CUA 2018: A Population-Based Study Demonstrating Passive Centralization of Radical Cystectomy: Potential Associations with Other Quality Indicators

Halifax, Nova Scotia ( Referral of complex surgical procedures in higher-volume centers leads to improved patient care and better outcomes. In England, centralization of radical cystectomies (RC) was mandated in 2003. Although not mandated in Canada, the authors hypothesized that centralization of RC has been occurring naturally in a passive way. In the presented study, the authors explored this process of centralization in Canada, and whether it is associated with other process-related quality indicators and outcomes.

The Ontario Cancer Registry was queried in an attempt to identify all patients who underwent RC for muscle-invasive bladder cancer between 1994 and 2013. Patients were classified in two temporal cohorts: a historical cohort with RC performed between 1994 and 2008, and a more contemporary cohort, with RC performed between 2009 and 2013. The primary objective was to describe mean annual surgeon and hospital RC volume. Secondary objectives included process and outcome measures, such as referral patterns to medical oncology (MO), receipt of perioperative chemotherapy, and postoperative mortality.

Overall, 5582 RCs were completed in Ontario during the study period: 3879 (69%) in 1994-2008 and 1703 (31%) in 2009-2013. The mean annual surgeon volume and hospital volume of RC during 1994-2008 was 4.17 (95% confidence interval [CI] 3.36-4.98) and 11.33 (95% CI 9.44-13.22), respectively. In the more contemporary era, these volumes had risen to 6.80 (95% CI 6.47-7.33) and 16.40 (95% CI 15.39-17.40) (p<0.01), respectively (Figure 1). Preoperative MO referral increased from 11% in 1994-2008 to 32% in 2009-2013 (p<0.01). Use of neoadjuvant chemotherapy increased substantially from 4% in 1994-2008 to 19% in 2009-2013 (p<0.001) (Figure 2). Lastly, the 5-year cancer-specific survival rates have also improved through time, as can be seen in Figure 3. 

The authors concluded that these data illustrate passive transference of RC cases to higher-volume providers in Ontario. Additional research is required to determine the potential effects of centralization on other quality indicators and patient outcomes.

Figure 1 – Proportion of cystectomies completed by surgeons >6.2 cases per year and hospitals > 20 cases per year for muscle-invasive bladder cancer
UroToday CUA 2018 Passive Centralization of Radical Cystectomy 1
Figure 2 – Proportion of muscle-invasive bladder cancer patients that went on to receive a cystectomy treated with peri-operative chemotherapy (ACT = adjuvant chemotherapy, NACT = Neoadjuvant chemotherapy):
UroToday CUA 2018 Passive Centralization of Radical Cystectomy 2

Figure 3 – Estimated 5-year cancer specific survival for all bladder cancer cases divided into quartiles representing different time periods:
UroToday CUA 2018 Passive Centralization of Radical Cystectomy 3

Presented by: Visram, Kash, Queen's University, Kingston, Canada

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, @GoldbergHanan at the 73rd Canadian Urological Association Annual Meeting - June 23 - 26, 2018 - Halifax, Nova Scotia

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