








































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Bladder cancer, coordination of care, regional 
medical programs, hospital mortality, patient 
navigation, patient care team

None declared. Soc Int Urol J.2022;3(4):198–200

DOI: 10.48083/DFBQ7749

198 SIUJ  •  Volume 3, Number 4  •  July 2022 SIUJ.ORG

UROLOGY AROUND THE WORLD

The CABEM Initiative: Saving Patients  
With Muscle-Invasive Bladder Cancer

Fernando Korkes, José Henrique D. Santiago, Guilherme Andrade Peixoto, 
Frederico Timóteo, Suelen P. Martins, Narjara P. Leite, Daisy Barreiros,   
Sidney Glina

Division of Urology, Centro Universitário FMABC Santo André, São Paulo, Brazil

Abstract

Muscle-invasive bladder cancer (MIBC) is an aggressive disease with a complex treatment. In Brazil, as in most 
developing countries, data are scarce, but mortality seems exceedingly high. We have created a centralized program 
involving a multidisciplinary clinic in a region comprising 7 municipalities. Helping patients with adequate performance 
status get the right treatment helped to reduce 90-day mortality after radical cystectomy from 37% to 1.9%.

In Brazil, as in many developing countries, taking care of oncologic patients is a considerable challenge. Among 
oncologic diseases, bladder cancer poses an even more significant challenge because of the complexity of the treatment 
and aggressiveness of the disease.

Access to health treatment is a right unambiguously outlined in the Brazilian Constitution. Aware that patients 
treated with radical cystectomy frequently died, we decided to conduct national studies to gather epidemiologic 
data[1] and study our region. We found an astonishing 90-day mortality rate of 37% after radical cystectomy in the 
public hospitals of our region[2].

In light of these unacceptable numbers, we started a program aimed at changing this terrible scenario. This was 
the so-called CABEM initiative. It was based on principles of centralization of treatment, multidisciplinary approach, 
and patient navigation to coordinate the treatment, and our primary goal was to reduce mortality for muscle-invasive 
bladder cancer (MIBC) patients.

 Our project comprised 3 phases: gathering the data, designing the strategies, and acting to meet our objectives. We 
mapped 4 main reasons for the high mortality rate: (1) advanced stage of disease at diagnosis, (2) poor patient perfor-
mance status, (3) lack of treatment protocols, (4) inadequate perioperative care.

The advanced stage of the disease at diagnosis results from the difficulties and long waiting times our patients face 
to see a specialist. Our patients have usually waited between 13 and 24 months to see a urologist, and almost half of 
the patients with bladder cancer are diagnosed with MIBC. Neoadjuvant chemotherapy (NAC) had not previously 
been offered was not performed, in part because bureaucratic challenges made it difficult to coordinate in our public 
setting. We implemented a program to allow NAC, which is currently administered in half of our MIBC patients. It 
enables the downstaging of many cases of advanced disease—half our MIBC patients have T3–T4 tumors—but also 
during this part of the treatment, we have found a fantastic opportunity to improve performance status. We were able 
to enhance nutritional therapy, support the cessation of tobacco consumption, give psychological support, reduce the 
risk of requiring transfusions in the future, and prepare the patient for the surgery.

http://SIUJ.org
https://orcid.org/0000-0003-4261-4345
mailto:fkorkes%40gmail.com?subject=SIUJ
https://orcid.org/0000-0002-6883-1762
https://orcid.org/0000-0002-9022-1880
https://orcid.org/0000-0002-0731-3734
https://orcid.org/0000-0003-2697-5896
https://orcid.org/0000-0002-7258-9796
https://orcid.org/0000-0003-1598-8229
https://orcid.org/0000-0002-9053-5046


All patients seen at our centralized clinic were evaluated 
according to scores selected after mapping the main 
reasons for death and complications in a systematic 
review of the literature[3]. These patients were referred 
by other treating physicians, who were incentivized to 
send us their patients with our promise to coordinate 
their treatment. Our team helped the patients navigate 
our complex public health system, aiming to avoid 
delays. After studying the medical literature, we 
concluded that, worldwide, most patients with MIBC 
are not treated with radical cystectomy (RC), even 
though it is recommended in most guidelines. We have 
established a protocol to allow most patients to benefit 
from RC, but that recognizes that some of these patients 
are fragile and cannot tolerate frequent complications 
after intestinal urinary diversion[4]. For that reason, we 
created a scoring system to classify these patients. The 
fit patients should undergo RC with intestinal diversion 
(either Bricker diversion or neobladder). Those with 
an intermediate status we believed could receive the 
benefit of RC and extended pelvic lymphadenectomy 
but should not face the risk of an intestinal diversion. 
For these patients, we performed unilateral cutaneous 
ureterostomy with a single stoma. Both ureters 
were placed side-by-side as a double-barrel, or a 
transureteroureterostomy was performed (Figure  1).  
For the very fragile patients, we found alternative 
treatments such as radiotherapy (RDT), chemotherapy 
(CT), transurethral resection (TURB), or combinations 
of these. Bladder preservation protocols were also offered 
in specific situations according to disease characteristics 
and patient preferences[5]. Our scoring system and 
decision algorithm have been previously published[5].

