Gender disparities in hematuria evaluation and bladder cancer diagnosis: a population based analysis

Stratifying risk of disease in haematuria patients using machine learning techniques to improve diagnostics

Background

Detailed and invasive clinical investigations are required to identify the causes of haematuria. Highly unbalanced patient population (predominantly male) and a wide range of potential causes make the ability to correctly classify patients and identify patient-specific biomarkers a major challenge. Studies have shown that it is possible to improve the diagnosis using multi-marker analysis, even in unbalanced datasets, by applying advanced analytical methods. Here, we applied several machine learning algorithms to classify patients from the haematuria patient cohort (HaBio) by analysing multiple biomarkers and to identify the most relevant ones.

Materials and methods

We applied several classification and feature selection methods (k-means clustering, decision trees, random forest with LIME explainer and CACTUS algorithm) to stratify patients into two groups: healthy (with no clear cause of haematuria) or sick (with an identified cause of haematuria e.g., bladder cancer, or infection). The classification performance of the models was compared. Biomarkers identified as important by the algorithms were also analysed in relation to their involvement in the pathological processes.

Results

Results showed that a high unbalance in the datasets significantly affected the classification by random forest and decision trees, leading to the overestimation of the sick class and low model performance. CACTUS algorithm was more robust to the unbalance in the dataset. CACTUS obtained a balanced accuracy of 0.747 for both genders, 0.718 for females and 0.803 for males. The analysis showed that in the classification process for the whole dataset: microalbumin, male gender, and tPSA emerged as the most informative biomarkers. For males: age, microalbumin, tPSA, cystatin C, BTA, HAD and S100A4 were the most significant biomarkers while for females microalbumin, IL-8, pERK, and CXCL16.

Conclusions

CACTUS algorithm demonstrated improved performance compared with other methods such as decision trees and random forest. Additionally, we identified the most relevant biomarkers for the specific patient group, which could be considered in the future as novel biomarkers for diagnosis. Our results have the potential to inform future research and provide new personalised diagnostic approaches tailored directly to the needs of the individuals.

Microbiome Sex-Related Diversity in Non-Muscle-Invasive Urothelial Bladder Cancer

Sex-specific discrepancies in bladder cancer (BCa) are reported, and new studies imply that microbiome may partially explain the diversity. We aim to provide characterization of the bladder microbiome in both sexes diagnosed with non-muscle-invasive BCa with specific insight into cancer grade. In our study, 16S rRNA next-generation sequencing was performed on midstream urine, bladder tumor sample, and healthy-appearing bladder mucosa. Bacterial DNA was isolated using QIAamp Viral RNA Mini Kit. Metagenomic analysis was performed using hypervariable fragments of the 16S rRNA gene on Ion Torrent Personal Genome Machine platform. Of 41 sample triplets, 2153 taxa were discovered: 1739 in tumor samples, 1801 in healthy-appearing bladder mucosa and 1370 in midstream urine. Women were found to have smaller taxa richness in Chao1 index than men (p = 0.03). In comparison to low-grade tumors, patients with high-grade lesions had lower bacterial diversity and richness in urine. Significant differences between sexes in relative abundance of communities at family level were only observed in high-grade tumors.

The influence of socioeconomic status and gender on incidence and survival in bladder cancer: a longitudinal study based on the Hamburg Cancer Registry

BACKGROUND

To investigate the influence of socioeconomic status (SES) and gender on the incidence and survival of patients with bladder cancer on a small scale within the city of Hamburg, Germany.

METHODS

Patients documented in the Hamburg Cancer Registry aged ≥ 18 years with primary bladder carcinoma (ICD-10: C67, D09.0), diagnosed in the period 2004-2020 (follow-up until 31.12.2021), and residing in Hamburg were included. The patients were divided into three groups (low, intermediate, and high SES) based on the socioeconomic situation at the district level, defined by the proportion of unemployed individuals, social housing, benefit recipients according to law, etc. Relative survival in the years 2004-2020 was calculated using a period approach.

RESULTS

Among the 10,659 patients included, age-standardized 5-year relative survival (5YRS) in 2004-2020 correlated with SES. The age-standardized 5YRS differed significantly between patients with high and intermediate SES vs low SES. Women with low SES had the worst 5YRS at 58.2%, while men with high SES presented the best relative 5YRS at 73.5%. This effect remained after stratification by UICC stages. Concerning incidence, there is an indication that women with low SES were more often diagnosed in higher UICC stages III or IV than women with high SES (18.3% versus 12.6%).

CONCLUSIONS

The socioeconomic situation at the time of diagnosis, as well as gender, has a substantial impact on the incidence and cancer survival rates in patients with bladder cancer. Further research, including the study of patient care, is needed to better understand and address these inequalities.

Sex differences in cancer incidence among solid organ transplant recipients

BACKGROUND

Males have 2-3-fold greater risk of cancer than females at most shared anatomic sites, possibly reflecting enhanced immune surveillance against cancer in females. We examined whether these sex differences remained among immunocompromised adults.

METHODS

Using the Transplant Cancer Match (TCM) study, we estimated the male-to-female incidence rate ratio in TCM (M:F IRRTransplant) for 15 cancer sites diagnosed between 1995 and 2017 using Poisson regression. Male to female IRRs in the general population (M:F IRRGP) were calculated using expected cancer counts from the Surveillance, Epidemiology, and End Results Program, standardized to the transplant population on age, race and ethnicity, and diagnosis year. Male to female IRRs were compared using a chi-square test.

RESULTS

Among 343 802 solid organ transplants, 211 206 (61.4%) were among men and 132 596 (38.6%) among women. An excess cancer incidence in males was seen in transplant recipients, but the sex difference was attenuated for cancers of the lip (M:F IRRTransplant: 1.81 vs M:F IRRGP: 3.96; P < .0001), stomach (1.51 vs 2.09; P = .002), colorectum (0.98 vs 1.43; P < .0001), liver (2.39 vs 3.44; P = .002), kidney (1.67 vs 2.24; P < .0001), bladder (2.02 vs 4.19; P < .0001), Kaposi sarcoma (1.79 vs 3.26; P = .0009), and non-Hodgkin lymphoma (1.34 vs 1.64; P < .0001). The M:F IRRTransplant was not statistically different from the M:F IRRGP for other cancer sites.

CONCLUSIONS

Although male solid organ transplant recipients have higher cancer incidence than female recipients, the attenuation in the male to female ratio for many cancers studied relative to the general population might suggest the importance of immunosurveillance, with some loss of advantage in female recipients due to immunosuppression after transplantation.

Sexual dimorphism in bladder cancer: a review of etiology, biology, diagnosis, and outcomes

Bladder carcinoma represents a prevalent malignancy, wherein the influence of sex extends across its incidence, biological attributes, and clinical outcomes. This scholarly exposition meticulously examines pertinent investigations, elucidating the nuanced impact of sex on bladder cancer, and posits cogent avenues for future research and intervention modalities. In the initial discourse, an exhaustive scrutiny is undertaken of the etiological underpinnings of bladder cancer, encompassing variables such as tobacco consumption, occupational exposures, and genetic aberrations. Subsequently, a comprehensive dissection unfolds, delving into the intricate biological disparities inherent in sex vis-à-vis the initiation and progression of bladder cancer. This analytical framework embraces multifaceted considerations, spanning sex hormones, sex chromosomal dynamics, metabolic enzymatic cascades, and the intricate interplay with the microbiome. Lastly, a synthesized exposition encapsulates the ramifications of gender differentials on the diagnostic and prognostic landscapes of bladder cancer, underscoring the imperative for intensified investigative endeavors directed towards elucidating gender-specific variances and the formulation of tailored therapeutic strategies.

Pre-diagnostic prescription patterns in bladder and renal cancer: a longitudinal linked data study

BACKGROUND

Understanding pre-diagnostic prescribing activity could reveal windows during which more timely cancer investigation and detection may occur.

AIM

To examine prescription patterns for common urological clinical features prior to renal and bladder cancer diagnoses.

DESIGN AND SETTING

A retrospective cohort study was performed using electronic primary care and cancer registry data on patients with bladder and renal cancer, who received their diagnosis between April 2012 and December 2015 in England.

