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Special Focus on Bladder Cancer – Part 4: Treatment

Once a diagnosis is confirmed and the cancer has been staged, a person’s healthcare team will work with them to develop a plan for treatment. The main types of treatment for bladder cancer are the following:

  • Surgery: there are 3 different types of surgery that can be used to treat bladder cancer depending on the stage of the cancer and type of tumour: transurethral resection, partial and radical cystectomy. Surgical procedures can range from endoscopically removing tumours (transurethral resection) that have developed in the bladder lining to removing the entire bladder and some surrounding tissue. More information on surgery to treat bladder cancer is provided in the next section.
  • Radiation therapy: bladder cancer is often treated using external beam radiation when a person has advanced cancer or is unable to undergo surgery. Also, radiation therapy and chemotherapy, combined with transurethral resection surgery (described above), can be used in select cases to save a person’s bladder from removal.
  • Immunotherapy: this type of treatment works to control and kill cancer by using natural and artificial chemicals that influence cell responses within the immune system. Immunotherapy is commonly used to treat tumours that are on the bladder lining but are a risk for further growth. In some cases, immunotherapy is used after chemotherapy or as a secondary treatment for more advanced stages of bladder cancer.
  • Chemotherapy: chemotherapeutic drugs may be prescribed to slow or stop cancer cells from growing. The type of chemotherapy used depends on the stage of cancer development and type of tumour: intravesical chemotherapy (within the bladder) is used for bladder cancer that is isolated to the lining of the bladder, while systemic chemotherapy (injected intravenously) is used to treat bladder cancer that has spread to other areas of the body. Both types of chemotherapy are used before or after surgery, depending on the clinical situation.

The roller coaster of emotions with cancer is absolutely brutal. Looking back, going to work and interacting with the public was the best decision I made. For my own sanity, it was very important.

Anonymous, bladder cancer survivor

Surgery

Types of surgery used to treat bladder cancer include the following:

  • Transurethral resection: bladder cancer that is only located within the bladder lining is typically removed using surgery known as transurethral resection of bladder tumour (TURBT). More advanced tumours can be diagnosed and treated using this type of surgery.
  • Partial (segmental) cystectomy: a partial cystectomy is where only a portion of the bladder is surgically removed. This type of surgery is only used in very unique situations
  • Radical cystectomy: this type of surgery involves the removal of the entire bladder, surrounding tissues, and (in some cases) reproductive organs. If this type of surgery is necessary, the person with cancer will undergo urinary diversion surgery to create a path for urine to exit the body. Neobladder reconstruction, which involves a surgical procedure to construct a new bladder, is one option for urinary diversion [1]. The most common diversion, however, is an ileal conduit, which is a permanent external drainage bag for urine.

I had to have a radical cystectomy, which included removal of the bladder and my reproductive organs. I had neobladder reconstruction, and [I] get to look ‘normal’ with a neobladder [i.e. with a drainage bag for urine]. But I have been incontinent ever since my surgery in January 2018. I wish I had more information prior to my surgery.

Anonymous, bladder cancer survivor

Wait time to cancer surgery

In Ontario, wait time to surgery is measured for distinct periods. The first period, called Wait 1, is the time that the person waits for a first consultation with a clinician. It is measured from the time the referral is received to the date of the first consultation with a clinician. The second period, called Wait 2, is the period from when it is decided that the person needs surgery to the date they receive surgery.

For both Wait 1 and Wait 2, people can be classified into 4 different priority levels (shown in Tables 1 and 2). The urgency for surgery varies, and the priority levels capture what Cancer Care Ontario considers to be the acceptable maximum wait time to surgery for these different priority levels. Many individuals will not have confirmed bladder cancer prior to surgery, therefore these recommended wait times do not apply to those people.

For more information about wait times for cancer surgery in Ontario, see Wait Times for Cancer Surgery.

I can't help but wonder if I would still have my bladder if the wait times for referrals to specialists would have been sooner. From the time my symptoms first appeared until I was finally diagnosed with bladder cancer was 6 months.

Anonymous, bladder cancer survivor

Table 1. Adult: Wait 1 Priority Assessment Tool

Priority

Definition

Time period

Priority 1

High suspicion of cancer or a biopsy that is positive for cancer where patient has severe life- or limb-threatening symptoms and signs, and where imminent morbidity or mortality without immediate intervention is high

 

Within 24 hours

Priority 2

High suspicion of cancer or a biopsy that is positive for cancer where patient has high likelihood of having a highly aggressive malignancy

Within 10 days

Priority 3

All patients with high suspicion of cancer that does not meet the criteria of Priorities 2 or 4

Within 21 days

Priority 4

All patients with an intermediate level of suspicion of cancer or patients with a biopsy that is positive for cancer, but with a high likelihood of an indolent (slow-growing) malignancy

Within 35 days

Table 2. Adult: Wait 2 Priority Assessment Tool

Priority

Definition

Time period

Priority 1

Patients require immediate emergency surgery

Within 24 hours

Priority 2

Patients are diagnosed with highly aggressive malignancies

Within 14 days

Priority 3

Patients have known or suspected invasive cancer that does not meet the criteria of Priorities 2 or 4

Within 28 days

Priority 4

Patients diagnosed with indolent (slow-growing) malignancies

Within 84 days

 

For Wait 1, 60% of people with bladder cancer having surgery in 2016 were classified as Priority 4 (meaning they had a wait time target of 35 days), compared to 35% who were identified as Priority 3, and 5% who were identified as Priority 2 (Figure 1). Overall, 81% of bladder cancer patients in Ontario are receiving surgical consultations within their priority level wait time (Figure 2). With 65% of priority 2, 77% of priority 3 and 84% of priority 4 bladder cancer patients receiving surgical consultation within their priority level wait times (Figure 2).  