The principles of fast-track recovery programs were 
adopted, allowing better preparation and recovery. These 
strategies included avoiding prolonged fasting, avoiding 
nasogastric tubes, using chewing gum, avoiding opioids, 
early mobilization, avoiding excessive volume load, 
thromboembolism prevention, and minimally invasive 
procedures. Either extraperitoneal open radical cystec-
tomies (Figure 2) or laparoscopic radical cystectomies 
were performed in most patients, aiming to reduce post-
operative ileus and improve recovery. Perioperative care 
was enhanced by establishing a dedicated team.

In a short period, we observed remarkable results. 
Ninety-day mortality was reduced from 37.0% to the 
current 1.9% rate. Along with that, we could reduce 
median hospitalization time after surgery from 14 to 
5 days. We have currently had 153 patients treated for 
MIBC since the beginning of the CABEM program.

The higher survival rate has also resulted in nurses 
having more experience in caring for patients with osto-
mies and oncologists developing greater expertise in 
treating MIBC, including NAC, adjuvant, and pallia-
tive care. We could also improve the recruitment of our 
research unit[6,7], and we are nowadays the top recruiter 
center of some of the international trials on bladder 
cancer in Brazil.

We currently have a preceptorship program to share 
our experience with other centers, and our main goal 
is to contribute and share our results with the medical 
community. We believe that small initiatives can make a 
huge difference in developing settings.

FIGURE 1. 

199SIUJ.ORG SIUJ  •  Volume 3, Number 4  •  July 2022

The CABEM Initiative: Saving Patients With Muscle-Invasive Bladder Cancer

http://SIUJ.org


References

1. Timoteo F, Korkes F, Baccaglini W, Glina S. Bladder cancer trends 
and mortality in the Brazilian public health system. Int Braz J 
Urol.2020;46(2):224–233.

2. Korkes F, Cunha FTS, Nascimento MP, Rodrigues AFS, Baccaglini 
W, Glina S. Mortality after radical cystectomy is strongly related 
to the institution’s volume of surgeries. Einstein (Sao Paulo).2020 
Dec 7;18:eAO5628. doi: 10.31744/einstein_journal/2020AO5628. 
eCollection 2020. Available at: ht tps://pubmed.ncbi.nlm.nih.
gov/33295426/ Accessed June 1,2022.

3. Korkes F, Palou J. High mortality rates after radical cystectomy: we 
must have acceptable protocols and consider the rationale of cutaneous 
ureterostomy for high-risk patients. Int Braz J Urol.2019;45:1090–1093. 
doi: 10.1590/S1677-5538.IBJU.2019.06.03

4. Korkes F, Fernandes E, Gushiken FA, Glina FPA, Baccaglini W, Timóteo 
F, et al. Bricker ileal conduit vs. cutaneous ureterostomy after radical 
cystectomy for bladder cancer: a systematic review. Int Braz J 
Urol.2022;48(1):18-30. doi: 10.1590/S1677-5538.IBJU.2020.0892. 
Available at: http://w w w.ncbi.nlm.nih.gov/pubmed/33861058. 
Accessed May 17, 2022.

5. Korkes F, Timóteo F, Martins S, Nascimento M, Monteiro C, Santiago 
JH, et al. Dramatic Impact of Centralization and a Multidisciplinary 
Bladder Cancer Program in Reducing Mortality: The CABEM Project. 
JCO Glob Oncol.2021;7(7):1547–1555. Available at: https://pubmed.
ncbi.nlm.nih.gov/34767463/. Accessed June 1, 2022. doi: 10.1200/
GO.21.00104

6. Monteiro CR de A, Korkes F, Krutman-Zveibil D, Glina S. Fibroblast 
growth factor receptor 3 gene (FGFR3) mutations in high-grade muscle-
invasive urothelial bladder cancer in a Brazilian population: evaluation 
and prevalence. Einstein (Sao Paulo).2022 Apr 1;20:eAO6450. doi: 
10.31744/einstein_journal/2022AO6450. eCollection 2022. Available 
at: https://pubmed.ncbi.nlm.nih.gov/35384983/. Accessed Apr 11, 
2022.

7. Korkes F, Timóteo F, Soledade LCB, Bugalho LS, Peixoto GA, Teich 
VD, et al. Stage-related cost of treatment of bladder cancer in Brazil. 
Pharmacoecon Open.2022 May;6(3):461-468. doi: 10.1007/s41669-
022-00325-7. Epub 2022 Feb 14. Available at: https://pubmed.ncbi.
nlm.nih.gov/35165828/. Accessed April 11, 2022.

FIGURE 2 . 

200 SIUJ  •  Volume 3, Number 4  •  July 2022 SIUJ.ORG

UROLOGY AROUND THE WORLD

https://pubmed.ncbi.nlm.nih.gov/33295426/
https://pubmed.ncbi.nlm.nih.gov/33295426/
http://www.ncbi.nlm.nih.gov/pubmed/33861058
https://pubmed.ncbi.nlm.nih.gov/34767463/
https://pubmed.ncbi.nlm.nih.gov/34767463/
https://pubmed.ncbi.nlm.nih.gov/35384983/
https://pubmed.ncbi.nlm.nih.gov/35384983/
https://pubmed.ncbi.nlm.nih.gov/35384983/
http://SIUJ.org



