Original Title: Modalités optimales d'organisation et de prestation des soins et services liés à la cystectomie radicale au Québec

Authors' objectives: Bladder cancer is more common in men than in women. It is the fourth most common cancer in men and the ninth most common cancer in women in Canada. It is also the ninth leading cause of cancer deaths, all sexes combined. Radical cystectomy is an effective curative treatment for certain bladder cancers. This complex and consequential surgery involves the complete removal of the bladder along with pelvic lymph node dissection, followed by urinary reconstruction in a second stage. Due to the high risks of postoperative complications and mortality associated with this procedure, some countries have implemented measures to improve the quality of care and services surrounding the practice of radical cystectomy. A urological oncology committee was established by the Programme québécois de cancérologie (PQC) of the Ministère de la Santé et des Services Sociaux (MSSS) to identify strategies to ensure the quality and accessibility of care and services in urology, including radical cystectomy. In support of this committee, the present work aims to formulate recommendations on the clinical and organizational modalities that promote the quality of care and services for people who must undergo radical cystectomy for the treatment of resectable bladder cancer.

Authors' results and conclusions: RESULTS (#1 RADICAL CYSTECTOMY FOR BLADDER CANCER TREATMENT IS PART OF A TRAJECTORY THAT REQUIRES HIGH QUALITY SPECIALIZED CARE AND SERVICES): In Quebec, the median overall survival of people who underwent surgery for bladder cancer between 2010 and 2019 was 4.5 years (95 % CI 4.1-5.0 years). Among these, 3 % died during hospitalization and 6 % died within 90 days of surgery (compared to a rate ranging from 1.9 % to 4.7 % and 2.9 % to 8.8 %, respectively, according to the scientific literature). • Various government bodies and urological oncology expert groups have proposed promoting adherence to best clinical practices and improving the performance of care and services, as well as health outcomes, by standardizing the organization and delivery of care and services. The centralization of the surgical offer is one of the approaches advocated in the literature. (#2 A HIGHER NUMBER OF RADICAL CYSTECTOMIES PERFORMED AT A HOSPITAL COULD BE ASSOCIATED WITH CERTAIN CLINICAL BENEFITS): • According to a group of Canadian organizations, hospitals performing fewer than five radical cystectomies per year should stop offering the procedure. • The data are too limited or heterogeneous to determine the relationship between the number of radical cystectomies per hospital and other health outcomes (death within 60 days of surgery, surgical complications, cancer-specific survival, surgical margin status, prevalence of pelvic lymphadenectomy during surgery and lymph node yield after dissection, blood transfusions). (#3 THE CENTRALIZATION OF RADICAL CYSTECTOMY PRACTICE IN OTHER JURISDICTIONS MAY HAVE CONTRIBUTED TO AN IMPROVEMENT IN RESULTS): The data indirectly raise the possibility that the centralization of surgical practice (adherence to surgical volume standards) may have contributed, at least in part, to national progress in overall survival in recent years, but this has not been proven. The data on the other health outcomes assessed are insufficient. (#4 THE PRACTICE OF RADICAL CYSTECTOMY HAS BEEN PARTIALLY CENTRALIZED IN QUEBEC SINCE 2009): Montréal and Montérégie regions have the highest concentration of hospitals and urologists who have performed the procedure. Apart from the regions where no provider was listed for the entire period (Côte-Nord, Nord-du-Québec, Gaspésie– Îles-de-la-Madeleine, Nunavik, and Terres-Cries-de-la-Baie-James), AbitibiTémiscamingue, Lanaudière, and the Laurentians were the only regions where hospitals did not have on-site radiation oncology services. • According to the clinicians consulted, mobility issues related to distance are known in regions on the periphery or further away from large urban centers, particularly in the presence of socioeconomic constraints and/or poor health.

Authors' recommendations: WITH THE GOAL OF PROMOTING EQUITABLE AND TIMELY ACCESS TO HIGH-QUALITY CARE AND SERVICES TAILORED TO THE COMPLEXITY OF USERS’ NEEDS THROUGHOUT THEIR CARE JOURNEY: • The performance of radical cystectomy procedures in Quebec should be restricted to reference centers with specialized activities focused on bladder cancer (clinical and university research activities) and to certain regional hospitals commissioned to perform the procedure. WITH THE AIM OF STRENGTHENING AND STANDARDIZING THE QUALITY OF CARE AND SERVICES RELATED TO THE MANAGEMENT OF OPERABLE BLADDER CANCER IN QUEBEC: • Reference centers with specialized activities focused on bladder cancer should perform at least 25 radical cystectomies per year to maintain appropriate levels of clinical and technical expertise for the management of more complex cases. • Regional hospitals commissioned within the framework of this service offering should perform at least seven radical cystectomies per year. (#3 WITH THE AIM OF MEASURING ADHERENCE TO CLINICAL PRACTICE GUIDELINES, IDENTIFYING AND CORRECTING EXISTING GAPS IN THE MANAGEMENT OF RESECTABLE BLADDER CANCER, AND ADDRESSING UNMET USER NEEDS): Hospitals responsible for performing radical cystectomy procedures (reference centers and commissioned regional hospitals) should continuously and periodically evaluate their performance using quality indicators and health outcomes with defined performance targets. For example, but not limited to, the indicators of the quality-of-care dashboard for bladder cancer in Canada endorsed by Bladder Cancer Canada – Canadian Urological Association – Canadian Uro-Oncology Group (BCC – CUA – CUOG) could be considered. Importance should be given to quality-of-life data, considering the significant impact of surgery on multiple patient abilities and lifestyle habits.

Authors' methods: The work (divided into three knowledge products) is based on a review of the main scientific data and guidelines on the subject, on a portrait of Quebec practice in relation to bladder cancer and radical cystectomy, as well as on consultations with various Quebec stakeholders. A scoping review was conducted to identify the existing evidence regarding the clinical outcomes of people who have undergone radical cystectomy for the treatment of resectable bladder cancer. National and international guidelines, clinical practice guidelines or guideline reviews, and published national regulatory documents addressing the clinical and organizational modalities that can promote quality of care and services on the subject were also consulted. The selection of documents was made according to inclusion and exclusion criteria predefined by two reviewers. The data extracted by one reviewer, then validated by a second, were analyzed and presented in the form of a narrative synthesis and results tables.

Authors' identified further research: The need to update this notice will be assessed and determined based on the availability of new data supporting any of the dimensions evaluated, including the publication of studies, systematic reviews, meta-analyses, guidelines, practice guides, or national regulations. An update of the practice landscape may be conducted later to monitor the evolution of services offered and results obtained.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/modalites-optimales-dorganisation-et-de-prestation-des-soins-et-services-lies-a-la-cystectomie-radicale-au-quebec.html

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/Oncologie/INESSS_Cystectomie_Avis.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)