Audit of patient pathway for those receiving radical radiotherapy for bladder cancer

The multi-modality nature of radical bladder cancer treatment requires interdisciplinary expertise and effective multi-disciplinary pathways for successful care delivery.

Surgery, chemotherapy and radiotherapy are all used in the radical treatment of muscle invasive bladder cancer. Transurethral resection of the bladder tumour (TURBT) is the initial treatment. It also provides important pathological information about tumour stage. Neo-adjuvant chemotherapy has demonstrated 5% survival benefit at 5 years prior to definitive treatment (radiotherapy or surgery) [1]. Good response to neo-adjuvant chemotherapy (as assessed on cystoscopy) can also be used to identify individuals particularly suitable for radiotherapy. Radiotherapy delivered with concurrent chemotherapy provides cure equivalent to cystectomy but allows functional bladder preservation [2].

Integrating this complex multidisciplinary treatment approach lends itself to potential delays. The chronological pathway of radical bladder cancer patients should be audited to ensure that significant delays are not occurring, as delays to definitive treatment are known to adversely affect patient outcome [3-5]. In the UK where multidisciplinary team directed care is mandatory and the majority of oncologists deliver both radiotherapy and chemotherapy it should be possible to ensure that definitive treatment is started in a timely manner.

The standard: 

Compliance with Department of Health recommendations (and additional local guidelines if in place)

Including:

• Documented MDT discussion

• Patient seen within 2 weeks if referred as urgent suspected cancer by GP

• Maximum 62 days from GP referral with urgent suspected cancer to first treatment

• Maximum 18 weeks from referral to start of treatment

• Maximum 90 days from diagnosis to start of treatment

• Maximum 31 days from decision to treat to start of treatment

Target: 

100% compliance; non-compliance justified with clinical reasons.

Indicators: 

Percentage of patients attending for bladder radiotherapy that do not exceed their breach deadlines.

Data items to be collected: 

Review patient pathway attending for bladder radiotherapy in a set time frame

• Record

• Referral source

• Evidence of MDT review

• Time from TURBT to treatment

Consider breakdown of pathway to also review

• Time from TURBT to pathology reporting

• Time from TURBT reporting to oncology referral

• Time from surgical referral (post TURBT) to receipt of referral by oncology team

• Time from receipt of referral by oncology team to appointment with oncology team

• Time from oncology review to start of treatment

Suggested number: 

All patients with bladder cancer treated with radiotherapy over 6-month period.

• Present audit results at appropriate local uro-oncology clinical governance meeting in order to raise awareness of issue

• Patients identified with localised or locally advanced bladder cancer should be discussed at centralised urology MDT

• Consider bladder cancer specific MDT performa with defined target times from TURBT to start of treatment

• MDT performa to be used as direct referral to cancer centre

• Access to patient notes

• Estimated time for completion 12 hours - no additional costs or expertise anticipated

1. Neoadjuvant chemotherapy in invasive bladder cancer: update of a systematic review and meta-analysis of individual patient data advanced bladder cancer (ABC) meta-analysis collaboration. Eur Urol. 2005;48(2):202-5; discussion 5-6.

2. James ND, Hussain SA, Hall E, Jenkins P, Tremlett J, Rawlings C, Crundwell M, Sizer B, Sreenivasan T, Hendron C et al: Radiotherapy with or without chemotherapy in muscle-invasive bladder cancer. N Engl J Med 2012, 366(16):1477-1488

3. NICE Guidelines. Improving outcomes in urological cancers 2002.

4. Multi-disciplinary Team (MDT) Guidance for Managing Bladder Cancer. 2nd Edition (January 2013). British Uro-oncology Group (BUG); British Association of Urological Surgeons (BAUS) Section of Oncology; Action on Bladder Cancer (ABC)

5. SIGN. Management of transitional cell carcinoma of the bladder. A national clinical guideline. 2006.

Shaista Hafeez