For Wait 2, 57% of people with bladder cancer in 2016 were classified as Priority 4 (meaning they had a wait time target of 84 days) (Figure 3). Comparatively, 4% and 39% of people with bladder cancer were classified as Priority 2 and 3, respectively (Figure 3). Overall, 90% of people with bladder cancer received surgery within their priority level wait time (Figure 4). For the most part, there has been minimal change in the percentage of people who received bladder cancer surgery within their Wait 2 priority access target, with the exception of Priority 2: 65% of people with bladder cancer had surgery in 2014 within their Priority 2 access target, compared to 73% in 2016 (Figure 4).

 

Figure 1. Distribution of bladder cancer surgery by Wait 1 priority level, 2016

Report date: February 5, 2018

Data source: Wait Time Information System

Prepared by: ATC Informatics, Analytics & Informatics, Cancer Care Ontario

Exclusion Criteria: Please refer to technical documentation

 

Figure 2. Percentage of patients whose bladder cancer surgery consult occurred within their respective Wait 1 priority access target, by priority level, 2016

Report date: February 5, 2018

Data source: Wait Time Information System

Prepared by: ATC Informatics, Analytics & Informatics, Cancer Care Ontario

Exclusion Criteria: Please refer to technical documentation

 

Figure 3. Distribution of bladder cancer surgery by Wait 2 priority level, 2014 to 2016

Report date: February 5, 2018

Data source: Wait Time Information System

Prepared by: ATC Informatics, Analytics & Informatics, Cancer Care Ontario

Exclusion Criteria: Please refer to technical documentation

 

Figure 4. Percentage of patients whose bladder cancer surgery occurred within their respective Wait 2 priority access target, by priority level, 2014 to 2016

Report date: February 5, 2018

Data source: Wait Time Information System

Prepared by: ATC Informatics, Analytics & Informatics, Cancer Care Ontario

Exclusion Criteria: Please refer to technical documentation

 

Figure 5. Percentage of synoptic resection reports for urothelial bladder cancer where margin was involved by invasive carcinoma, fiscal year 2014/2015 to fiscal year 2016/2017, by Local Health Integration Network (LHIN) of surgery facility

More information regarding the methodology is available.

Report date: December 2017

Data source: CCO eMaRC

Prepared by: Analytics & Informatics, Cancer Care Ontario

Note:

  1. † Values have been supressed due to small cell counts. All margins are included in the analysis.
  2. See technical notes for detailed methodology and inclusions/exclusions

 

Figure 6. Percentage of patients who had bladder surgery for cancer and an unplanned emergency department visit or who were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017

More information regarding the methodology is available.

Report date: December 2017

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note: See technical notes for detailed methodology and inclusions/exclusions

 

Figure 7. Percentage of patients who had bladder, breast, colorectal, prostate or thyroid surgery for cancer and an unplanned emergency department visit or who were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017

 

 

Figure 8. Percentage of patients who had bladder, breast, colorectal, prostate or thyroid surgery for cancer and an unplanned emergency department visit or who were admitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017, by Local Health Integration Network (LHIN) of surgery facility

Report date: December 2017

Source: CIHI-DAD, CIHI-NACRS

Prepared by: Analytics & Informatics, Cancer Care Ontario

Notes: See technical notes for detailed methodology and inclusions/exclusions

 

Figure 9. Percentage of reoperations after bladder, breast, colorectal, prostate and thyroid surgeries for cancer patients, fiscal year 2015/2016 to fiscal year 2016/2017

 

Figure 10. Percentage of reoperations after bladder, breast, colorectal, prostate and thyroid surgeries for cancer patients, fiscal year 2015/2016 to fiscal year 2016/2017, by Local Health Integration Network (LHIN) of surgery

Report date: December, 2017

Source: CIHI-DAD, CIHI-NACRS

Prepared by: Analytics & Informatics, Cancer Care Ontario

Notes: See technical notes for detailed methodology and inclusions/exclusions

 

Data Table 1. Distribution of bladder cancer surgery by Wait 1 priority level, 2016

Priority Volume of completed cases within Wait 1 target in 2016 Distribution by priority in 2016
Priority 2 (10 days) 43 4.8
Priority 3 (21 days) 316 34.9
Priority 4 (35 days) 546 60.3
Priority 2 to 4 combined 905 -

Report date: February 5, 2018

Data source: Wait Time Information System

Prepared by: ATC Informatics, Analytics & Informatics, Cancer Care Ontario

Note:

  1. Please refer to technical documentation

Data Table 2. Percentage of patients whose bladder cancer surgery consult occurred within their respective Wait 1 priority access target, by priority level, 2016

Priority Volume of completed cases within Wait 1 target in 2016 Volume of completed cases within Wait 1 in 2016 Percentage of cancer surgery patients whose surgical consult occurs within priority access target for Wait 1 in 2016
Priority 2 (10 days) 28 43 65.1
Priority 3 (21 days) 244 316 77.2
Priority 4 (35 days) 461 546 84.4
Priority 2 to 4 combined 733 905 81.0

Report date: February 5, 2018

Data source: Wait Time Information System

Prepared by: ATC Informatics, Analytics & Informatics, Cancer Care Ontario

Note:

