Delayed Bladder Cancer Referrals Up Death Risk

Long wait times before a first urologist visit was associated with a 29% higher risk of death after radical cystectomy.
Long wait times before a first urologist visit was associated with a 29% higher risk of death after radical cystectomy.

Long delays in referring patients to a urologist increase the risk of death after radical cystectomy for bladder cancer, according to a Canadian study.

The findings reinforce the importance of highlighting for general practitioners the symptoms related to bladder cancer and the need for prompt urology referral, the investigators concluded in Current Oncology (2015;22:e20-e26).

A team led by Armen Aprikian, MD, of McGill University Health Centre in Montreal analyzed data from 1,271 patients who underwent radical cystectomy for bladder cancer in Quebec during the 10-year period 2000–2009. The investigators classified patients according to whether they were directly or indirectly referred to a urologist. They considered patients to have been directly referred if they had 5 or fewer visits with a general practitioner before their first urologist. They considered all other patients to have been indirectly referred, and therefore to have experienced a greater median referral delay.

“We chose indirect referral as a surrogate for the delay elapsed between first cancer symptoms and urologist referral because of its logical appeal and clinical intuitiveness,” the researchers explained. “The idea that early diagnosis and treatment should lead to improved survival has strong face validity.”

Results showed that 49% of women and 33% of women fell into the indirect referral group. After adjusting for age, patients who were indirectly referred after their first symptoms of bladder cancer had a 29% increased risk of death after surgery compared with patients who were directly referred, the researchers reported Women and men who were indirectly referred had a significant 47% and 25% increased risk of death after surgery, respectively.

The median referral delay for the cohort overall was 30 days—56 days for women, 23 days for men. The median referral delays for the directly referred and indirectly referred patients were 40 and 75 days, respectively, among the women and 21 days and 30 days, respectively, among the men.

“Our findings of an increased risk of mortality among patients (especially women) experiencing long wait times raise, for patients and [general practitioners] alike, the importance of awareness of first bladder cancer symptoms and prompt management,” the authors wrote.

Dr. Aprikian's group noted that available guidelines recommend that all patients with bladder cancer symptoms—especially patients with hematuria and without evidence of infections or other factors—undergo immediate cystoscopy and urinary tract imaging. Still, research indicates that general practitioners frequently do not adhere to guidelines for prompt investigation of patients with hematuria.

The researchers acknowledged some study limitations. They noted, for example, that they were unable to measure some confounding factors, such as grade, stage, and severity of the bladder tumor, which can play an important role in long-term overall survival.

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