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Despite the known survival benefit of neoadjuvant chemotherapy, the current low utilization rates of neoadjuvant chemotherapy prior to radical cystectomy inspired this study and subsequent quality improvement initiative at our institution (reference 8 in article). Although our academic medical center had a higher utilization rate than those reported nationally, 15% of patients in our cohort were not referred to medical oncology, some of whom may have had a survival benefit. Conversely, those inappropriately referred with a known medical contraindication likely had unnecessary delays in their surgical care, especially if they were referred outside of our health system.¹ In the short-term, our institution aims to streamline the medical oncology referral process and ensure that patients with muscle invasive bladder cancer have the option to discuss neoadjuvant chemotherapy, while minimizing referrals where surgery could be expedited.

As the treatment landscape continues to evolve with emerging therapies, including immunotherapy (eg atezolizumab) and targeted therapies (eg erdafitinib), an increasing number of patients will benefit from coordinated care between urologists and medical oncologists.² Beyond updating clinical guidelines, we believe that quality improvement initiatives that address care pathways within their local contexts can expedite and improve care regardless of the treatment modalities utilized in the coming years.