  1. Please refer to technical documentation

Data Table 3. Distribution of bladder cancer surgery by Wait 2 priority level, 2014 to 2016

Priority Volume of completed cases within Wait 2 in 2014 Distribution by priority in 2014 Volume of completed cases within Wait 2 in 2015 Distribution by priority in 2015 Volume of completed cases within Wait 2 2016 Distribution by priority in 2016
Priority 2 (14 days) 248 7.8 215 6.5 151 4.3
Priority 3 (28 days) 1,068 33.8 1,116 33.5 1,368 38.5
Priority 4 (84 days) 1,846 58.4 1,999 60.0 2,033 57.2
Priority 2 to 4 combined 3,162 - 3,330 - 3,552 -

Report date: February 5, 2018

Data source: Wait Time Information System

Prepared by: ATC Informatics, Analytics & Informatics, Cancer Care Ontario

Note:

  1. Please refer to technical documentation

Data Table 4. Percentage of patients whose bladder cancer surgery occurred within their respective Wait 2 priority access target, by priority level, 2014 to 2016

Priority Volume of completed cases within Wait 2 target in 2014 Volume of completed cases within Wait 2 in 2014 Percentage of cancer surgery patients whose surgery occurs within priority access target for Wait 2 in 2014 Volume of completed cases within Wait 2 target in 2015 Volume of completed cases within Wait 2 in 2015 Percentage of cancer surgery patients whose surgery occurs within priority access target for Wait 2 in 2015 Volume of completed cases within Wait 2 target in 2016 Volume of completed cases within Wait 2 in 2016 Percentage of cancer surgery patients whose surgery occurs within priority access target for Wait 2 in 2016
Priority 2 (14 days) 161 248 64.9 169 215 78.6 110 151 72.8
Priority 3 (28 days) 860 1,068 80.5 907 1,116 81.3 1,096 1,368 80.1
Priority 4 (84 days) 1,806 1,846 97.8 1,963 1,999 98.2 1,975 2,033 97.1
Priority 2 to 4 combined 2,827 3,162 89.4 3,039 3,330 91.3 3,181 3,552 89.6

Report date: February 5, 2018

Data source: Wait Time Information System

Prepared by: ATC Informatics, Analytics & Informatics, Cancer Care Ontario

Note:

  1. Please refer to technical documentation

Data Table 5. Percentage of synoptic resection reports for urothelial bladder cancer where margin was involved by invasive carcinoma, fiscal year 2014/2015 to fiscal year 2016/2017, by Local Health Integration Network (LHIN) of surgery facility

LHIN Percentage of margin(s) involved by invasive carcinoma Number of margin(s) involved by invasive carcinoma Number of urothelial bladder cancer surgeries Margin(s) involved by invasive carcinoma lower confidence interval Margin(s) involved by invasive carcinoma upper confidence interval
Province 14.0 117 835 11.6 16.4
Erie St. Clair 6.4 Ɨ Ɨ 0.0 14.4
South West 17.0 17 100 9.1 24.9
Waterloo Wellington 20.0 Ɨ Ɨ 2.3 37.7
Hmltn-Ngr-Hldmnd-Brnt 9.4 10 107 3.4 15.3
Central West 15.6 Ɨ Ɨ 1.5 29.8
Mississauga Halton 11.1 Ɨ Ɨ 0.0 24.8
Toronto Central 13.4 28 209 8.5 18.3
Central 12.2 6 49 2.1 22.4
Central East 11.5 12 104 4.9 18.2
South East 25.0 Ɨ Ɨ 3.5 46.5
Champlain 15.2 12 79 6.6 23.7
North Simcoe Muskoka 37.5 Ɨ Ɨ 0.0 77.3
North East 25.0 Ɨ Ɨ 0.7 49.3
North West 33.3 Ɨ Ɨ 2.5 64.2

Report date: December 2017

Data source: CCO eMaRC

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions
  2. † Values have been suppressed due to small cell counts

Data Table 6. Percentage of patients who had bladder surgery for cancer and an unplanned emergency department visit or who were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017

LHIN Acronym Percentage unplanned emergency department visits Unplanned emergency department lower confidence interval Unplanned emergency department upper confidence interval Percentage unplanned readmissions Unplanned readmission lower confidence interval Unplanned readmission upper confidence interval Percentage unplanned emergency department visits or readmissions Unplanned emergency department visits or readmissions lower confidence interval Unplanned emergency department visits or readmissions upper confidence interval
Province ON 18.4 16.2 20.6 17.5 15.4 19.7 35.9 33.3 38.6
Erie St. Clair ESC 23.1 10.7 35.5 15.4 4.6 26.2 38.5 24.3 52.6
South West SW 20.1 13.7 26.6 17.7 11.5 23.8 37.8 30.1 45.5
Waterloo Wellington WW 21.1 6.8 35.3 26.3 11.0 41.6 47.4 30.2 64.6
Hmltn-Ngr-Hldmnd-Brnt HNHB 14.2 8.6 19.8 20.1 13.8 26.5 34.3 26.9 41.8
Central West CW 22.9 7.5 38.2 8.6 0.0 19.3 31.4 14.6 48.2
Mississauga Halton MH 7.3 0.0 15.0 16.4 5.7 27.1 23.6 11.5 35.8
Toronto Central TC 17.4 13.2 21.7 19.3 14.8 23.7 36.7 31.3 42.1
Central Cen 14.1 6.1 22.1 14.1 6.1 22.1 28.2 18.1 38.4
Central East CE 22.4 14.1 30.8 15.0 7.7 22.2 37.4 27.8 47.0
South East SE 18.9 5.0 32.9 13.5 1.1 25.9 32.4 16.0 48.9
Champlain Ch 24.4 16.7 32.2 19.9 12.6 27.1 44.3 35.4 53.2
North Simcoe Muskoka NSM 8.3 0.0 21.5 8.3 0.0 21.5 16.7 0.0 33.7
North East NE 27.0 11.4 42.7 18.9 5.0 32.9 46.0 28.5 63.4
North West NW 12.5 0.0 31.8 0.0 0.0 3.1 12.5 0.0 31.8