METHOD

Primary care prescriptions up to 2 years pre- diagnosis were analysed for five groups of clinical features (irritative urological symptoms, obstructive symptoms, urinary tract infections [UTIs], genital infections, and atrophic vaginitis). Poisson regressions estimating the inflection point from which the rate of prescriptions increased from baseline were used to identify the start of diagnostic windows during which cancer could be detected.

RESULTS

A total of 48 094 prescriptions for 5322 patients were analysed. Inflection points for an increase in UTI prescriptions were identified 9 months pre- diagnosis for renal (95% confidence interval [CI] = 5.3 to 12.7) and bladder (95% CI = 7.4 to 10.6) cancers. For bladder cancer, the change in UTI antibiotic prescription rates occurred 4 months earlier in females (11 months pre- diagnosis, 95% CI = 9.7 to 12.3) than in males (7 months pre-diagnosis, 95% CI = 5.4 to 8.6). For other clinical features, no inflection points were identified and, as such, no diagnostic windows could be defined.

CONCLUSION

Prescription rates for UTIs increased 9 months before bladder and renal cancer diagnoses, indicating that there is potential to expedite diagnosis of these cancers in patients presenting with features of UTI. The greatest opportunity for more timely diagnosis may be in females with bladder cancer, who experienced the earliest increase in UTI prescription rate.

Performance Characteristics of a Rule-Based Electronic Health Record Algorithm to Identify Patients with Gross and Microscopic Hematuria

BACKGROUND

Two million patients per year are referred to urologists for hematuria, or blood in the urine. The American Urological Association recently adopted a risk-stratified hematuria evaluation guideline to limit multi-phase computed tomography to individuals at highest risk of occult malignancy.

OBJECTIVES

To understand population-level hematuria evaluations, we developed an algorithm to accurately identify hematuria cases from electronic health records (EHRs).

METHODS

We used International Classification of Diseases (ICD)-9/ICD-10 diagnosis codes, urine color, and urine microscopy values to identify hematuria cases and to differentiate between gross and microscopic hematuria. Using an iterative process, we refined the ICD-9 algorithm on a gold standard, chart-reviewed cohort of 3,094 hematuria cases, and the ICD-10 algorithm on a 300 patient cohort. We applied the algorithm to Geisinger patients ≥35 years (n = 539,516) and determined performance by conducting chart review (n = 500).

RESULTS

After applying the hematuria algorithm, we identified 51,500 hematuria cases and 488,016 clean controls. Of the hematuria cases, 11,435 were categorized as gross, 26,658 as microscopic, 12,562 as indeterminate, and 845 were uncategorized. The positive predictive value (PPV) of identifying hematuria cases using the algorithm was 100% and the negative predictive value (NPV) was 99%. The gross hematuria algorithm had a PPV of 100% and NPV of 99%. The microscopic hematuria algorithm had lower PPV of 78% and NPV of 100%.

CONCLUSION

We developed an algorithm utilizing diagnosis codes and urine laboratory values to accurately identify hematuria and categorize as gross or microscopic in EHRs. Applying the algorithm will help researchers to understand patterns of care for this common condition.

Biological differences underlying sex and gender disparities in bladder cancer: current synopsis and future directions

Sex and gender disparities in bladder cancer have long been a subject of interest to the cancer research community, wherein men have a 4 times higher incidence rate than women, and female patients often present with higher-grade disease and experience worse outcomes. Despite the known differences in disease incidence and clinical outcomes between male and female bladder cancer patients, clinical management remains the same. In this review, we critically analyze studies that report on the biological differences between men and women and evaluate how these differences contribute to sex and gender disparities in bladder cancer. Distinct characteristics of the male and female immune systems, differences in circulating hormone levels and hormone receptor expression, and different genetic and epigenetic alterations are major biological factors that all likely contribute to disparate incidence rates and outcomes for male and female bladder cancer patients. Future preclinical and clinical studies in this area should employ experimental approaches that account for and consider sex and gender disparities in bladder cancer, thereby facilitating the development of precision medicine for the effective treatment of bladder cancer in all patients.

"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals

BACKGROUND

There is a critical need to identify specific causes of and tailored solutions to diagnostic error in sexual and gender minority (SGM) populations.

PURPOSE

To identify challenges to diagnosis in SGM adults, understand the impacts of patient-reported diagnostic errors on patients' lives and elicit solutions.

METHODS

Qualitative study using in-depth semistructured interviews. Participants were recruited using convenience and snowball sampling. Recruitment efforts targeted 22 SGM-focused organisations, academic centres and clinics across the USA. Participants were encouraged to share study details with personal contacts. Interviews were analysed using codebook thematic analysis.

RESULTS

Interviewees (n=20) ranged from 20 to 60 years of age with diverse mental and physical health symptoms. All participants identified as sexual minorities, gender minorities or both. Thematic analysis revealed challenges to diagnosis. Provider-level challenges included pathologisation of SGM identity; dismissal of symptoms due to anti-SGM bias; communication failures due to providers being distracted by SGM identity and enforcement of cis-heteronormative assumptions. Patient-level challenges included internalised shame and stigma. Intersectional challenges included biases around factors like race and age. Patient-reported diagnostic error led to worsening relationships with providers, worsened mental and physical health and increased self-advocacy and community-activism. Solutions to reduce diagnostic disparities included SGM-specific medical education and provider training, using inclusive language, asking questions, avoiding assumptions, encouraging diagnostic coproduction, upholding high care standards and ethics, involving SGM individuals in healthcare improvement and increasing research on SGM health.

CONCLUSIONS

Anti-SGM bias, queerphobia, lack of provider training and heteronormative attitudes hinder diagnostic decision-making and communication. As a result, SGM patients report significant harms. Solutions to mitigate diagnostic disparities require an intersectional approach that considers patients' gender identity, sexual orientation, race, age, economic status and system-level changes.

Global trends in the epidemiology of bladder cancer: challenges for public health and clinical practice

Bladder cancer is among the ten most common cancers globally, causes considerable morbidity and mortality and is, therefore, a substantial burden for health-care systems. The incidence of bladder cancer is affected by demographic trends, most notably population growth and ageing, as well as exposure to risk factors, especially tobacco smoking. Consequently, the incidence has not been stable throughout the world over time, nor will it be in the near future. Further primary prevention efforts are of the utmost importance to reduce the medical and financial burden of bladder cancer on populations and health-care systems. Simultaneously, less-invasive and lower-cost approaches for the diagnosis of both primary and recurrent bladder cancers are required to address challenges posed by the increasing shortage of health-care professionals and limited financial resources worldwide. In this regard, urinary biomarkers have demonstrated promising diagnostic accuracy and efficiency. Awareness of the risk factors and symptoms of bladder cancer should also be increased in society, particularly among health-care professionals and high-risk groups. Studies investigating the associations between lifestyle factors and bladder cancer outcomes are scarce and should be a research priority. In this Review, we outline global trends in bladder cancer incidence and mortality, and discuss the main risk factors influencing bladder cancer occurrence and outcomes. We then discuss the implications, challenges and opportunities of these epidemiological trends for public health and clinical practice.

Feminist Emergence in a Traditionally Male Industry: Case from Jordan—The Jordanian Banking Industry

Purpose: This research explored the role of female managers as change agents and the “problem of making women visible,” specifically in top management positions in in Jordanian banking industry. Methods: This research design is built on the basis of qualitative research, analyzing the perceptions in the mind of research subjects. Interviews were conducted with 32 participants from the Jordanian banking industry. Findings: Our research has revealed different and important insights into the changing role of Jordanian female workers, not only in such a male-dominant industry but also more broadly in Jordan’s wider society, in which the Arab masculine culture has been dominant. The positive impact of increased acceptance of females’ roles is significantly evident in our research, and we support the assertion that women can survive and prosper in the face of Arab or Eastern culture traditions. In addition, we asserted that females’ managers are deemed to be internal change agents through their knowledge, experience, and leadership traits and behavior. Conclusions: We shed the light on emancipation, in which females have had the opportunity to cross previous social and taken-for-granted boundaries, and which has eroded gender-biased boundaries and behavior as a response to the situational demands.

"I Just Want to Feel Safe Going to a Doctor": Experiences of Female Patients with Chronic Conditions in Australia

Background

The androcentric history of medicine and medical research has led to an ongoing sex and gender gap in health research and education. Sex and gender gaps in research and education may translate into real-life health inequities for women. This study aimed to explore the experiences of female patients with chronic health conditions in the Australian health system, considering existing sex and gender gaps in medicine.

