Radical cystectomy with urinary diversion is the gold standard first-line treatment for muscle-invasive bladder cancer. Researchers from the University of Washington School of Medicine report that underuse of this surgical approach is compromising patient survival.

John Gore and colleagues investigated adherence to the evidence-based treatment recommendations issued by the National Comprehensive Cancer Network in the USA. The team used data from the Surveillance, Epidemiology, and End Results national cancer registry, for patients diagnosed between 1 January 1992 and 31 December 2002, linked with Medicare claims. Procedure codes were used to identify the management strategy (radical cystectomy, radiation therapy alone, chemotherapy alone, combined radiation and chemotherapy, or surveillance) for 3,262 patients with stage II non-metastatic muscle-invasive bladder malignancy.

Just 21% of the studied cohort underwent radical cystectomy. This procedure was less likely to be performed on older patients with several comorbidities, and on those who needed to travel long distances to reach an available surgical specialist.

Overall survival was superior following radical cystectomy—42% at 5 years, compared with 21% for chemotherapy and/or radiation and 15% for surveillance.

The concerns of both treatment providers and patients probably contribute to the worryingly low frequency of cystectomy. The procedure is complex, with high morbidity and mortality rates, and patients require intensive postoperative care. Many are distressed by the perceived negative impact of urinary diversion on their quality of life. Gore et al. assert that patient education must be a cornerstone of efforts to overcome the “formidable obstacles of ... resistance” to optimal treatment for all.