Report date: December 2017

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Data Table 8. Percentage of patients who had bladder, breast, colorectal, prostate or thyroid surgery for cancer and an unplanned emergency department visit or who were admitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017, by Local Health Integration Network (LHIN) of surgery facility

LHIN Acronym Percentage of total unplanned visits after bladder surgery Lower confidence interval after bladder surgery Upper confidence interval after bladder surgery Percentage of total unplanned visits after breast surgery Lower confidence interval after breast surgery Upper confidence interval after breast surgery Percentage of total unplanned visits after colorectal surgery Lower confidence interval after colorectal surgery Upper confidence interval after colorectal surgery Percentage of total unplanned visits after prostate surgery Lower confidence interval after prostate surgery Upper confidence interval after prostate surgery Percentage of total unplanned visits after thyroid surgery Lower confidence interval after thyroid surgery Upper confidence interval after thyroid surgery
Province ON 35.9 33.3 38.6 14.2 13.8 14.6 23.4 22.7 24.2 25.1 23.9 26.3 12.6 11.9 13.3
Erie St. Clair ESC 38.5 24.3 52.6 14.1 12.3 15.9 20.7 17.4 24.0 19.9 14.3 25.5 14.6 11.1 18.0
South West SW 37.8 30.1 45.5 16.6 15.1 18.1 28.9 26.3 31.5 32.6 28.4 36.8 17.1 13.8 20.3
Waterloo Wellington WW 47.4 30.2 64.6 13.1 11.4 14.9 21.8 18.6 25.0 28.8 16.4 41.2 14.4 10.3 18.4
Hmltn-Ngr-Hldmnd-Brnt HNHB 34.3 26.9 41.8 14.9 13.7 16.1 21.6 19.5 23.7 22.4 19.4 25.5 16.1 12.7 19.4
Central West CW 31.4 14.6 48.2 10.2 8.6 11.8 16.2 12.7 19.6 22.0 16.0 28.0 9.4 6.8 12.0
Mississauga Halton MH 23.6 11.5 35.8 14.7 13.3 16.0 18.8 16.2 21.4 24.7 18.8 30.5 7.6 5.6 9.6
Toronto Central TC 36.7 31.3 42.1 10.7 9.9 11.5 26.1 23.9 28.2 24.2 21.6 26.9 11.9 10.5 13.2
Central Cen 28.2 18.1 38.4 12.6 11.5 13.7 19.9 17.8 22.1 26.4 22.1 30.8 10.3 8.2 12.5
Central East CE 37.4 27.8 47.0 14.3 13.1 15.5 22.1 19.9 24.4 22.0 18.4 25.7 11.2 9.2 13.2
South East SE 32.4 16.0 48.9 18.9 16.7 21.2 23.9 20.1 27.7 24.8 16.4 33.2 14.4 7.7 21.2
Champlain Ch 44.3 35.4 53.2 16.5 15.2 17.8 23.4 21.1 25.8 25.2 21.4 29.1 17.7 14.3 21.1
North Simcoe Muskoka NSM 16.7 0.0 33.7 19.3 16.9 21.6 25.0 21.1 28.9 23.3 16.1 30.5 16.2 11.2 21.2
North East NE 46.0 28.5 63.4 16.4 14.4 18.4 30.0 26.4 33.6 29.6 21.7 37.4 13.5 9.3 17.6
North West NW 12.5 0.0 31.8 24.0 20.0 28.1 39.5 32.8 46.1 59.5 42.3 76.6 17.6 10.5 24.7

Report date: December 2017

Data source:CIHI-DAD, CIHI-NACRS

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Data Table 10. Percentage of reoperations after bladder, breast, colorectal, prostate and thyroid surgeries for cancer patients, fiscal year 2015/2016 to fiscal year 2016/2017, by Local Health Integration Network (LHIN) of surgery

