title: Understanding avoidance, refusal, and abandonment of chemotherapy before and after cystectomy for bladder cancer.
abstract: OBJECTIVE
  To analyze trends in perioperative chemotherapy and optimize use of neoadjuvant chemotherapy for bladder cancer.
  
  
  METHODS
  From 2005-2012, 284 consecutive patients underwent robot-assisted radical cystectomy at our facility. Patients with disease ≥ T2 and nodal involvement and positive surgical margins were reviewed and considered candidates for referral to medical oncology for chemotherapy. The study was conducted in two phases: phase 1 included 242 consecutive patients between 2005 and 2011, and phase 2 analyzed the effect of changes in 42 patients during a 1-year period (2011-2012).
  
  
  RESULTS
  In phase 1, 148 patients (61%) were candidates for neoadjuvant chemotherapy (NAC). Consultation for NAC was sought for 44 patients (29%), and 104 (71%) did not receive consultation. Of the 44 patients, 36% received NAC, 7% refused, 32% were recommended for immediate cystectomy, and 25% did not receive NAC for other reasons. Phase 2 was more stringent, with a multidisciplinary approach. Significant improvement in referral and NAC use was seen. About 78% vs 30% of patients were seen by medical oncology for consideration of NAC before robot-assisted radical cystectomy and 71% vs 36% received NAC compared with phase 1. The NAC utilization rate improved from 10.8% to 55% over 1 year with a diligent multidisciplinary approach. Medical comorbidities were the main reason for patients not receiving adjuvant chemotherapy (AC; 30% and 33%).
  
  
  CONCLUSIONS
  A multidisciplinary approach and coordination of services can help optimize the use of neoadjuvant chemotherapy for bladder cancer.
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, NY.
authors.forename: Shabnam
authors.initials: S
authors.lastname: Rehman
authors.forename: Alice
authors.initials: A
authors.lastname: Crane
authors.forename: Rakeeba
authors.initials: R
authors.lastname: Din
authors.forename: Syed Johar
authors.initials: SJ
authors.lastname: Raza
authors.forename: Yi
authors.initials: Y
authors.lastname: Shi
authors.forename: Gregory
authors.initials: G
authors.lastname: Wilding
authors.forename: Ellis G
authors.initials: EG
authors.lastname: Levine
authors.forename: Saby
authors.initials: S
authors.lastname: George
authors.forename: Roberto
authors.initials: R
authors.lastname: Pili
authors.forename: Donald L
authors.initials: DL
authors.lastname: Trump
authors.forename: Khurshid A
authors.initials: KA
authors.lastname: Guru
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D017024:Chemotherapy, Adjuvant; D015897:Comorbidity; D015653:Cystectomy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation; D016079:Refusal to Treat; D012371:Robotics; D016312:Treatment Refusal; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy* / Q000453:epidemiology / Q000601:surgery*