Methods

This qualitative study used semistructured in-depth interviews with a sample of adult women with chronic conditions in Australia. Thematic analysis was undertaken, guided by Braun and Clarke. Software NVivoX64 assisted in the management of the data. Coding was performed before grouping into subthemes and central themes. To allow for potential researcher biases, the principal researcher engaged in the practice of reflexivity, including the writing of detailed notes during analysis.

Results

Twenty adult Australian women with chronic conditions were interviewed. Diagnoses were varied and included Ehlers-Danlos syndrome, chronic fatigue syndrome, functional neurological disorder, and inflammatory bowel disease. Four central themes emerged: diagnostic difficulties; spectrum of health care experiences; understanding medical complexity; and coping with symptoms.

Conclusions

Women with chronic conditions in Australia report pain, fatigue, and suffering that significantly impacts upon their daily lives. There was a shared experience of feeling that the pain and suffering of women was dismissed or not taken seriously. Many women expressed trauma because of their experiences in health care and often this led to a fear of accessing health services. The participants highlighted a need for more knowledge, understanding, and empathy from health care practitioners.

Survival outcomes following treatment delays among patients with early-stage female cancers: a nationwide study

BACKGROUND

The coronavirus disease 2019 (COVID-19) severely hindered the timely receipt of health care for patients with cancer, especially female patients. Depression and anxiety were more pronounced in female patients than their male counterparts with cancer during treatment wait-time intervals. Herein, investigating the impact of treatment delays on the survival outcomes of female patients with early-stage cancers can enhance the rational and precise clinical decisions of physicians.

METHODS

We analyzed five types of cancers in women from the Surveillance, Epidemiology, and End Results (SEER) program between Jan 2010 and Dec 2015. Univariate and multivariate Cox regression analyses were used to determine the impacts of treatment delays on the overall survival (OS) and cancer-specific survival (CSS) of the patients.

RESULTS

A total of 241,661 females with early-stage cancer were analyzed (12,617 cases of non-small cell lung cancer (NSCLC), 166,051 cases of infiltrating breast cancer, 31,096 cases of differentiated thyroid cancer, 23,550 cases of colorectal cancer, and 8347 cases of cervical cancer). Worse OS rates were observed in patients with treatment delays ≥ 3 months in stage I NSCLC (_adjustedHazard ratio (HR) = 1.11, 95% Confidence Interval (CI): 1.01-1.23, p = 0.044) and stage I infiltrating breast cancer (_adjustedHR = 1.23, 95% CI 1.11-1.37, p < 0.001). When the treatment delay intervals were analyzed as continuous variables, similar results were observed in patients with stage I NSCLC (_adjustedHR = 1.04, 95% CI 1.01-1.06, p = 0.010) and in those with stage I breast cancer (_adjustedHR = 1.03, 95% CI 1.00-1.06, p = 0.029). However, treatment delays did not reduce the OS of patients with differentiated thyroid cancer, cervical cancer, or colorectal cancer in the early-stage. Only intermediate treatment delays impaired the CSS of patients with cervical cancer in stage I (_adjustedHR = 1.31, 95% CI 1.02-1.68, p = 0.032).

CONCLUSION

After adjusting for confounders, the prolonged time from diagnosis to the initiation of treatment (< 6 months) showed limited negative effects on the survival of most of the patients with early-stage female cancers. Whether our findings serve as evidence supporting the treatment deferral decisions of clinicians for patients with different cancers in resource-limited situations needs further validation.

Precision Medicine in the Treatment of Locally Advanced or Metastatic Urothelial Cancer: New Molecular Targets and Pharmacological Therapies

Simple Summary

Therapeutic breakthroughs in urothelial carcinoma have been occurring rapidly over the past 10 years. However, the resistance and prognosis of this disease is always quite a difficult health challenge. Trying to understand the new therapeutic perspectives is a priority to try to bring in new drug models that can counteract the advancing prognosis and inauspicious diagnosis.

Abstract

Many variants of urothelial cancer present diagnostic challenges and carry clinical implications that influence prognosis and treatment decisions. The critical issues of treatment-resistant clones are a crucial barrier to care in individuals affected by urothelial carcinoma. Laying the foundations for the resistance evolution, a wide mutational heterogeneity characterizes urothelial carcinoma, noticeable also in patients affected by a early stage disease. In recent years the growing knowledge of the pathogenesis and molecular paths underlying the onset and progression of urothelial cancer are leading to the development of new therapies based on immune checkpoints. Chemotherapy and immunotherapy both operate selectively by shaping the developmental trajectory of urothelial carcinoma in the course of the illness. To date, a promising new therapeutic treatment is represented by antibody-drug conjugates, therapeutic tools that exploit the targeted ability of an antibody to administer cytotoxic drugs directly to the tumor. Indeed, nowadays in the clinical setting there are several treatments available for the treatment of locally advanced or metastatic urothelial cancer, from classic chemotherapeutics such as Gemcitabine, Cisplatin and Carboplatin, Paclitaxel and Docetaxel, to Programmed cell death protein 1 (PD-1) or Programmed death-ligand 1 (PD-L1) inhibitors such as Atezolizumab, Avelumab, Nivolumab, Pembrolizumab, up to anti-nectin 4 Enfortumab Vedotin and Sacituzumab govitecan, which binds Tumor-associated calcium signal transducer 2 (Trop-2) and activates as a topoisomerase inhibitor. The aim of this work is to describe the molecular mechanisms underlying the onset of the urothelial cancer and provide an overview of the immunotherapies that can be used in the clinical setting to counteract it, deepening the efficacy and safety results of the pivotal studies and the place in therapy of these treatments.

[Gender-associated differences in bladder cancer]

BACKGROUND AND OBJECTIVES

Although the incidence of bladder cancer among women is lower, they tend to more often have advanced disease at presentation with a more aggressive course. It is still unclear which factors are responsible for the poorer prognosis of bladder cancer in women.

MATERIALS AND METHODS

Original papers and reviews from 2004 until 2022 were identified in a PubMed search and evaluated.

RESULTS

Multiple factors are likely responsible for the different courses of bladder cancer in women versus men. In the literature, epidemiologic and clinical aspects are discussed. Furthermore, genetic and hormonal causes and the role of the urobiome have been the focus of discussion more recently.

CONCLUSIONS

Earlier diagnosis and better surgical treatment could lead to a more favorable course of bladder cancer in women. Further analyses of genetic, hormonal, und microbiological factors could open new perspectives in the prevention, diagnosis, and treatment of bladder cancer.

The Role of Adjuvant Single Postoperative Instillation of Gemcitabine for Non-Muscle-Invasive Bladder Cancer: A Systematic Review and Meta-Analysis

Bladder cancer is a heterogeneous disease with variable natural history. Non-muscle-invasive bladder cancer has a favorable prognosis following transurethral resection, but the optimal adjuvant chemotherapy plan is still in debate. The aim of this study was to evaluate the effect of the adjuvant intravesical administration of a single dose of gemcitabine in the outcome of this disease. For that purpose, we performed a systematic review and meta-analysis on available randomized control trials on MEDLINE, EMBASE, Cochrane, Scopus, and Google Scholar databases. Ultimately, two studies were included with a total number of 654 patients. The statistical analysis performed showed that a single post-operative intravesical dose of gemcitabine does not affect the recurrence rate of non-muscle-invasive bladder cancer compared to placebo. Therefore, this therapeutic strategy does not offer any significant improvement on the outcomes of the disease. Nonetheless, due to the plethora of available therapeutic agents and treatment strategies, further research is needed to establish the optimal treatment in this category of patients.

Demographic Factors Associated With Non-Guideline-Based Treatment of Kidney Cancer in the United States

Importance

Significant demographic disparities have been found to exist in the delivery of health care. Demographic factors associated with clinical decision-making in kidney cancer have not been thoroughly studied.

Objective

To determine whether demographic factors, including sex and race/ethnicity, are associated with receipt of non-guideline-based treatment for kidney cancer.