LHIN Acronym Percentage of reoperations after bladder surgery Lower confidence interval after bladder surgery Upper confidence interval after bladder surgery Percentage of reoperations after breast surgery Lower confidence interval after breast surgery Upper confidence interval after breast surgery Percentage of reoperations after colorectal surgery Lower confidence interval after colorectal surgery Upper confidence interval after colorectal surgery Percentage of reoperations after prostate surgery Lower confidence interval after prostate surgery Upper confidence interval after prostate surgery Percentage of reoperations after thyroid surgery Lower confidence interval after thyroid surgery Upper confidence interval after thyroid surgery
Province ON 7.4 5.9 8.8 1.2 1.0 1.3 5.0 4.6 5.4 1.0 0.7 1.3 1.1 0.9 1.4
Erie St. Clair ESC 1.9 0.0 6.6 0.8 0.3 1.2 6.1 4.2 8.1 0.0 0.0 0.2 0.9 0.0 1.9
South West SW 5.5 1.7 9.3 2.3 1.7 2.9 4.1 2.9 5.2 1.6 0.4 2.8 1.3 0.2 2.3
Waterloo Wellington WW 10.5 0.0 21.6 1.3 0.7 2.0 5.7 3.8 7.5 0.0 0.0 0.9 0.6 0.0 1.7
Hmltn-Ngr-Hldmnd-Brnt HNHB 3.6 0.5 6.6 1.0 0.6 1.3 4.7 3.7 5.8 1.3 0.4 2.2 1.7 0.4 2.9
Central West CW 0.0 0.0 1.4 0.6 0.1 1.0 3.7 1.8 5.5 0.0 0.0 0.3 0.9 0.0 1.9
Mississauga Halton MH 18.2 7.1 29.3 0.8 0.4 1.1 3.6 2.3 4.9 0.9 0.0 2.3 0.7 0.0 1.4
Toronto Central TC 5.8 3.1 8.5 1.3 1.0 1.6 5.3 4.2 6.4 0.9 0.3 1.5 1.3 0.8 1.8
Central Cen 8.2 1.8 14.7 0.7 0.4 1.0 5.7 4.5 7.0 2.4 0.8 4.0 0.9 0.2 1.6
Central East CE 5.6 0.8 10.4 1.3 0.9 1.7 4.6 3.5 5.8 0.4 0.0 1.0 1.0 0.3 1.7
South East SE 13.5 1.1 25.9 1.2 0.5 1.9 4.3 2.5 6.2 0.0 0.0 0.4 0.9 0.0 2.9
Champlain Ch 12.2 6.2 18.2 0.9 0.5 1.2 5.5 4.2 6.8 1.4 0.3 2.5 1.0 0.0 1.9
North Simcoe Muskoka NSM 12.5 0.0 27.8 1.9 1.0 2.7 5.5 3.4 7.6 0.0 0.0 0.3 0.9 0.0 2.3
North East NE 8.1 0.0 18.3 1.7 1.0 2.4 5.7 3.8 7.6 0.7 0.0 2.4 2.5 0.5 4.5
North West NW 31.3 5.4 57.1 1.1 0.0 2.2 5.8 2.5 9.1 0.0 0.0 1.4 0.8 0.0 2.8

Report date: December 2017

Data source:CIHI-DAD, CIHI-NACRS

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. See technical notes for detailed methodology and inclusions/exclusions

Figure 7. Percentage of patients who had bladder, breast, colorectal, prostate or thyroid surgery for cancer and an unplanned emergency department visit or who were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017

The figure is a flow chart with 6 labeled boxes linked by lines.

Here the flow chart is presented as lists in which the connections are listed beneath each box label. Each box label includes the relevant number and percentage of cancer patients who had a breast, bladder, colorectal, prostate or thyroid resection.

  1. Patients who had cancer surgery:
  • Bladder N= 1,277
  • Breast N=33,527
  • Colorectal N=12,941
  • Prostate  N=4,909
  • Thyroid N=8,436
    1. Connects to ED visit only:
      • Bladder N=235 (18%)
      • Breast N=3,535 (10%)
      • Colorectal N=1,813 (14%)
      • Prostate N=1,078 (22%)
      • Thyroid N=855 (10%)
    2. Connects to Readmitted:
      • Bladder N=224 (17%)
      • Breast N=1,230 (4%)
      • Colorectal N=1,218 (9%)
      • Prostate N=153 (3%)
      • Thyroid N=206 (2%)
  1. Connects to Via ED
    • Bladder N=162 (13%)
    • Breast N=294 (1%)
    • Colorectal N=944 (7%)
    • Prostate N=129 (3%)
    • Thyroid N=95 (1%)
  2. Connects to Direct readmission
    • Bladder N=62 (5%)
    • Breast N=936 (3%)
    • Colorectal N=274 (2%)
    • Prostate N=24 (1%)
    • Thyroid N=111(1%)
    • Connects to No ED/Admission visit:
      • Bladder N=818 (64%)
      • Breast N=28,762 (86%)
      • Colorectal N=9,910 (77%)
      • Prostate N=3,678 (75%)
      • Thyroid N=7,375 (87%)

Report date: December 2017
Data source: CIHI-DAD, CIHI-NACRS
Prepared by: Analytics and Informatics, Cancer Care Ontario

Note: Numbers shown are for Ontario. Groups are mutually exclusive

Due to rounding, percentages may not add up to 100%.

Figure 9. Percentage of reoperations after bladder, breast, colorectal, prostate and thyroid surgeries for cancer patients, fiscal year 2015/2016 to fiscal year 2016/2017

The figure is a flow chart with 6 labeled boxes linked by lines.

 

Here the flow chart is presented as lists in which the connections are listed beneath each box label. Each box label includes the relevant number and percentage of cancer patients who had a breast, bladder, colorectal, prostate or thyroid resection.

  1. Patients who had cancer surgery: N=61,090
  1. Connects to Reoperation: 1,274 (2%)
  2. Connects to No Reoperation: N=59,816 (98%)

 

  1. Patients who had cancer surgery:
  • Breast N=33,527
  • Bladder N= 1,277
  • Colorectal N=12,941
  • Prostate  N=4,909
  • Thyroid N=8,436
    1. Connects to Reoperation:
    2. Breast N=390 (1%)
    3. Bladder N=94 (7%)
    4. Colorectal N=646 (5%)
    5. Prostate N=49 (1%)
    6. Thyroid N=95 (1%)
    7. Connects to No Reoperation:
  • Breast N=33,137 (99%)
  • Bladder N=1,183 (93%)
  • Colorectal N=12,295 (95%)
  • Prostate N=4,860 (99%)
  • Thyroid N=8,341 (99%)

Report date: December 2017
Data source: CIHI-DAD, CIHI-NACRS
Prepared by: Analytics and Informatics, Cancer Care Ontario

Note: Numbers shown are for Ontario. Groups are mutually exclusive

Due to rounding, percentages may not add up to 100%.

Data Table 1. Distribution of bladder cancer surgery by Wait 1 priority level, 2016 Data Table 2. Percentage of patients whose bladder cancer surgery consult occurred within their respective Wait 1 priority access target, by priority level, 2016 Data Table 3. Distribution of bladder cancer surgery by Wait 2 priority level, 2014 to 2016 Data Table 4. Percentage of patients whose bladder cancer surgery occurred within their respective Wait 2 priority access target, by priority level, 2014 to 2016 Data Table 5. Percentage of synoptic resection reports for urothelial bladder cancer where margin was involved by invasive carcinoma, fiscal year 2014/2015 to fiscal year 2016/2017, by Local Health Integration Network (LHIN) of surgery facility Data Table 6. Percentage of patients who had bladder surgery for cancer and an unplanned emergency department visit or who were readmitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017 Data Table 8. Percentage of patients who had bladder, breast, colorectal, prostate or thyroid surgery for cancer and an unplanned emergency department visit or who were admitted within 30 days after surgery, fiscal year 2015/2016 to fiscal year 2016/2017, by Local Health Integration Network (LHIN) of surgery facility Data Table 10. Percentage of reoperations after bladder, breast, colorectal, prostate and thyroid surgeries for cancer patients, fiscal year 2015/2016 to fiscal year 2016/2017, by Local Health Integration Network (LHIN) of surgery

Post-surgery

Positive surgical margins

The goal of bladder cancer surgery is to remove all cancer cells. After surgery, the removed tissue is examined to see if there are any remaining cancer cells at the edge of the collected sample [2]. If cancer cells are present along the edge of the sample, this means that all of the cancer may not have been removed during surgery [2]. This is called a positive margin resection.

Cases of bladder cancer surgery with positive margin resection are tied to an increased recurrence and decreased survival rate. For that reason, it is important to minimize bladder positive margin resection rates. Currently, there is a surgical margin benchmark of less than 10% for bladder cancer surgeries [3].

From fiscal years 2014/2015 to 2016/2017, the positive margin resection rate for bladder cancer was 14%. However, there was significant regional variation, with 6.4% to 38% of bladder cancer surgeries involving positive margin resection rates (Figure 5).

Unplanned hospital visits after surgery

Complications after bladder cancer surgery can result in an unplanned hospital visit after surgery. The rate of unplanned hospital visits after surgery can help monitor the number of complications or adverse events after cancer surgery, and it is a measure of the safety of the cancer system.

Thirty-six percent of people with bladder cancer during fiscal years 2015/2016 to 2016/2017 had an unplanned emergency department visit, with half of them (18%) resulting in readmission (Figure 6). There was significant regional variation for both metrics. The percentage of people with bladder cancer who visited the emergency department ranged from 7% to 27%. Furthermore, after bladder cancer surgery, one region had no people with bladder cancer readmitted to hospital, while another region saw 26% of people with bladder cancer readmitted after cancer surgery (Figure 6).

Only 64% of people with bladder cancer did not have an unplanned hospital visit after cancer surgery in fiscal years 2015/2016 to 2016/2017 (compared to 87% of people with thyroid cancer).

I was not informed that my prostate would also need to be removed during the surgery, but the cancer had spread and there was a sense of urgency. Sexual dysfunction impacted the quality of our relationship as a couple. We had to work hard to redefine our relationship and ourselves.

Anonymous, bladder cancer survivor

 

Of the 36% of people who did have an unplanned hospital visit, 18% had an emergency department visit only (compared to 10% of people with breast or thyroid cancer). A greater number of people with bladder cancer were readmitted to hospital after surgery (18%) than people with thyroid cancer (2%) (Figure 7). Overall, people with bladder cancer are more likely to have an unplanned hospital visit after cancer surgery than people with breast, colorectal, prostate or thyroid cancer (Figure 8).

Although the reasons for the unplanned hospital visit are unknown, some research suggests that reasons for emergency department visits or readmission include wound/urinary tract infection, nausea/ vomiting, dehydration, pulmonary embolism and pyelonephritis [4]. Ileus and small bowel obstruction are other reasons that a person with bladder cancer may visit the emergency department or undergo reoperation after bladder cancer surgery. Reasons for reoperation include a reopened wound, ureterointestinal stenosis, parastomal/incisional hernia, and ureterointestinal anastomosis [5].

For more information on unplanned hospital visits, see Unplanned Hospital Visits after Cancer Surgery.

From a psychological perspective [of] someone who has never had surgery in his life, bladder cancer surgery had a huge impact, both physically and psychologically.

Anonymous, bladder cancer survivor

 

Reoperations after surgery

Post-operative complications are one of the many reasons a person with bladder cancer may undergo an unplanned reoperation after surgery. A reoperation is defined as a secondary surgical procedure that is required as a result of direct or indirect complications following the initial surgery [6]. For more information on this indicator, see Reoperations after Cancer Surgery. Overall, 93% of people with bladder cancer who underwent surgery did not have a reoperation in fiscal years 2015/2016 to 2016/2017. From a comparative perspective, 95% of people with colorectal cancer and 99% of people with breast, prostate or thyroid cancer did not have a reoperation within the same time frame (Figure 9). Overall, people with bladder cancer are more likely to have a reoperation (7% of them have a reoperation) after cancer surgery when compared to the other 4 disease sites (Figure 10).

