Delay from Upper Tract Urothelial Cancer Diagnosis to Surgery Linked with Poor Outcomes

A delay in the receipt of definitive radical cystectomy or radical nephro-ureterectomy (RNU) was associated with poor survival in patients with urothelial carcinoma of the bladder upper tract (UTUC), according to a recent meta-analysis published in Frontiers in Surgery.

“The impact of the COVID-19 crisis on elective urological cancer surgery has been significant and disruptive worldwide and is compounded by the concerns of a second or third wave of COVID-19 cases,” wrote Jeffrey J. Leow, of Tan Tock Seng Hospital, Singapore, and colleagues. “The [European Association of Urology] Guidelines Office Rapid Reaction Group recommend that radical cystectomy should be performed within 3 months from MIBC diagnosis and RNU within 6 weeks of high-risk UTUC diagnosis.”

Leow and colleagues conducted a meta-analysis of data from 30 studies investigating delayed urologic cancer surgery up to June 2020. The researchers explained varying definitions of delay to radical cystectomy, with 11 studies identifying the ‘start point’ as ‘diagnosis of bladder cancer,’ while another 10 used ‘time of transurethral resection of bladder tumour’ (TURBT).

Six studies evaluated delay of RNU for UTUC; these included 4,629 patients. For the delay between diagnosis of UTUC and RNU, the pooled hazard ratio (HR) for overall survival was 1.55 (P=.001); for cancer-specific survival it was 2.56 (P=.001).

Thirteen studies evaluated a delay from diagnosis of bladder cancer/TURBT to radical cystectomy. Here delay was associated with poorer overall survival (HR=1.25; P=.002).

The poorer outcomes were attenuated in patients who underwent neoadjuvant chemotherapy prior to radical cystectomy. In 5 studies, a delay between neoadjuvant chemotherapy and radical cystectomy was not significantly associated with overall survival (HR=1.37; P=.08).

Although the study was prompted by the pandemic, the researchers pointed out that delays to surgery can be multifactorial.

“Patients undergoing radical cystectomy or RNU are often elderly and may have cardiovascular and respiratory comorbidities following years of exposure to cigarette smoking,” the researchers wrote. “Hence, it is likely this patient cohort requires a multidisciplinary evaluation and a period of ‘prehabilitation’ prior to radical surgery which may result in a delay in time to treatment.”

Delays may also result when referral from a community hospital is necessary.

“As the world moves on from the COVID-19 pandemic, healthcare systems can learn from the gaps exposed and put together comprehensive plans to remedy shortcomings in healthcare inefficiencies, particularly those related to delay in definitive treatment for cancer,” the researchers wrote.