to move a patient as expeditiously as possible from diagnosis to cystectomy, since a delay of >12 weeks is associated with worse overall and disease-specific mortality. The study is well done, within the limits of any national database study. Limitations that are true for all such studies include the fact that it only looks at Medicare-eligible patients, cannot account for details on the source of any delay to surgery, and inherent potential inaccuracies of using claims data to assess procedure details and outcomes. It is also important to bear in mind that this study specifically does not address the issue of neoadjuvant chemotherapy and its role in invasive bladder cancer, since the time period of the study precedes the growing utilization of that approach, and that particular population was specifically excluded from analysis. These issues not withstanding, this study serves as another reminder that muscle-invasive bladder cancer is a potentially lethal disease in which any undo delay from diagnosis to definitive therapy should be avoided whenever possible.