Radiation therapy

External beam radiation, the primary type of radiation therapy used for treating bladder cancer, uses X-rays or other high-energy particles to kill bladder cancer cells. The main machine that provides the radiation therapy is located outside of the body, unlike internal radiation therapy, where the radioactive treatment is placed into the body or near the cancer. In most cases, radiation therapy is used in combination with surgery and chemotherapy to treat bladder cancer more effectively [7].

Radiation therapy may be the main treatment for people who cannot have surgery. It also may be given to relieve symptoms caused by advanced bladder cancer. More specifically, a study based in the United Kingdom that focused on the effectiveness of combining chemotherapy and radiation therapy found that 67% of individuals who underwent both interventions were cancer-free for 2 years. Comparatively, individuals who were treated using only radiation therapy had a 2-year recurrence-free rate of 54% [8]. The same study also showed that individuals treated using both chemotherapy and radiation therapy had a higher 5-year overall survival than individuals treated using only radiation therapy (48% compared to 35%).

Chemotherapy treatment

Chemotherapy may be used to treat bladder cancer before cystectomy (neoadjuvant chemotherapy) or after cystectomy (adjuvant chemotherapy).

The use of neoadjuvant chemotherapy to treat muscle-invasive bladder cancer has increased significantly, as it has proven to be a very effective treatment option. Rates of neoadjuvant chemotherapy have increased from 4% for the period of 1994 to 2008 to 19% for the period of 2009 to 2013 [9]. This increase has continued yearly: rates for neoadjuvant chemotherapy rose from 12% in 2009 to 27% in 2013. Reasons for this increased rate of treatment can be linked to the increased referral rate of people with bladder cancer to medical oncologists, who are increasingly using neoadjuvant chemotherapy. Overall, both adjuvant and neoadjuvant chemotherapy have been proven effective to treat bladder cancer [9].

Additionally, the use of guideline-recommended chemotherapy to treat people with bladder cancer was found to be linked to several influential factors. Prominent barriers to using chemotherapy include (a) the belief that the benefits of chemotherapy for treating bladder cancer are not clinically important, (b) inadequate collaboration between disciplines, (c) a lack of advocates, who are key facilitators for endorsing the use of chemotherapy to treat bladder cancer, and (d) ambiguity within the referral process, despite more people being referred to medical oncologists [10]. There is work currently underway to understand what interventions should be implemented to help increase the treatment of bladder cancer using chemotherapy [10]

Because bladder cancer is never highlighted as a major cancer, more efforts need to be put into research and public awareness.

Blair P., bladder cancer survivor

Distance to treatment

Measuring whether or not people have to travel to receive treatment is an important measure of the equity of our cancer system. Travelling long distances to receive treatment not only takes up more time for people and caregivers, but it also requires additional resources for travel that may not be readily available to everyone. It also affects overall quality of life.

Immunotherapy treatment

Immunotherapy uses the immune system to help destroy cancer cells. Immunotherapy often is used to treat tumours that are only in the lining of the bladder, but that have a higher risk for growing. The vaccine bacillus Calmette-Guérin (BCG), which is passed into the bladder through a urinary catheter (tube), is most often used [11]. Other forms of intravenous immunotherapy may be offered as a second-line therapy for locally advanced or metastatic bladder cancer.  

Advanced bladder cancer is difficult to treat. First-line treatment is cisplatin-based chemotherapy treatment. However, 5 new immunotherapy medications are currently being approved by the United States Food and Drug Administration (FDA) to treat advanced bladder cancer. Further research is also being conducted to improve understanding of how different treatment options can be used to treat advanced bladder cancer and in what order those treatments should be administered to provide the best possible outcome [12].

Cancer system considerations

In Canada, bladder cancer is currently one of the most expensive types of cancer to treat [13]. The high cost of bladder cancer treatment can be attributed to its high recurrence rate and the associated follow-up care that is needed to ensure an individual remains free of bladder cancer after treatment. This trend is mirrored in other international jurisdictions (such as the United States) [14].

In 2009, same-day bladder cancer surgery in Ontario for those who lived past the first year of diagnosis was $1,700; the second most expensive cancer to treat with outpatient surgery was esophagus cancer at $1,689 (all figures in Canadian dollars) [15]. Within the same time frame, treatment for bladder cancer cost the Ontario healthcare system an average of $20,858 for people who survived 1 year after diagnosis. Individuals who did not live more than 1 year after their diagnosis directly cost the Ontario healthcare system an average of $46,206.

Table 3. Average Total Cost for Treatment of a Person with Bladder Cancer

Location

Cost (all costs converted to CAD)

Ontario (2009)

$20,858 [15]

Quebec (2009)

$25,553 [13]

United States: first-line treatment (2017)

$47,508 [16]

United States: second-line treatment (2017)

$34,517 [16]

From a wait times perspective or quality of care from my doctors, I didn't have issues. But I do have issues with how bladder cancer is not funded like other cancers. I understand that it may not be the top disease site in terms of incidence, but it is just as important.

Anonymous, bladder cancer survivor

Aside from potential costs associated with bladder cancer treatment, it is important to take into consideration the experience of people with bladder cancer. Despite the limited information about their experience, current research suggests that individuals coping with bladder cancer have worse experiences than those being treated for other types of cancer [17].

 

Most people, men and women, are embarrassed by the cancer because it is part of the urinary system. People need to speak out . . . public awareness by people experiencing bladder cancer is critical. I'm not ashamed of my disease.

Blair P., bladder cancer survivor

Based on the 2015 Bladder Cancer: Diagnosis and Management publication by the National Institute for Health and Care Excellence (NICE), reasons for worse reported experiences among people with bladder cancer include the following:

  • not being given a choice of different treatment options;
  • lack of consideration of patient views;
  • potential side effects not being explained in an understandable way;
  • not being offered a written care plan; and
  • lack of support after leaving the hospital [18].

It should be noted, however, that the report did highlight the need to conduct further research related to the experience of people with bladder cancer to better understand why these trends exist and to address related weaknesses in the healthcare system [18].

 

I did not get referred to a nutritionist or dietitian, even though I had bowel issues. My pelvic floor physiotherapist is actually the one who gave me a list of foods to avoid.

Anonymous, bladder cancer survivor

Notes

  1. Treatments for Bladder Cancer [Internet]. Toronto (ON): Cancer Care Ontario; c2018. Available from: here.
  2. Orosco RK, Tapia VJ, Califano JA, Clary B, Cohen EE, Kane C, et al. Positive surgical margins in the 10 most common solid cancers. Sci Rep. 2018;8(1):5686. doi:10.1038/s41598-018-23403-5
  3. Kassouf W, Aprikian A, Black P, Kulkarni G, Izawa J, Eapen L, et al. Recommendations for the improvement of bladder cancer quality of care in Canada: a consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015 [Internet]. Can Urol Assoc J. 2016;10(1–2):E46. Available from: here.
  4. Harraz AM, Osman Y, El‐Halwagy S, Laymon M, Mosbah A, Abol‐Enein H, et al. Risk factors of hospital readmission after radical cystectomy and urinary diversion: analysis of a large contemporary series. BJU Int. 2015;115(1):94–100.
  5. Liedberg F, Holmberg E, Holmäng S, Ljungberg B, Malmström PU, Månsson W, et al. Long-term follow-up after radical cystectomy with emphasis on complications and reoperations: a Swedish population-based survey. Scand J Urol Nephrol. 2012;46(1):14–18.
  6. Kroon HM, Breslau PJ, Lardenoye JWH. Can the incidence of unplanned reoperations be used as an indicator of quality of care in surgery? Am J Med Qual. 2007;22(3):198–202.
  7. Understanding Radiation Therapy [Internet]. American Society of Clinical Oncology; c2005–2018 (updated 2016 Dec). Available from: here.
  8. Tester W, Caplan R, Heaney J, Venner P, Whittington R, Byhardt R, et al. Neoadjuvant combined modality program with selective organ preservation for invasive bladder cancer: results of Radiation Therapy Oncology Group Phase II Trial 8802. J Clin Oncol. 1996;14(1):119–126.
  9. Booth CM, Karim S, Brennan K, Siemens DR, Peng Y, Mackillop WJ. Perioperative chemotherapy for bladder cancer in the general population: are practice patterns finally changing?. Urol Oncol. 2018;36(3):89.e13–89. 
  10. Walker M, Doiron RC, French SD, Feldman-Stewart D, Siemens DR, Mackillop WJ, et al. Perioperative chemotherapy for bladder cancer: a qualitative study of physician knowledge, attitudes, and behaviour. Can Urol Assoc J. 2108;12(4):E182–E190.  
  11. Karam JA, Wood CG. Genitourinary cancer. In: Feig BW, Ching CD, eds. M.D Anderson surgical oncology handbook. 5th ed. [place unknown]: Lippincott Williams & Wilkins; 2012. p. 604–635.
  12. Godwin JL, Hoffman-Censits J, Plimack E. Recent developments in the treatment of advanced bladder cancer. Urol Oncol. 2018;36(3):109–114.
  13. Santos F, Dragomir A, Zakaria AS, Kassouf W, Aprikian A. Health-care services utilization and costs associated with radical cystectomy for bladder cancer: a descriptive population-based study in the province of Quebec, Canada. BMC Health Serv Res. 2015;15:308.
  14. Sievert KD, Amend B, Nagele U, Schilling D, Bedke J, Horstmann M, et al. Economic aspects of bladder cancer: what are the benefits and costs? World J Urol. 2009;27(3):295–300.
  15. de Oliveira C, Bremner KE, Pataky R, Gunraj N, Chan K, Peacock S, et al. Understanding the costs of cancer care before and after diagnosis for the 21 most common cancers in Ontario: a population-based descriptive study. CMAJ Open. 2013;1(1):E1–8.
  16. Flannery K, Cao X, He J, Zhong Y, Shah AY, Kamat A. Real world treatment costs and resource utilization among patients with metastatic bladder cancer. Ann Oncol. 2017;28(5).  
  17. Edmondson AJ, Birtwistle JC, Catto JW, Twiddy M. The patients’ experience of a bladder cancer diagnosis: a systematic review of the qualitative evidence. J Cancer Surviv. 2017;11(4):453–461.
  18. Bladder Cancer: Diagnosis and Management [Internet]. National Institute for Health Care and Excellence; c2018 (updated 2015 Feb 15). Available from: here.
  19. Garg T, Connors JN, Ladd IG, Bogaczyk TL, Larson SL. Defining priorities to improve patient experience in non-muscle invasive bladder cancer. Bladder Cancer. 2018;4(1):121–128.