The Clinical Impact of Delaying Radical Cystectomy in Muscle Invasive Bladder Cancer - Expert Commentary

The standard treatment for muscle-invasive bladder cancer (MIBC) is radical cystectomy (RC) with neoadjuvant chemotherapy (NAC). Although NAC is associated with a 5-10% increase in overall survival (OS) compared to RC alone, it is underutilized. The European Association of Urology recommends RC within 3 months of diagnosis but there is a lack of recommendations regarding timing of RC in the context of NAC. To fill this knowledge gap, Nuijens et al. investigated the association between delayed RC in patients receiving NAC and survival outcomes.

The investigators collected data from the Dutch BlaZIB cohort which includes 996 patients diagnosed with MIBC who underwent RC. Of these, 292 patients also received NAC and 237 patients were included in the final cohort for the present study. Most patients were male (69%) and the median age was 64 years. The median time from diagnosis of MIBC to RC (TTRC) was 23 weeks. The interval between diagnosis and start of NAC, the duration of NAC treatment, and the interval between the last cycle of NAC and RC were 5 weeks, 10 weeks, and 7 weeks, respectively. The 2-year overall survival (OS) rate in the cohort was 67% (95% CI, 59% - 74%). A Cox regression analysis revealed a non-significant association between TTRC and 2-year OS with an adjusted hazard ratio (HR) of 1.06 (95% CI, 1.00 - 1.12; p = 0.03). Similarly, a multivariate analysis indicated that there was no significant association between TTRC and the risk of pN+ disease (p = 0.1). However, a sensitivity Cox regression analysis showed that the time between diagnosis and the last NAC cycle was a significant variable with an adjusted HR of 1.13 (95% CI, 1.06 - 1.21; p < 0.0001). The association with pN+ was also significant, with an adjusted odds ratio (OR) of 1.21 (95% CI, 1.05 - 1.40; p = 0.01).

Specifically, the only delay that negatively impacted survival among patients with MIBC was that between the last cycle of NAC and RC. Accordingly, this interval should be shortened to a minimum.

Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine


  1. Nuijens ST, van Osch FHM, van Hoogstraten LMC, Witjes JA, Aben KKH, Hermans TJN. Longer time to radical cystectomy in patients treated with neoadjuvant chemotherapy is associated with worse oncological outcomes. Urol Oncol. Published online January 17, 2024. doi:10.1016/j.urolonc.2023.12.014
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