UROLOGICAL ONCOLOGY

Cystectomy Delay More Than 3 Months from Initial Bladder Cancer Diagnosis Results in Decreased Disease Specific and Overall Survival
Lee CT, Madii R, Daignault S, Dunn RL, Zhang Y, Montie JE, Wood DP Jr
Michigan Urology Center, University of Michigan, Ann Arbor, Michigan, USA
J Urol. 2006; 175: 1262-7

• Purpose: Some groups hypothesize that a delay in cystectomy may result in higher pathological stage and possibly alter survival in patients with bladder cancer. The timing of this delay has been somewhat arbitrary. We evaluated the timing from T2 bladder cancer diagnosis to cystectomy, its impact on survival and potential causes of delay.
• Materials and Methods: A contemporary cohort of 214 consecutive patients presented with clinical T2 bladder cancer and underwent radical cystectomy as primary therapy. Clinicopathological parameters were maintained in an institutional database. A review of time to cystectomy, pathological stage, disease specific survival and OS was performed. Variables were tested in univariate and multivariate analyses. The log rank test was used for exploratory analyses to determine meaningful delay cutoff points.
• Results: Mean followup and time to cystectomy in the entire cohort was 40 months and 60 days, respectively. A significant disease specific survival and OS advantage was observed in patients undergoing cystectomy by 93 days or less (3.1 months) compared to greater than 93 days (p = 0.05 and 0.02, respectively). Pathological staging was similar between the groups (p = 0.15). A multivariate benefit in OS was observed in patients treated with timely cystectomy. The most common factor contributing to cystectomy delay was scheduling delay, as seen in 46% of cases.
• Conclusions: A cystectomy delay of 3.1 months undermines patient survival, likely through the development of micrometastases, since local stage progression is not apparent at this point. Most delays are avoidable and should be minimized. Despite the need for second opinions and the impact of busy surgical schedules clinicians must strive to schedule patients efficiently and complete surgical treatment within this time frame.
  
  
• Editorial Comment
  A recent editorial comment in this journal on the effects of delay in radical bladder cancer surgery is supported by this brand new paper from Ann Arbor, Michigan.
  The authors analyze their data on 214 consecutive pathological stage T2 cystectomies and performed uni- and multivariate analyses. The mean time to cystectomy was 53 days in the cohort with no delay (that is, 93 days or less), and 124 days in the cohort with delay (that is greater than 93 days delay).
  Both, disease-specific and overall survival was impaired in the delay group.
  Interestingly, scheduling delay was the reason most often indicated.
  In conclusion, a delay of more than three months may be dangerous for the patients and cystectomy should be performed as soon as possible – a scheduling delay of more than 3 months should not be tolerable.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany