title: The initiation of a multidisciplinary bladder cancer clinic and the uptake of neoadjuvant chemotherapy: A time-series analysis.
abstract: BACKGROUND
  While level 1 evidence supports the use of neoadjuvant chemotherapy (NAC) for patients with muscle-invasive bladder cancer (MIBC), its uptake has been underwhelming, even in academic centres. Our aim was to determine if the initiation of a multidisciplinary bladder cancer clinic (MDBCC) in 2008 at our institution, where patients are assessed simultaneously by bladder cancer-focused urologists and radiation oncologists with easy access to a medical oncologist, was associated with an increased use of NAC.
  
  
  METHODS
  Patients with MIBC initiating treatment between July 2000 and June 2013 were identified and classified by academic year (July 1 to June 30). Time-series analyses using interventional autoregressive integrated moving average (ARIMA) models with ramp intervention functions were then conducted. A sensitivity analysis was performed on clinical N0 patients.
  
  
  RESULTS
  The cohort included 278 patients: 168 from 2000-2007 and 110 from 2008-2012 (academic years). Forty-two (15.1%) patients received NAC and 74 (26.6%) received adjuvant chemotherapy (AC). Overall the proportion of patients receiving NAC increased from 7.7% before the MDBCC to 47.6% in 2012 (Interventional ARIMA p=0.036). The results were similar when restricting to cN0 patients (p<0.001). NAC use gradually increased over time regardless of MDBCC attendance, although the proportion of patients receiving NAC appears to have risen more sharply among MDBCC attendees.
  
  
  CONCLUSIONS
  At our institution, the initiation of the MDBCC was temporally associated with increased use of NAC. In addition to multidisciplinary collaboration, having a critical mass of NAC physician advocates and support from institutional leaders are essential to the uptake of NAC.
authors.affiliation: Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada;
authors.forename: Madhur
authors.initials: M
authors.lastname: Nayan
authors.affiliation: Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada;
authors.forename: Bimal
authors.initials: B
authors.lastname: Bhindi
authors.affiliation: Department of Anesthesia, Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada;
authors.forename: Julie L
authors.initials: JL
authors.lastname: Yu
authors.affiliation: Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada;
authors.forename: Muhammad
authors.initials: M
authors.lastname: Mamdani
authors.affiliation: Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada;
authors.forename: Neil E
authors.initials: NE
authors.lastname: Fleshner
authors.affiliation: Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada;
authors.forename: Thomas
authors.initials: T
authors.lastname: Hermanns
authors.affiliation: Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada;
authors.forename: Peter
authors.initials: P
authors.lastname: Chung
authors.affiliation: Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada;
authors.forename: Michael
authors.initials: M
authors.lastname: Milosevic
authors.affiliation: Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada;
authors.forename: Robert
authors.initials: R
authors.lastname: Bristow
authors.affiliation: Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada;
authors.forename: Padraig
authors.initials: P
authors.lastname: Warde
authors.affiliation: Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada;
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Hamilton
authors.affiliation: Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada;
authors.forename: Antonio
authors.initials: A
authors.lastname: Finelli
authors.affiliation: Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada;
authors.forename: Michael A S
authors.initials: MA
authors.lastname: Jewett
authors.affiliation: Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada;; Division of Urology, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada;
authors.forename: Alexandre R
authors.initials: AR
authors.lastname: Zlotta
authors.affiliation: Division of Medical Oncology, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada;
authors.forename: Srikala S
authors.initials: SS
authors.lastname: Sridhar
authors.affiliation: Division of Urology, Departments of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, ON, Canada;
authors.forename: Girish S
authors.initials: GS
authors.lastname: Kulkarni