Treatment of muscle-invasive bladder cancer in Canada: A survey of genitourinary medical oncologists and urologists

Abstract

Introduction: Uptake of neoadjuvant chemotherapy (NC) for muscle invasive bladder cancer (MIBC) has been low despite evidence of a survival benefit. The primary aim of this study was to better understand why the rates are low and determine what factors specifically influence the decision to recommend NC for MIBC. Methods: A 31-question survey was emailed between 2009 and 2011 to medical oncologists belonging to the Canadian Association of Genitourinary Medical Oncologists (CAGMO); and to urologists belonging to the Canadian Urologic Oncology Group (CUOG). We gathered data on practice characteristics, referrals for NC, factors influencing NC use, and chemotherapy regimens offered. Responses were summarized using descriptive statistics. Results: In total, 26/30 (87%) medical oncologists and 25/84 (30%) urologists, who were primarily academic, completed the survey. Most clinicians (medical oncologists 96%, urologists 88%) recommended NC for MIBC, because they considered it to be the standard of care, but most medical oncologists saw ≤6 referrals annually. Performance status, presence of comorbidities and renal function were key considerations in offering NC. NC was not offered if performance status ≥2 (medical oncologists 38%, urologists 44%), age >80 (medical oncologists 46%, urologists 39%), or glomerular filtration rate ≤40 mL/min (medical oncologists 81%, urologists 50%). Conclusions: Most academic clinicians in Canada believe that cisplatin-based combination NC is the standard of care for MIBC and recommend it for patients with adequate performance status and renal function. Using a multidisciplinary approach to treat this disease may be one strategy to increase referral rates for NC and uptake of NC.

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).…”

“…The study did not explore barriers and enablers of chemotherapy delivery. In a survey of 51 Canadian MOs and urologists Hsu et al (18) found that >88% of respondents reported offering NACT to patients with MIBC. While the focus of Hsu's study was the impact of patient comorbidity on physician practice, the authors mention that provider-and system-level barriers to chemotherapy delivery included: belief that NACT does not improve survival, concern about disease progression during delivery of NACT, and lack of chemotherapy uptake in the community.…”

“…Most studies are surveys that describe self-reported practice patterns but do not investigate underlying knowledge, attitude, and beliefs (17)(18). To our knowledge there are no studies that use a knowledge translation (KT) conceptual framework.…”

Contemporary Patterns of Multidisciplinary Care in Patients With Muscle-invasive Bladder Cancer

“…A prime example of how a multidisciplinary model can influence treatment recommendations is the increase in the utilization of neoadjuvant chemotherapy in MIBC. Despite level 1 randomized clinical trial data supporting its clinical benefits, preoperative systemic therapy has traditionally had poor uptake in contemporary studies 13, 14 This low usage has been attributed to patient related factors (e.g., age, co-morbidities and stage), physician disbelief in the degree of benefit, and referral patterns at non-academic institutions 15, 17 A previous survey of genitourinary medical oncologists in Canada revealed that the referral rates for neoadjuvant chemotherapy were the highest in the setting of an established care pathway or a multidisciplinary clinic 16 . Supporting this observation, other studies have demonstrated a significant increase in adherence to guidelines and utilization of neoadjuvant chemotherapy with the initiation of a multidisciplinary model 21, 22…”

Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada

“…Significant systematic variation in NAC utilization rates also exist [117]. In settings where a multidisciplinary approach is used, rates of NAC use are higher, up to 50% [118,119]. This highlights the importance of ongoing multidisciplinary collaboration, patient and provider education.…”