A risk stratification tool to optimise the treatment pathway of patients with newly diagnosed bladder cancer in the covid-19 era

ABSTRACT

INTRODUCTION AND OBJECTIVE: The pandemic has resulted in increased pressures on waiting times for elective cancer surgery due to significant cancellations during national lockdowns, which has adversely impacted on patient care. Treatment of patients with high-risk bladder cancer (HBC) is time-critical. They often also require adjunctive treatment following their index transurethral resection of bladder tumour (TURBT) including intravesical immunotherapy or cystectomy, thus any delays may result in disease progression and adverse outcomes. We conducted a service improvement project to prioritise patients with newly diagnosed HBC on the waiting list. METHODS: We collected data on all patients with newly diagnosed bladder tumours at the Haematuria Clinic from July 2020 to January 2021 at our District General Hospital, paying particular attention to the following parameters time interval from flexible cystoscopy (FC) to TURBT;quality of bladder tumour assessment at diagnostic FC;differences in time interval between low-risk bladder cancer (LBC) and HBC. We excluded patients operated on in the emergency setting, those with equivocal findings at FC and those with recurrent bladder cancer. We developed a risk stratification tool based on the NICE guidelines, in order to help triage patients at the Haematuria Clinic into low-risk and high-risk with a view to expediting treatment for those with suspected HBC. On the waiting list request form, those with suspected HBC are listed as Category 2A, and those with low/ intermediate risk as Category 2B. RESULTS: 45 patients had newly diagnosed bladder tumours during that seven-month period. There was a male preponderance overall, with a median age of 73 in the low-risk group, 79.5 in the intermediate-risk and 71.5 in the high-risk group. 60% of patients were inadequately risk-stratified at the time of their index FC. The mean interval from FC to TURBT was 30 days in the low-risk group, 26 in the intermediate-risk group and 31 days in the high-risk group. CONCLUSIONS: A significant proportion of newly diagnosed bladder cancer patients were inadequately risk-stratified at FC. Moreover, patients with HBC are waiting just as long if not longer than patients with LBC disease for their TURBT. By designing and implementing a simple risk stratification tool to be used at the Haematuria Clinic we have prioritised those with suspected high-risk disease to the top of the waiting list in order to avoid delays and optimise their care. We currently await the outcome of a re-audit of our practice.