Identifying Institutional Causes of Delay to Radical Cystectomy among Patients with High Risk Bladder Cancer Treated at a Tertiary Referral Center Using Process Map Analysis.

INTRODUCTION: Treatment delay among patients with muscle invasive bladder cancer is associated with reduced survival. With limited existing literature examining institutional causes of treatment delay, we identified such causes of delay to radical cystectomy among patients with high risk bladder cancer. METHODS: We conducted a retrospective review of 176 patients with bladder cancer who underwent radical cystectomy at our tertiary referral center in 2013 to 2014. Process mapping was used to define each step in the path to cystectomy and the time interval between each step was quantified. Patients experiencing treatment delay (more than 90 days to cystectomy or chemotherapy initiation) were identified and the causes of delay examined. RESULTS: Median time from diagnosis to referral was 17 days (IQR 9-36). Following referral the urology and medical oncology evaluations occurred at a median of 5 (IQR 2-9) and 6 days (IQR 1-9), respectively. Median time from urological evaluation to transurethral resection was 14 days (IQR 8-20) and from oncology evaluation to chemotherapy initiation was 9 days (IQR 7-14). Median time to cystectomy for patients proceeding directly from urological evaluation was 28 days (IQR 20-46). Longer intervals were noted from transurethral bladder tumor resection or chemotherapy completion to cystectomy (41 and 44 days, respectively). Overall 24 patients (13.6%) experienced treatment delay. Delays in referral, awaiting preoperative medical clearance, staging studies and surgical scheduling prolonged the time to treatment. CONCLUSIONS: Several institutional factors contribute to treatment delays among patients with bladder cancer. Process mapping allowed characterization of complex paths to cystectomy and identification of causes of treatment delay.

Multidisciplinary Clinics for Colorectal Cancer Care Reduces Treatment Time.

INTRODUCTION: Management of locally advanced and metastatic colorectal cancer (CRC) requires the expertise of multiple specialists. Multidisciplinary clinics (MDCs) are a working model designed to facilitate delivery of coordinated care. The present study evaluated the effects of MDC on the time to treatment (TTT). PATIENTS AND METHODS: Patients with CRC or locally advanced anal cancer who were evaluated at a single-institution MDC from January 2014 to October 2015 were identified from an institutional registry. The clinical characteristics and timelines for various aspects of treatment were retrospectively reviewed and recorded. A control population of patients not evaluated at the MDC was matched 1:2 by disease and the number of treating specialties. The primary endpoints were the TTT from diagnosis and the TTT from the first consultation. RESULTS: A total of 105 patients were included: 35 were evaluated at the MDC and 70 were controls. The MDC patients experienced a 7.8-day shorter TTT from the first consultation (21.5 vs. 29.3 days; P = .01). The difference was greater for patients visiting 3 departments (21.3 vs. 30.6 days; P < .001). Patients requiring neoadjuvant chemoradiation accounted for most of the decreased interval compared with those requiring surgery alone as their first treatment. The proportion of patients initiating treatment within 3 weeks from the first consultation was greater for those seen in the MDC (57.1% vs. 30% for controls; P = .01). CONCLUSION: Implementation of a multidisciplinary CRC clinic yielded decreased intervals from the first consultation to treatment in our institution. Focusing efforts to increase MDC usage will improve treatment efficiency and improve patient access.

Healthcare Costs Reduced After Incorporating the Results of the American College of Surgeons Oncology Group Z0011 Trial into Clinical Practice.

The purpose of our study was to quantitate the changes in axillary lymph node dissection (ALND), frozen section (FS), and the impact on costs after the publication of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial. We compared axillary nodal management and cost data in breast cancer patients who met Z0011 criteria and were treated with lumpectomy and sentinel lymph nodes (SLN) biopsy from 2007 to July 2013. Of 800 patients, 67 (13.5%) and 34 (12.5%) patients in the pre- and post-Z0011 era had 1-2 positive SLN. ALND decreased from 78% to 21% (p < 0.001) after publication of Z0011. The mean overall cost of SLN biopsy was $41,059 per patient, while SLN biopsy with completion ALND was $50,999 (p < 0.001). Intraoperative FS use decreased from 95% to 66% (p = 0.015). Omitting the FS decreased mean costs from $4,319 to $2,036. The application of Z0011 resulted in an overall mean cost savings of $571,653 from 2011 to July 2013. ACOSOG Z0011 significantly impacted axillary management resulting in a 20% reduction in the mean overall cost per patient by omitting ALND. In these patients, intraoperative FS analysis had poor sensitivity (56%) and doubled the cost of pathologic examination. Fewer ALND and intraoperative FS were performed after the publication of ACOSOG Z0011. Eliminating FS and ALND in patients who met Z0011 criteria, results in significant cost savings.