Design, Setting, and Participants

This retrospective cohort study was conducted using data from the National Cancer Database for the years 2010 through 2017. Included patients were individuals aged 30 to 70 years with localized (ie, cT1-2, N0, M0) kidney cancer and no major medical comorbidities (ie, Charlson-Deyo Comorbidity Index score of 0 or 1) treated at Commission on Cancer-accredited health care institutions in the United States. Data were analyzed from November 2020 through March 2021.

Exposures

Demographic factors, including sex, race/ethnicity, and insurance status.

Main Outcomes and Measures

Receipt of non-guideline-based treatment (undertreatment or overtreatment) for kidney cancer, as defined by accepted clinical guidelines, was determined.

Results

Among 158 445 patients treated for localized kidney cancer, 99 563 (62.8%) were men, 120 001 individuals (75.7%) were White, and 91 218 individuals (57.6%) had private insurance. The median (interquartile range) age was 58 (50-64) years. Of the study population, 48 544 individuals (30.6%) received non-guideline-based treatment. Female sex was associated with lower adjusted odds of undertreatment (odds ratio [OR], 0.82; 95% CI, 0.77-0.88; P < .001) and higher adjusted odds of overtreatment (OR, 1.27; 95% CI, 1.24-1.30; P < .001) compared with male sex. Compared with White patients, Black and Hispanic patients had higher adjusted odds of undertreatment (Black patients: OR, 1.42; 95% CI, 1.29-1.55; P < .001; Hispanic patients: OR, 1.20; 95% CI, 1.06-1.36; P = .004) and overtreatment (Black patients: OR, 1.09; 95% CI, 1.05-1.13; P < .001; Hispanic patients: OR, 1.06; 95% CI, 1.01-1.11, P = .01). Individuals who were uninsured, compared with those who had insurance, had statistically significantly higher adjusted odds of undertreatment (OR, 2.63; 95% CI, 2.29-3.01; P < .001) and lower adjusted odds of overtreatment (OR, 0.72; 95% CI, 0.67-0.77; P < .001).

Conclusions and Relevance

This study found that there were significant disparities in treatment decision-making for patients with kidney cancer, with increased rates of non-guideline-based treatment for women and Black and Hispanic patients. These findings suggest that further research into the mechanisms underlying these disparities is warranted and that clinical and policy decision-making should take these disparities into account.

Genetic Analysis Reveals Rare Variants in T-Cell Response Gene MR1 Associated with Poor Overall Survival after Urothelial Cancer Diagnosis

Urothelial carcinoma of the bladder (UC) is the fifth most common cancer in the United States. Germline variants, especially rare germline variants, may account for a portion of the disparity seen among patients in terms of UC incidence, presentation, and outcomes. The objectives of this study were to identify rare germline variant associations in UC incidence and to determine its association with clinical outcomes. Using exome sequencing data from the DiscovEHR UC cohort (n = 446), a European-ancestry, North American population, the complex influence of germline variants on known clinical phenotypes were analyzed using dispersion and burden metrics with regression tests. Outcomes measured were derived from the electronic health record (EHR) and included UC incidence, age at diagnosis, and overall survival (OS). Consequently, key rare variant association genes were implicated in MR1 and ADGRL2. The Kaplan-Meier survival analysis reveals that individuals with MR1 germline variants had significantly worse OS than those without any (log-rank p-value = 3.46 × 10^-7). Those with ADGRL2 variants were found to be slightly more likely to have UC compared to a matched control cohort (FDR q-value = 0.116). These associations highlight several candidate genes that have the potential to explain clinical disparities in UC and predict UC outcomes.

The impact of hormones and reproductive factors on the risk of bladder cancer in women: results from the Nurses' Health Study and Nurses' Health Study II

BACKGROUND

With three out of four new bladder cancer (BCa) cases occurring in men, an apparent gender disparity exists. We aimed to investigate the role of hormonal and reproductive factors in BCa risk using two large female US prospective cohorts.

METHODS

Our study population comprised 118 256 and 115 383 female registered nurses who were recruited in the Nurses' Health Study (NHS) and NHS II, respectively. Reproductive and hormonal factors and other relevant data were recorded in biennial self-administered questionnaires. Cox-regression analyses were performed to estimate age- and multivariable-adjusted incidence risk ratios (IRRs) and 95% confidence intervals (CIs). Inverse-variance-weighted meta-analysis was used to pool estimates across cohorts.

RESULTS

During up to 36 years of follow-up, 629 incident BCa cases were confirmed. In the NHS, 22 566 women (21.3%) were postmenopausal at baseline, compared with 2723 women (2.4%) in the NHS II. Among women in the NHS, younger age at menopause (≤45 years) was associated with an increased risk of BCa (IRR: 1.41, 95% CI: 1.11-1.81, Ptrend = 0.01) compared with those with menopause onset at age 50+ years, particularly among ever-smokers (IRR for age at menopause ≤45 years: 1.53, 95% CI: 1.15-2.04; PIntx = 0.16). Age at menarche and first birth, parity, oral-contraceptive use and postmenopausal hormone use were not associated with BCa risk.

CONCLUSIONS

Overall, we found little support for an association between female reproductive factors and BCa risk in these prospective cohort studies. Earlier age at menopause was associated with a higher risk of BCa, particularly among smokers, indicating the potential for residual confounding.

Evaluating Patient-Defined Priorities for Female Patients with Bladder Cancer

BACKGROUND: Although bladder cancer is much more common in men than in women, female patients with bladder cancer present with more locally advanced tumors and have worse disease-specific outcomes than male patients, even after controlling for biological differences. There is a paucity of research regarding the optimal approach to caring for female patients with bladder cancer in ways that maximize patient satisfaction, preferences, and values. OBJECTIVE: We sought to explore patient-defined priorities and areas in need of improvement for female patients with bladder cancer from the patient perspective. METHODS: We conducted focus group sessions and semi-structured interviews of women treated for bladder cancer to identify patient priorities and concerns until reaching topic saturation. Transcripts were analyzed thematically. RESULTS: Eight patients with muscle-invasive bladder cancer and six patients with non-muscle-invasive bladder cancer participated in two focus groups and seven interviews total. Three themes emerged as significantly affecting the care experience: physical impacts, mental health and emotional wellbeing, and the patient-provider interaction. Each theme included patient-defined specific recommendations on approaches to optimizing the care experience for women with bladder cancer. CONCLUSIONS: Although most participants were satisfied with the quality of care they received, they identified several opportunities for improvement. These concerns centered around enhancing support for patients’ physical and mental needs and strengthening the patient-provider interaction. Efforts to address these needs and reduce gender disparate outcomes via quality improvement initiatives are ongoing.

Gender discrepancies in bladder cancer: potential explanations

INTRODUCTION

Gender differences in urothelial carcinoma of the bladder (UCB) exist. Although men have a higher incidence of UCB, women tend to have poorer outcomes. We have explored and summarized the evidence for gender differences of UCB diagnosis and prognosis, together with reasons for these disparities.

AREAS COVERED

The incidence of UCB is 3-4 times higher in men than women. However, women are more likely to be diagnosed with advanced disease. Women have a higher stage-for-stage mortality compared to men, and their greatest risk of death appears to be within the first 2 years of diagnosis. Survival outcomes following radical cystectomy (RC) and radiotherapy are also poorer in women. Delays in diagnosis, differences in female anatomy, as well as poorer surgical outcomes post-RC appear to contribute significantly to the disparities noted between genders. Other factors such as exposure to risk factors, differential hormone signaling, and carcinogen breakdown may also have a role.

EXPERT OPINION

The gender divide in UCB outcomes has to be addressed. Improved medical and patient education and centralization of RC are recommended.

Gender Disparities in Bladder Cancer-Specific Survival in High Poverty Areas Utilizing Ohio Cancer Incidence Surveillance System (OCISS)

OBJECTIVE

To better understand the interplay of socioeconomic and demographic traits on bladder cancer outcomes utilizing the Ohio state cancer registry, Ohio Cancer Incidence Surveillance System (OCISS).

METHODS

We obtained demographic, clinical and outcome data on 47,182 bladder cancer cases diagnosed from 1996 to 2016 from OCISS. Multivariable Cox proportional hazards regression to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between sex, race and poverty and survival, adjusting age, stage, and primary treatment.

