Insights Into Rural Chemotherapy Usage for Muscle‐Invasive Bladder Cancer: An Australian Multi‐Site Institution Perspective

The relationship between geographical location and access to healthcare services is both complex and multifaceted. Rural patients encounter unique challenges in obtaining timely and effective treatments, largely due to their distance from specialised care. These challenges contribute to poorer cancer survival rates, which have been consistently documented to worsen with increasing rurality [1]. Despite extensive research on rural–metropolitan disparities in cancer outcomes, there remains limited investigation into bladder cancer (BC) outcomes specifically within rural populations. BC is a significant public health concern, being ranked as the 11th most common cancer in Australia [2]. Furthermore, among the 15 most common cancers in Australia, BC is the only cancer where survival rates have actually decreased, with a five-year relative survival between 1990–1994 and 2015–2019 declining from 65% to 57% [2, 3]. Muscle-invasive bladder cancer (MIBC), which accounts for approximately one-quarter of BC diagnoses, is an aggressive disease with a poor prognosis [4]. Given MIBC is a chemotherapy-sensitive disease, it is important to assess if patients are receiving standard of care chemotherapy, particularly in vulnerable cohorts such as rural patients. We aim to outline the systemic barriers to chemotherapy uptake among rural MIBC patients, as well as explore the current initiatives being used to overcome them. Additionally, we review data from a multi-site tertiary center which collaborates closely with rural centers to highlight the encouraging progress that has been made in rural chemotherapy uptake by this model, and potential avenues for improvement. By examining contemporary patterns of chemotherapy utilization in rural settings, we aim to contribute actionable insights toward reducing healthcare disparities for rural patients. Major clinical guidelines, including the National Comprehensive Cancer Network (NCCN), European Association of Urology (EAU), and American Urological Association (AUA), recommend neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) [5, 6]. This is supported by level 1a evidence, showing an overall survival benefit of 8% at 5 years, compared to surgery alone [6]. Adjuvant chemotherapy (AC) is also a valid alternative option, with a recent systematic review and meta-analysis demonstrating benefits to both overall survival and recurrence-free survival in patients with aggressive disease at RC [7]. Despite the benefits of perioperative chemotherapy, real-world adherence to guidelines remains a challenge. Despite approximately one-third of Australia's population residing in regional and remote areas, rural patients continue to face socio-economic barriers, including greater travel time, slower clinician adoption of new guidelines, and limited access to specialist healthcare professionals [1, 8, 9]. In 2008, only 27 medical oncologists were practicing in rural areas, representing just 6% of the national medical oncology workforce [10]. Such workforce shortages further compound the difficulties faced by rural patients in accessing timely cancer care. Over the past few decades, numerous public health strategies have been implemented to address rural–metropolitan healthcare inequities. One such strategy is the Regional Cancer Centre initiative, introduced by the federal government in 2010, which aimed to improve infrastructure and access to cancer services in regional areas [1]. Additionally, the increased adoption of telehealth services, especially during the COVID-19 pandemic, has significantly improved the provision of care. Telehealth enables rural sites to link with metropolitan centres for multidisciplinary care, facilitating better coordination and reducing the need for extensive travel [1]. Our multi-site tertiary centre is the largest health service in the state, covering 1.8 million residents. Between January 1st, 2011, and December 31st, 2021, we retrospectively identified 46 metropolitan patients and 23 rural patients who underwent curative RC for MIBC. Rurality was classified using the Modified Monash (MM) 2019 model, with rural areas defined as MM ≥ 2. Among the 23 rural patients, 15 were eligible for NAC, and four patients (26.7%) received it. Among the 46 metropolitan patients, 30 were eligible for NAC, but only one patient (3.33%) received it. For AC, 13 rural patients were eligible, and 4 patients (30.8%) received AC. Among the 24 metropolitan patients who were eligible for AC, 15 patients (62.5%) received it. Comparative data from other Australian studies highlights this variability. Lim et al., a recent Australian retrospective study examining chemotherapy rates for MIBC within the general population, found that 9.8% of eligible patients received NAC and 44.4% received AC [11]. Similarly, Millar et al., an older Australian study, reported NAC utilisation at 9.7% [12]. Our health service has a distinctive collaborative care model between rural and metropolitan clinicians. While rural patients often travel to metropolitan centres for major surgical procedures like RC, they can access chemotherapy closer to home through local healthcare providers. This model likely contributes to the higher NAC uptake in rural patients compared to the national average. The lower AC uptake in rural patients is likely multifactorial, influenced by patient recovery post-surgery, patient preference for upfront NAC, clinician recommendations, availability of therapies, and coordination of care. We also reviewed the records of specific chemotherapy regimen details within our hospital's electronic medical record system, including medical summaries, outpatient correspondences and inpatient notes. In the absence of this information, we classified it as ‘incomplete information’. It also includes any medical information transferred to the hospital's electronic medical record system from external sources. It was found that 75% of rural patients lacked detailed records of their chemotherapy regimens, compared to just 7% in metropolitan patients. Effective medical documentation is essential for improving communication between healthcare providers across specialties, and more so important for patients receiving care from both rural and metropolitan services. The lack of comprehensive documentation in rural patients highlights a significant barrier to evaluating and improving treatment outcomes for this vulnerable population. Furthermore, incomplete information increases the risk of clinical errors and fragmented care, ultimately affecting the timeliness and quality of care provided to rural patients [13, 14]. Our results are limited by the retrospective design and small sample size, limiting our ability to contextualise treatment decisions and generalise our findings. Ensuring rural patients with MIBC receive standard of care chemotherapy is a challenge that requires ongoing commitment from multiple key stakeholders. Incentivizing the recruitment and retention of oncologists in rural areas is a critical step to ensure regional cancer centers are adequately staffed. Establishing partnerships with metropolitan health services to create a collaborative care model would promote integrated care between rural and metropolitan providers. Multidisciplinary tumor board meetings (MDT) that incorporate rural healthcare specialists would facilitate better communication and streamlined care, ensuring timely and appropriate decision-making for perioperative chemotherapy. Expanding telehealth infrastructure is equally important to facilitate real-time consultations and enable rural participation in MDT, bridging the gap created by geographic distance. Data collection also requires significant improvement in rural areas, which can be achieved through the adoption of electronic medical records and standardized documentation practices. Implementing uniform protocols for recording chemotherapy details will enhance data accuracy and support effective care evaluation. Collecting robust data is fundamental to assessing the success of public health strategies and informing future initiatives. While rural MIBC patients have shown progress in NAC uptake within the last decade, significant gaps remain in AC uptake and documentation quality. Addressing these disparities requires targeted interventions, including bolstering the rural oncology workforce, establishing metropolitan and rural collaborative care models, and standardizing documentation practices. Interventions at the hospital, state, territory, and federal levels are essential to ensure equitable care for MIBC patients regardless of geographical location.