Exploring the 3 A's of cystectomy access to care for muscle-invasive bladder cancer.

Despite a known survival benefit, gross underutilization of radical cystectomy in the treatment of muscle-invasive bladder cancer (MIBC) continues. The leading hypothesis for these low utilization rates is access to care, with barriers that can be classified into 3 categories: acceptability, availability, and affordability. Acceptability is highlighted by patient miseducation, fears, and cultural beliefs, which can lead to poor treatment decisions and emphasizes the need for decision-making research for MIBC. Availability is defined by structural barriers such as facility type and physician access. Understanding and improving differences in treatment among community vs. academic centers may improve access to cystectomy among patients who are treated locally. Affordability is marked by both direct (e.g., hospital) and indirect (e.g., travel) costs, with insurance type and travel distance notably affecting cystectomy receipt. Understanding the interplay of the "3 A's" that comprise cystectomy access to care is needed before we can successfully increase utilization of cystectomy in the vulnerable MIBC population.