RESULTS

Within the OCISS database, there were 47,182 patients with a diagnosis of bladder cancer identified, with females representing 12,056 (26%) of the population. There were a total of 9255(35.2%) deaths due to bladder cancer, with median follow-up time of 4.4 years. After adjusting for confounding variables, women were statistically significantly less likely to die from any cause (HR: 0.94, 95% CI: 0.91-0.96), compared with men, but more likely to die from bladder cancer (HR: 1.21, 95% CI: 1.15-1.27). We also found that after adjusting for confounding variables, including sex and poverty, black race was statistically significantly associated with a higher risk of overall (HR: 1.12, 95% CI: 1.06-1.18) and bladder cancer-specific mortality (HR: 1.25, 95% CI: 1.15-1.36).

CONCLUSION

Using the OCISS database, female gender, self-reported black race, and neighborhood poverty level were associated with worse bladder cancer-specific survival. By recognizing these disparities, we can prospectively address risk factors in efforts to improve survival among these patient populations.

Diagnostic and treatment delays among patients with primary bladder cancer in Poland: a survey study

Introduction

The aim of this study was to determine and quantify the mechanisms responsible for the delays in bladder cancer diagnosis and initial treatment.

Material and methods

Patients referred to two academic hospitals in Poland with a primary bladder tumor were prospectively identified and structurally interviewed. For all patients, time intervals between symptom onset, diagnostic and therapeutic interventions were assessed.

Results

A total of 144 patients diagnosed with bladder cancer were included in the analysis. The median time from symptom onset to treatment was 112 days. This comprised of the following median waiting times: 1) patient waiting time of 13 days, 2) assessment waiting time of 14 days and 3) treatment waiting time of 42 days. In the multivariate analysis, large city residence (OR 0.2, 95% CI 0.1-0.6) and comorbidity (OR 0.3, 95% CI 0.1-0.8) reduced the risk of delay, whereas medium-sized city residence (OR 1.4, 95% CI 0.4-5.1) and general practitioner as the first medical professional contact (OR 5.3, 95% CI 0.6-50.0) increased the risk of delay.

Conclusions

Diagnostic and treatment waiting times for bladder cancer in Poland are unsatisfactory. Potential solutions for shortening these delays include healthcare policy changes such as utilization of the oncological priority programs, primary care education and public health campaigns.

Disparities in Bladder Cancer Outcomes Based on Key Sociodemographic Characteristics

PURPOSE OF REVIEW

A review of the impact of several key patient characteristics on oncologic outcomes in bladder cancer (BC) summarized and analyzed in a narrative fashion.

RECENT FINDINGS

The bulk of the published literature suggests that females and blacks have poorer cancer-specific outcomes. Both groups tend to present with worse disease, which may be driven by differences in access to timely and quality care. Attempts to assess the association between smoking status and history and BC outcomes have been hindered by the quality and heterogeneity of the data, although several studies have linked smoking with higher rates of recurrence and poorer survival. Being married, particularly in men, may improve survival after radical cystectomy (RC). Limited data suggests that socioeconomic and education levels may be associated with poorer survival; however, the data is limited. A growing body of investigation suggests that there are significant differences in oncologic outcomes in BC patients based on race, gender, smoking status, socioeconomic status, and others. Further focus and investigation is needed to validate these findings, investigate the root cause of these differences, and offer solutions to mitigate them.

The impact of gender on oncologic outcomes of bladder cancer

PURPOSE OF REVIEW

The purpose of this article is to review the current literature on the impact of gender on oncologic outcomes of bladder cancer (BCa).

RECENT FINDINGS

Women are more likely to experience disease recurrence, progression, and/or death across all disease states. Furthermore, women are less likely to respond to intravesical therapy for nonmuscle invasive BCa. These disparities are explained by several hypotheses such as differential exposure to environmental carcinogens, hormonal factors, and/or disease management. Additionally, it has been shown that women suffer from delays in diagnosis because of inefficiencies in healthcare delivery. On genomic analyses, women were found to be more likely to harbor basal subtypes of BCa compared with men.

SUMMARY

A steadily growing body of evidence reveals that women present with more advanced BCa and have stage-for-stage worse outcome compared with men. The underlying mechanisms for this gender difference are multifactorial. Further studies are needed to elucidate the molecular underpinning of this gender-gap and subsequently explore potential novel gender-specific management strategies.

Sex and the Diagnostic Pathway to Bladder Cancer among Veterans: No Evidence of Disparity

BACKGROUND

Longer time intervals from presentation with hematuria to bladder cancer diagnosis have been reported among women compared with men. Despite women being the fastest growing cohort within the Department of Veterans Affairs, little is known about women veterans with bladder cancer. Our objectives were to quantify the time from hematuria to bladder cancer diagnosis in Department of Veterans Affairs and assess differences between sexes.

METHODS

This was a retrospective cohort study of patients diagnosed with bladder cancer from 2001 to 2016. Included were patients with hematuria for fewer than 365 days before a bladder cancer diagnosis and who had a record of diagnostic cystoscopy after hematuria but before diagnosis. We evaluated the number of days from hematuria to diagnostic cystoscopy (clinical appraisal), cystoscopy to bladder cancer diagnosis (surgical appraisal), and hematuria to bladder cancer diagnosis (total diagnostic appraisal). We used quantile regression models to separately evaluate the effect of sex on the three appraisal intervals.

RESULTS

Data from 213 women and 24,295 men were analyzed. The median clinical appraisal time was 78 days for women and 72 for men (p = .49). The median surgical appraisal time was 32 days for women and 33 for men (p = .74). The median total diagnostic appraisal time was 135 days for women and 130 for men (p = .71). Multivariable analyses showed no differences between men and women for any of the three appraisal intervals.

CONCLUSIONS

The majority of time from hematuria to bladder cancer diagnosis is spent in clinical appraisal, but little difference was observed between men and women in Department of Veterans Affairs.

Spotlight on gender-specific disparities in bladder cancer

Men are at a higher risk of developing bladder cancer, but women present with more advanced disease and have more unfavourable outcomes. Although epidemiologic and genetical studies have underlined the multifactorial aetiology and gender-related differences of bladder cancer, there is lack of evidence-based recommendation for gender-specific management of bladder cancer. We summarize the evidence and most recent findings on gender-specific differences in bladder cancer incidence, diagnosis, treatment and outcome, spotlighting the gender disparities in genetic and hormonal risk factors, pelvic anatomy, diagnostic setting and surgical choices. We reviewed the literature published on PubMed between 1981 and 2018. Males have a threefold to fourfold higher risk of bladder cancer as compared to females; however, women have higher stage-for-stage mortality, being diagnosed with more advanced disease, mostly due to a delay in haematuria evaluation. Numerous studies indicate an increased risk of disease recurrence or progression in women with non-muscle-invasive bladder cancer treated with trans-urethral resection, with or without intravesical chemotherapy or immunotherapy, compared to males. In particular, recent molecular evidence show that there is an excess of female Ta mutant tumours. At the time of radical cystectomy, women have a significantly longer length of hospital stay, operative time, higher blood loss and higher 90-day mortality and perioperative complication rate. Moreover, females are less likely to receive a continent diversion. Future research should guarantee greater inclusion of women in trials and focus on improving the effectiveness of therapies in women, perhaps exploring different therapeutic approaches in men and women. Specific data on functional and oncological outcomes can be analysed to define predictive factors able to guide the surgeon in decisions based on evidence. It is urgently needed to limit gender-related discrepancies in early diagnosis and treatment of bladder cancer. Public awareness and bladder cancer female patients' consciousness on gender inequalities must be similarly uprisen.

Radical Cystectomy in Female Patients - Improving Outcomes

PURPOSE OF REVIEW

To review the methods of improving surgical, oncological, and functional outcomes in women with bladder cancer treated with radical cystectomy.

RECENT FINDINGS

Οrthotopic urinary diversion (ONB) is a safe option for well-selected women as it combines high rates of daytime and nighttime continence with exceptional oncologic outcomes. It is considered safe even for patients with limited lymph node disease and trigone involvement, as long as a preoperative biopsy of the bladder neck or an intraoperative frozen section analysis of distal urethral margin rules out malignant disease. Nerve-sparing techniques have shown promising results. For well-selected patients with early invasive disease, sparing of internal genitalia has proven to be oncologically safe. Yet, generally accepted and evidence-based oncological and functional follow-up schemes for women after radical cystectomy are still lacking. Properly designed prospective studies are needed with adequate number of participants in order to safely conclude about a broader use of pelvic organ-sparing cystectomy.

