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Bladder cancer is the seventh most common cancer in the UK, and around a quarter of the 10,000 new cases each year involve the muscle-wall of the bladder. Unfortunately, muscle-invasion is associated with a low survival rate, and so a rapid diagnosis and treatment is extremely important. However, the pathway for diagnosing muscle-invasive bladder cancer is complex, and consequently has many associated delays. In 2016, the time from initial referral to referral for definitive treatment for muscle-invasive bladder cancer patients at Royal Cornwall Hospitals NHS Trust (RCHT) was around 90 days. The aim of this project was to use simulation modelling to help the trust to identify delays in the pathway and test the impact of potential changes to the pathway on referral to treatment times.
We developed a Discrete Event Simulation model using two years of data from the trust, and simulated the flow of patients through the system. The simulation exposed the two key bottlenecks in the system - a delay between patients being referred and receiving their Transurethral Resection of Bladder Tumour (TURBT), and a delay waiting for the nurse specialist to contact the patient to discuss their diagnosis and treatment options. The simulation was demonstrated to a group of RCHT consultants and urologists. This facilitated a discussion of practical changes that could be made to reduce delays, which we then 'live' tested in the model to give them instant feedback about which solutions could have the biggest impact.
The model predicted that by making two key changes - fast-tracking bladder cancer patients with suspected muscle-invasion to the TURBT within 14 days, and asking the nurse specialist to speak to the patient to discuss options whilst on the ward for their TURBT - the average referral to treatment time could reduce by up to five and a half weeks.
On the back of the evidence generated by the model, the Cancer Lead for Urology at RCHT immediately rewrote the protocol for muscle-invasive bladder cancer patients to incorporate these changes, and the new protocol was implemented less than 24 hours later. Analysis of data collected six months later showed that muscle-invasive patients are now waiting 25 days less for their TURBT and 5 weeks less to be contacted to inform them of their diagnosis. There has also been a positive impact seen across all bladder cancer patients, including an 8 day reduction in time to TURBT and an 18 day reduction in time to be informed of diagnosis.