Main Article Content
Introduction: Elective waiting lists have become more stretched because of the COVID-19 pandemic and patients have evidently been waiting longer for treatment. Patients with high-risk bladder cancer require timely treatment and there is strong evidence to suggest that delay in treatment contributes to a risk of disease progression, metastases and death. Studies have shown that bladder tumour appearances at flexible cystoscopy (FC) can accurately predict high-risk disease on histopathology following transurethral resec-tion. An opportunity for service improvement resulted in a review of the practice followed by the authors and the development of a risk stratification tool for the haematuria clinic which aimed to prioritise the
pathway of those with high-risk disease.
Materials and methods: A risk stratification tool was developed for patients with newly diagnosed bladder tumours at the haematuria clinic. A tumour assessment carried out at FC is used to predict patients with high-risk disease, thus allowing those patients to be prioritised over those with low-risk disease on the waiting list. It also includes a reminder to request staging investigations for those with suspected high-risk disease. A closed loop audit was carried to review the following: the quality of tumour risk assessment at the haematuria clinic; time from FC to transurethral resection of bladder tumour (TURBT); concordance between tumour assessment at FC and histopathology after TURBT; efficiency of arranging early staging investigations for those with suspected high-risk bladder cancer; time from FC to staging CT scan.
Results: A risk assessment was carried out for 93% of patients in the second cycle compared with 40% in the first cycle. Concordance was noted in 83% of those with confirmed high-risk non-muscle invasive bladder cancer (NMIBC) and 83% of muscle invasive bladder cancer (MIBC) in the first cycle, and in 100% of patients with high-risk NMIBC and MIBC in the second cycle. The interval from FC to TURBT decreased from 27 days in the first cycle to 21 days in the second cycle in those with high-risk NMIBC, and from 27 to 13 days in those with MIBC. Time from FC to staging CT for patients with high-risk bladder cancer was 6 days in the first cycle and 3 days in the second cycle if the request was made from the haematuria clinic. If the CT scan was requested later, the interval increased to 39 days in the first cycle and 22 days in the second cycle.
Conclusion: There is a high degree of concordance between tumour risk assessment at FC and final pathol-ogy following TURBT which is supported by several series. Performing risk assessment and requesting staging investigations at the haematuria clinic for patients with newly diagnosed high-risk bladder cancer can minimise delays in their treatment pathway and improve patient outcomes.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright of articles published in all DPG titles is retained by the author(s). The author(s) grants DPG the rights to publish the article and identify itself as the original publisher. The author grants DPG exclusive commercial rights to the article. The author grants any party the rights to use the article freely for non-commercial purposes provided that the original work is properly cited.
2. Costing report: bladder cancer [Online]. Nice.org.uk. 2015 [cited 14 May 2021]. Available from: https://www.nice.org.uk/guidance/ng2/resources/costing-report-pdf-3780397.
3. Cancer Research UK [Online]. Cancerresearchuk.org. 2020 [cited 10 May 2021 May 10]. Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bladder-cancer#:~:text=In%20females%20in%20the%20UK%2C%20bladder%20cancer%20is%20the%2013th,around%203%2C700%20deaths%20in%202018.
4. Cox E, Saramago P, Kelly J et al. Effects of bladder cancer on UK healthcare costs and patients' health-related quality of life: evidence from the BOXIT trial. Clin Genitourin Cancer. 2020 August; 18(4):418-42.
5. Harrison S [Online]. Gettingitrightfirsttime.co.uk. 2018 [cited 10 May 2021]. Available from: https://www.gettingitrightfirsttime.co.uk/wp-content/uploads/2018/07/Urology-June18-M.pdf.
6. Wallis C, Novara G, Marandino L et al. Risks from deferring treatment for genitourinary cancers: a collaborative review to aid triage and management during the COVID-19 pandemic. Eur Urol. 2020 July; 78(1):29-42.
7. NICE guidelines. [Online]. Nice.org.uk. 2015 [cited 10 May 2021]. Available from: https://www.nice.org.uk/guidance/ng2/resources/bladder-cancer-diagnosis-and-management-pdf-51036766405.
8. The Lancet Rheumatology. Too long to wait: the impact of COVID-19 on elective surgery. Lancet Rheumatol. 2021 February; 3(2).
9. Babjuk M, Burger M, Comperat E et al. uroweb.org. [Online]. Uroweb.org. 2021 [cited 10 May 2021]. Available from: https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/.
10. Knowles M, Hurst C. Molecular biology of bladder cancer: new insights into pathogenesis and clinical diversity. Nat Rev Cancer. 2015 January; 15(1):25-41.
11. Sylvester R, Oosterlinck W, Holmang S et al. Systematic Review and Individual Patient Data Meta-analysis of Randomized Trials Comparing a Single Immediate Instillation of Chemotherapy After Transurethral Resection with Transurethral Resection Alone in Patients with Stage pTa-pT1 Urothelial Carcinoma. Eur Urol. 2016 February; 69(2):231-44.
12. Wallis C, Catto J, Finelli A et al. The impact of the COVID-19 pandemic on genitourinary cancer: re-envisioning the future. Eur Urol. 2020 November; 78(5):731-42.
13. Matulay J, Soloway M, Witjes J et al. Risk-adapted management of low-grade bladder tumours: recommendations from the international bladder cancer group (IBCG). BJUI. 2020 Jan; 125(4):497-505.
14. Herr H. Tumor progression and survival of patients with high grade, noninvasive papillary (TaG3) bladder tumors: 15-year outcome. J Urol. 2020 January; 163(1):60-1.
15. Nieder A, Brausi M, Lamm D et al. Management of stage T1 tumors of the bladder: International Consensus Panel. Urology. 2005 December; 66(6):108-25.
16. Pasin E, Josephson D, Mitra A et al. Superficial bladder cancer: an update on etiology, molecular development, classification, and natural history. Rev Urol. 2008; 10(1):31-43.
17. Gore J, Lai J, Setodji C et al. Mortality increases when radical cystectomy is delayed more than 12 weeks. Cancer. 2009 January; 115(5):988-96.
18. Fahmy N, Mahmud S, Aprikian A. Delay in the surgical treatment of bladder cancer and survival: systematic review of the literature. Eur Urol. 2006 December; 50(6):1176-82.
19. During V, Sole G, Jha A et al. Prediction of histological stage based on cystoscopic appearances of newly diagnosed bladder tumours. Ann R Coll Surg Engl. 2016 November; 98(8):547-51.
20. Mitropoulos D, Kiroudi-Voulgari A, Nikolopoulos P et al. Accuracy of cystoscopy in predicting histologic features of bladder lesions. J Endourol. 2005 September; 19(7):861-4.
21. Satoh E, Miyao N, Tachiki H et al. Prediction of muscle invasion of bladder cancer by cystoscopy. Eur Urol. 2002 February; 41(2):178-81.