Longitudinal patterns of cost and utilization of medicare beneficiaries with bladder cancer

BACKGROUND

Bladder cancer (BC) is highly prevalent and costly. This study documented cost and use of services for BC care and for other (non-BC) care received over a 15-year follow-up period by a cohort of Medicare beneficiaries diagnosed with BC in 1998.

METHODS

Data came from the Surveillance, Epidemiology and End Results Program linked to Medicare claims. Medicare claims provided data on diagnoses, services provided, and Medicare Parts A and B payments. Cost was actual Medicare payments to providers inflated to 2018 US$. Cost and utilization were BC-related if the claim contained a BC diagnosis code. Otherwise, costs were for "other care." For utilization, we grouped Part B-covered services into 6 mutually-exclusive categories. Utilization rates were ratios of the count of claims in a particular category during a follow-up year divided by the number of beneficiaries with BC surviving to year-end.

RESULTS

Cumulatively over 15-years, for all stages combined, total BC-related cost per BC beneficiary was $42,011 (95% Confidence Interval (CI): $42,405-$43,417); other care cost was about twice this number. Cumulative total BC-related cost of 15-year BC survivors for all stages was $43,770 (CI: $39,068-$48,522), intensity of BC-related care was highest during the first year following BC diagnosis, falling substantially thereafter. After follow-up year 5, there were few statistically significant changes in BC-related utilization. Utilization of other care remained constant during follow-up or increased.

CONCLUSIONS

Substantial costs were incurred for non-BC care. While increasing BC survivorship is an important objective, non-BC care would remain a burden to Medicare.

Quality of the diagnostic process in patients presenting with symptoms suggestive of bladder or kidney cancer: a systematic review

OBJECTIVES

In urological cancers, sex disparity exists for survival, with women doing worse than men. Suboptimal evaluation of presenting symptoms may contribute.

DESIGN

We performed a systematic review examining factors affecting the quality of the diagnostic process of patients presenting with symptoms of bladder or kidney cancer.

DATA SOURCES

We searched Medline, Embase and the Cochrane Library from 1 January 2000 to 13 June 2019.

ELIGIBLE CRITERIA

We focused on one of the six domains of quality of healthcare: timeliness, and examined the quality of the diagnostic process more broadly, by assessing whether guideline-concordant history, examination, tests and referrals were performed. Studies describing the factors that affect the timeliness or quality of the assessment of urinary tract infections, haematuria and lower urinary tract symptoms in the context of bladder or kidney cancer, were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were independently performed by two authors. Due to the heterogeneity of study design and outcomes, the results could not be pooled. A narrative synthesis was performed.

RESULTS

28 studies met review criteria, representing 583 636 people from 9 high-income countries. Studies were based in primary care (n=8), specialty care (n=12), or both (n=8). Up to two-thirds of patients with haematuria received no further evaluation in the 6 months after their initial visit. Urinary tract infections, nephrolithiasis and benign prostatic conditions before cancer diagnosis were associated with diagnostic delay. Women were more likely to experience diagnostic delay than men. Patients who first saw a urologist were less likely to experience delayed evaluation and cancer diagnosis.

CONCLUSIONS

Women, and patients with non-cancerous urological diagnoses just prior to their cancer diagnosis, were more likely to experience lower quality diagnostic processes. Risk prediction tools, and improving guideline ambiguity, may improve outcomes and reduce sex disparity in survival for these cancers.

Symptoms and diagnostic delays in bladder cancer with high risk of recurrence: results from a prospective FinnBladder 9 trial

Purpose

To investigate the symptoms and delays in the clinical pathway of bladder cancer (BC).

Methods

This is a substudy of a prospective, randomized, multicenter phase III study (FinnBladder 9, NCT01675219) where the efficacy of photodynamic diagnosis and 6 weekly optimized mitomycin C instillations are studied in pTa bladder cancer with high risk for recurrence. The data of presenting symptoms and critical time points were prospectively collected, and the effect of factors on delays was analyzed.

Results

At the time of analysis, 245 patients were randomized. Analysis included 131 patients with primary bladder cancer and their complete data. Sixty-nine percent had smoking history and 67% presented with macroscopic hematuria. Median patient delay (from symptoms to health-care contact) was 7 days. The median general practice delay (from health-care contact to urology referral) was 8 days. Median time from urology referral to cystoscopy was 23 days and from cystoscopy to TUR-BT 21 days. Total time used in the clinical pathway (from symptom to TUR-BT) was 78 days. Current and former smokers had non-significantly shorter patient-related and general practice delays compared to never smokers. TUR-BT delay was significantly shorter in patients with malignant cytology (16 days) compared to patients with benign cytology (21 days, p = 0.03).

Conclusions

Patient-derived delay was short and most of the delay occurred in the referral centers. The majority had macroscopic hematuria as the initial symptom. Surprisingly, current and past smokers were more prone to contact the health-care system compared to never smokers.

Screening for Microscopic Hematuria in a Urogynecologic Population

OBJECTIVES

The objectives of this were to determine the correlation of greater than or equal to 3 red blood cells per high-power field (RBCs/HPF) with a positive urine dipstick for blood and to identify clinically relevant factors than can influence this relationship.

METHODS

The charts of women with positive blood urine dipsticks were reviewed from August 2012 to August 2013. The cohort of women was divided into 2 groups; those with urine with greater than or equal to 3 RBCs/HPF on microscopy and those without. Relevant clinical and demographic variables were extracted from the electronic medical record. Data analysis was conducted using SAS version 9.4 (SAS Institute, Cary, NC).

RESULTS

Most of the 203 patients eligible for analysis were Caucasian, and the total cohort had a mean age of approximately 62.8 years. Microscopy confirmed greater than or equal to 3 RBCs/HPF in 25.6% of the urine samples. A dipstick finding of moderate or large blood was significantly more likely to have greater than or equal to 3 RBCs/HPF on univariate and multivariable analyses (P < 0.001). Factors significantly associated with greater than or equal to 3 RBCs/HPF were increasing age, recurrent urinary tract infections, and urinary specific gravity of greater than 1.010.

CONCLUSIONS

Lower urinary specific gravities appear to be associated with underestimating microhematuria, likely owing to the underrepresentation of the true number of red blood cells. Urine dipstick indicators of moderate or large blood increase the likelihood the microscopy samples demonstrated greater than or equal to 3 RBCs/HPF. These findings suggest that clarification of microhematuria detection and evaluation guidelines should be considered, given both important clinical and economic consequences.

Urologic oncology workforce diversity: A first step in reducing cancer disparities

Urologic cancer disparities based on race/ethnicity and gender are well-documented across the cancer continuum. Patients cared for by physicians of similar race/ethnicity and gender report better communication, patient satisfaction, and care adherence which has the potential to translate into better health outcomes. We believe that ensuring a diverse Urologic Oncology workforce is an important first step toward eliminating cancer disparities due to the downstream effects of improved communication between concordant patient-physician dyads. In this essay, we review the demographics of the Urologic cancer patient population and Urologic Oncology workforce; describe current evidence supporting healthcare workforce diversity, especially related to race and gender-based concordant patient-physician relationships; and make recommendations for individual and institutional strategies to develop and support a diverse workforce in Urologic Oncology.

Gender Disparity in Cystectomy Postoperative Outcomes: Propensity Score Analysis of the National Surgical Quality Improvement Program Database

BACKGROUND

While female gender is considered a protective determinant in the majority of cancers, outcomes in women diagnosed with bladder cancer have continued to show disproportional mortality when compared with men.

OBJECTIVE

The aim of this retrospective propensity score-matched analysis was to evaluate the intra- and postoperative differences among genders, as well as to evaluate reproductive organ-preserving radical cystectomy (ROPRC) as compared with radical cystectomy (RC) as a potential confounder in female cystectomy patients.

DESIGN, SETTING, AND PARTICIPANTS

Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), men and women undergoing a cystectomy between 2011 and 2017 were analyzed. In addition, females undergoing ROPRC and RC were analyzed for immediate postoperative outcomes.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Men and women undergoing a cystectomy were evaluated through propensity score matching (PSM) for baseline differences using a 1:1 caliper width of 0.2 to the nearest neighbor. Using multivariable logistic regression analysis, we evaluated differences in the risk of readmission, complications, and reoperation in the immediate postsurgical period in males and females. Similarly, differences were assessed in ROPRC and RC groups.

RESULTS AND LIMITATIONS

We achieved a balance between males and females after PSM: 1263 males and 1263 females treated with cystectomy. The risks of readmission (adjusted odds ratio [aOR] 1.228 [1.005-1.510], p=0.045), superficial surgical site infection (aOR 1.507 [1.095-2.086], p=0.012), and transfusion (aOR 2.031 [1.713-2.411], p<0.001) were increased in females undergoing a cystectomy compared with males. No differences were observed in surgical outcomes in ovarian sparing/RC cohort.

CONCLUSIONS

Using the 2011-2017 NSQIP database, we were able to demonstrate an increased rate of postoperative transfusion, readmission rate, and surgical site infection in females who underwent cystectomy. Our findings suggest that females experience an increased rate of complications in the immediate postoperative period. This may ultimately lead to worse oncologic outcomes in females after an RC. Lastly, we did not find any increased rate of complications in ROPRC as compared with RC.

PATIENT SUMMARY

This study highlights differences in immediate postoperative outcomes between males and females undergoing cystectomy for bladder cancer. Some of these potential differences include higher risk of infection, transfusion, and readmission. These differences may predispose females to worse long-term outcomes. In addition, due to potential benefits of ovarian preservation in the recent literature, we also evaluated the risks and complications of ovarian sparing cystectomy. We found ovarian preservation to be a safe and feasible procedure in a highly selected group of patients.

Impact of sex difference on survival of bladder cancer: A population-based registry data in Japan

OBJECTIVE

To investigate the impact of sex on the prognosis of bladder cancer in Japan.

METHODS

In total, 18 728 patients diagnosed as having bladder cancer from 1993 to 2006 were registered in population-based cancer registries of six prefectures in Japan. We estimated relative survival by sex, age, clinical stage at initial diagnosis and pathology.

RESULTS

Patients included 14 203 men (75.8%) and 4525 women (24.2%). The stage at initial diagnosis in women was significantly higher than in men (P < 0.0001). Pathologically, women were more likely to have non-urothelial cancer than men (women 18.0%, men 9.5%, P < 0.0001). The 5-year relative survival was 80.3% for men and 67.7% for women. The 5-year relative survival was 93.0% for men and 87.7% for women in the localized cancer group, 34.8% for men and 23.9% for women in the locally advanced cancer group, and 7.1% for men and 8.3% for women in the metastatic cancer group. The relative survival of women was worse than that of men in the localized cancer group (hazard ratio 1.29, 95% confidence interval 1.05-1.57; P = 0.0145) and locally advanced cancer group (hazard ratio 1.32, 95% confidence interval 1.15-1.52; P = 0.0001), but not different in the metastatic cancer group (hazard ratio 1.04, 95% confidence interval 0.87-1.25; P = 0.6555).

CONCLUSIONS

Population-based registry data in Japan show that the cancer stage at initial diagnosis is higher in women than in men, and women with localized or locally advanced bladder cancer have a worse prognosis compared with men.

Disparities in the diagnostic evaluation of microhematuriaand implications for the detection of urologic malignancy

INTRODUCTION

Disparities in survival for bladder and kidney cancer among the genders and patients with varying insurance coverage have been identified. Microhematuria (MH), a potential early clinical sign of genitourinary malignancy, should prompt a standardized diagnostic evaluation. However, many patients do not complete a full evaluation and may be at risk of a missed or delayed identification of genitourinary pathology.

METHODS

Patients 35 and older with a new diagnosis of MH between 2007 and 2015 were retrospectively identified at a large health system. Our primary outcome of interest was completion of cystoscopy and imaging. Regression modeling was used to assess associations between gender and insurance status with completion of a MH evaluation, adjusted for clinical factors, urinalysis data, and patient demographics.

RESULTS

Of 15,161 patients with MH, only 1,273 patients (8.4%) completed upper tract imaging and a cystoscopy; 899 (5.9%) within 1 year. Median time to imaging was 75days and 68.5days for cystoscopy. Of those with an incomplete evaluation, 23.7% underwent cystoscopy and 76.3% underwent imaging. Male gender, private insurance, and increased MH severity on UA were associated with a complete evaluation. More patients who completed an evaluation were diagnosed with bladder (4.8% vs. 0.3%) and kidney cancer (3.1% vs. 0.4%) when compared to those who did not.

CONCLUSION

Few patients complete a timely evaluation of MH. Women and underinsured patients are disproportionately less likely to complete a work-up for microhematuria and this may have downstream implications for diagnosis.

Geographic Variation in Cystoscopy Rates for Suspected Bladder Cancer between Female and Male Medicare Beneficiaries

OBJECTIVE

To assess geographic variation in cystoscopy rates among women vs men with suspected bladder cancer, lending insight into gender-specific differences in cystoscopic evaluation.

METHODS

We conducted a cross-sectional study of all fee-for-service Medicare beneficiaries within 306 Hospital Referral Regions (HRRs) who received care in 2014. For each HRR, we calculated the age- and race-adjusted cystoscopy rate for women and men as our primary outcome. The rate was the number of beneficiaries who underwent cystoscopy for bladder cancer symptoms (using procedure and ICD-9 diagnosis codes) divided by all beneficiaries in the HRR. We used the coefficient of variation to compare relative variability of cystoscopy rates.

RESULTS

Overall, 173,551 women (n = 14.8 million) and 286,090 men (n = 11.5 million) underwent cystoscopy in 2014. While women received less cystoscopies compared to men (mean 11.0 vs 23.5 per 1000, P < .001), there was greater variation in cystoscopy rates among women (coefficient of variation 27.5 vs 23.5, P = .010). When restricting to ICD-9 codes for hematuria only, women continued to demonstrate greater variation in cystoscopy rates (coefficient of variation 27.8 vs 24.2, P = .022). Findings were robust across larger HRR sizes-thereby removing some random variation seen in smaller HRRs-as well as across years 2010, 2011, 2012, and 2013.

CONCLUSION

Cystoscopy rates are lower in women than men, likely due to their lower bladder cancer incidence. However, there is greater variation in cystoscopy rates among women with symptoms of bladder cancer. This may reflect increased provider uncertainty whether to refer and work-up women with suspected bladder cancer.

Bladder Cancer Survivorship

PURPOSE OF REVIEW

Bladder cancer (BC) is the second most common genitourinary malignancy, with a growing population of survivors globally. Over the past two decades, there has been a growing awareness of not only the oncologic, but also the quality of life ramifications of a BC diagnosis, treatment, and surveillance. In the current review, the literature surrounding the many domains that encompass bladder cancer survivorship is summarized and analyzed.

RECENT FINDINGS

There have been ongoing efforts to decrease perioperative morbidity, particularly in patients undergoing radical cystectomy, with mixed results. There is a growing emphasis on the short and long-term health-related quality of life (HR-QoL) impacts of bladder cancer spanning the domains of physical and mental QoL related to urinary function, sexual function, and financial and psychological burden, with validated measures specific to BC patients. There continue to be disparities in oncologic outcomes by race and gender. The impact of BC is prolonged and there is an unmet need for long term support and survivorship resources to address this. There is a growing global population of bladder cancer patients, and their needs are complex and vary by stage, treatment, and certain demographic features. Outcome-centered perioperative strategies show potential to diminish treatment morbidity, and validated BC specific HR-QoL tools have helped to define the impact and burden of BC, but there continue to be large areas of unmet need that warrant greater study and intervention.

Treatment according to guidelines may bridge the gender gap in outcome for patients with stage T1 urinary bladder cancer

OBJECTIVE

The aim of this investigation was to study differences between male and female patients with stage T1 urinary bladder cancer (UBC) regarding intravesical instillation therapy, second resection and survival.

MATERIALS AND METHODS

This study included all patients with non-metastatic primary T1 UBC reported to the Swedish National Register of Urinary Bladder Cancer (SNRUBC) from 1997 to 2014, excluding those treated with primary cystectomy. Differences between groups were evaluated using chi-squared tests and logistic regression, and survival was investigated using Kaplan-Meier and log-rank tests and Cox proportional hazards analysis.

RESULTS

In all, 7681 patients with T1 UBC (77% male, 23% female) were included. Females were older than males at the time of diagnosis (median age at presentation 76 and 74 years, respectively; p < .001). A larger proportion of males than females underwent intravesical instillation therapy (39% vs 33%, p < .001). Relative survival was lower in women aged ≥75 years and women with G3 tumours compared to men. However, women aged ≥75 years who had T1G3 tumours and underwent second resection followed by intravesical instillation therapy showed a relative survival equal to that observed in men.

CONCLUSIONS

This population-based study demonstrates that women of all ages with T1 UBC undergo intravesical instillation therapy less frequently than men, and that relative survival is poorer in women aged ≥75 years than in men of the same age when intravesical instillation therapy and second resection are not used. However, these disparities may disappear with treatment according to guidelines.

Clinical utility of a non-invasive urine test for risk assessing patients with no obvious benign cause of hematuria: a physician-patient real world data analysis

Background

The non-invasive Cxbladder urine test system has demonstrated clinical utility in ruling out urothelial carcinoma (UC) in patients with asymptomatic microscopic hematuria (AMH), suggesting that the number of invasive diagnostic tests, including cystoscopy, used in this patient population may be reduced by Cxbladder testing prior to conducting a full urological work-up. The aim of this study was to demonstrate the enhanced clinical utility of communicating objective information on diagnostic decisions made by individual physicians on individual patients with AMH.

Methods

Three hundred ninety-six physician-patient decisions were generated from twelve participant physicians evaluating real world case notes from the same 33 patients presenting with AMH. Each physician reviewed and recommended diagnostic tests and procedures based on each patient’s referral data and then re-evaluated their clinical recommendation following disclosure of the non-invasive Cxbladder urine test result. Changes assessed were the total number of requested diagnostic procedures and the number of invasive procedures, including cystoscopy, following addition of information from Cxbladder in the Triage and Triage and Detect modalities.

Results

Physicians made significant changes to their diagnostic behavior for patients with AMH when presented with Cxbladder test results, including a reduction in the number of total and invasive procedures including cystoscopy for individuals identified as having a low probability of UC. The intensity of investigation was targeted and increased, including use of total procedures and cystoscopy, for patients identified by Cxbladder tests as having a high probability of UC: urologists increased the level of investigation for both total procedures and invasive procedures. The outcome resulted in patients with a high risk of UC receiving appropriate guideline-recommended invasive diagnostic tests. Patients who tested negative were offered fewer and significantly less invasive procedures. This change in physician behavior results in an increased clinical and patient utility, lower risk of missed UC and invasive test-related harm incidents.

Conclusions

This study demonstrated the potential for increased clinical resolution and significantly enhanced patient management, when physicians consider Cxbladder test results in their clinical evaluation. The change in physician behavior led to more appropriate diagnostic procedure selection and resource allocation to the benefit of both patients and healthcare systems.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0327-6) contains supplementary material, which is available to authorized users.

Urinary Tract Infection in a Small Animal Model: Transurethral Catheterization of Male and Female Mice

Urinary tract infections (UTI) are extremely common worldwide, incurring significant morbidity and healthcare-associated expenses. Small animal models, which accurately reflect disease establishment and progression, permit dissection of host-pathogen interactions and generation of immunity to infection. In mice, intravesical instillation of uropathogenic E. coli, the causative agent in more than 85% of community acquired UTI, recapitulates many of the stages of infection observed in humans. Until recently, however, UTI could only be modeled in female animals. This limitation has hindered the study of sex-related differences in UTI, as well as other bladder pathologies, such as cancer. Here, we describe a method to instill male mice that allows direct comparison between female and male animals and provide a detailed protocol to assess bladder tissue by flow cytometry as a means to better understand host responses to infection. Together, these approaches will aid in the identification of host factors that contribute to sex biases observed in UTI and other bladder-associated diseases.

Diagnostic evaluation of patients presenting with hematuria: An electronic health record-based study

BACKGROUND

To gain new insights into the origin and prevention of diagnostic delays in the evaluation of hematuria in an electronic health record (EHR)-based integrated care setting.

METHODS

We performed a retrospective review of 298 consecutive patients with new-onset hematuria at a Veterans Affairs facility from January 1, 2011 to December 31, 2013 excluding those where diagnostic evaluation was unnecessary (i.e., cystoscopy within 3 years prior). We collected data on presentation, such as red flags of painless gross hematuria (PGH) or asymptomatic microhematuria (AMH) and subsequent evaluation (imaging, urologic referral, and cystoscopy). Delay was defined when evaluation was not completed within 60 days. Logistic regression was performed to identify predictors of delay.

RESULTS

Of 201 patients, 149 had delays. PGH was present in 99 patients. These patients had a higher rate of urology referral within 1 year than patients with AMH (86.7% vs. 64.7%; P<0.01) and were more likely to undergo cystoscopy (75.8% vs. 52%; P<0.01). Delays occurred in 67% of PGH patients vs. 81% of AMH patients (OR 0.46; P = 0.02), and roughly a third were related to scheduling/coordination, patient-related issues, or delay in primary care referral. Bladder neoplasms were detected in 18% of patients with PGH and 2% of those with AMH.

CONCLUSION

Delays in evaluation for hematuria occur commonly, regardless of strength of the red-flag. Many delays were preventable and could be targeted with interventions including EHR-based tracking systems or reformed scheduling practices.

Fast-track access to urologic care for patients with macroscopic haematuria is efficient and cost-effective: results from a prospective intervention study

Background:

The delay between onset of macroscopic haematuria and diagnosis of bladder cancer is often long.

Methods:

We evaluated timely diagnosis and health-care costs for patients with macroscopic haematuria given fast-track access to diagnostics. During a 15-month period, a telephone hotline for fast-track diagnostics was provided in nine Swedish municipalities for patients aged ⩾50 years with macroscopic haematuria. The control group comprised 101 patients diagnosed with bladder cancer in the same catchment area with macroscopic haematuria who underwent regular diagnostic process.

Results:

In all 275 patients who called ‘the Red Phone' hotline were investigated, and 47 of them (17%) were diagnosed with cancer and 36 of those had bladder cancer. Median time from patient-reported haematuria to diagnosis was 29 (interquartile range (IQR) 14−104) days and 50 (IQR 27−165) days in the intervention and the control group, respectively (P=0.03). The median health-care costs were lower in the intervention group (655 (IQR 655−655) EUR) than in the control group (767 (IQR 490−1096) EUR) (P=0.002).

Conclusions:

Direct access to urologic expertise and fast-track diagnostics is motivated for patients with macroscopic haematuria to reduce diagnostic intervals and lower health-care expenditures.

Using community outreach to explore health-related beliefs and improve surgeon-patient engagement

BACKGROUND

Fostering surgeon engagement in community outreach was recently identified as a major priority toward reducing health care disparities in surgery. We aimed to increase surgeon engagement in the local community, understand prevalent beliefs, and identify educational opportunities in the local community regarding cancer screening and treatment using community outreach.

MATERIALS AND METHODS

In collaboration with the university's cancer center, the medical student surgical interest group, surgical faculty, and residents developed a community outreach program. The program consisted of networking time, a formal presentation, panel discussion, and question and answer time. A survey was distributed to all participants before the educational session, and a program assessment was distributed at the program's conclusion.

RESULTS

A total of 256 community members and 22 surgical volunteers attended at least one of the two events. Attendees were insured (175; 92.7%), female (151; 80%), and African-American (176; 93.1%), with a mean age of 61 y (standard deviation 14.0). About 56 participants (29.6%) were unwilling to undergo screening colonoscopy. Forty-eight respondents (25.4%) endorsed mistrust in doctors and 25% believed surgery causes cancer to spread; a significantly higher proportion of them aged <60 y old. About 113 (59.8%) and 87 (46.1%) misunderstood the definitions of malignant and metastatic, respectively. Males were more unsure than females (61% versus 55%, P = 0.5 and 70% versus 55%; P = 0.01).

CONCLUSIONS

Risk perceptions related to fatalism, mistrust, or lack of knowledge were prevalent. The ability of surgeons to reach at-risk populations in the prehospital setting is an important opportunity waiting to be capitalized upon.