Review of Recent Article: Treatment Disparities in Muscle-invasive Bladder Cancer—Evidence from a Large Statewide Cancer Registry

David Ambinder, MD

Lower socioeconomic backgrounds are associated with suboptimal treatment in the management of muscle invasive bladder cancer, including patients less likely to undergo surgical management and when undergoing surgical management, less likely to receive neoadjuvant treatment according to a study recently published in the Journal of Urologic Oncology. 1 The investigators, led by Anup A. Shah, MD (Department of Urology, University of Pennsylvania School of Medicine), believe that their findings shed light on important factors that can potentially contribute to disparities in bladder cancer care and should be addressed through changes in state public health policy and clinical practice.

A number of studies already showed associations between outcomes and demographic, social, and economic factors, including gender, race, and insurance status in patients with MIBC,2-4 which spurred Dr Shah’s group to investigate patient-level factors that might contribute to differences in treatment for MIBC. A previous analysis of data obtained from the National Cancer Database, presented at the 2021 American Society of Clinical Oncology (ASCO) Genitourinary (GU) Cancers Symposium, found that among MIBC patients across the US, Black patients, women, patients on Medicaid, and the uninsured were less likely to receive cancer-directed therapies.5

The researchers were interested in MIBC care across Pennsylvania, the fifth largest state in the US, with the eighth highest rate of bladder cancer diagnoses. The population of Pennsylvania is mixed rural and urban, allowing study of multiple disparities in many settings, the researchers note. The Pennsylvania Cancer Registry tracks all cancer patients across the state, as reported by hospitals and other healthcare locations, and ancillary services. The study identified a total of 2,434 patients diagnosed with non-metastatic MIBC between 2010 and 2015. The population studied was mostly non-Hispanic, white, male, insured through Medicare, diagnosed at lymph node stage N0 or unknown, and urban dwelling.  Definitive management was defined as either radical cystectomy, partial cystectomy, or trimodal therapy, comprising maximal transurethral resection of bladder tumor (TURBT), chemotherapy, and radiation therapy. Non-definitive management included isolated TURBT, chemotherapy, or radiation.

The researchers found that only 64% (1548/2434) of patients diagnosed with MIBC in Pennsylvania between 2010 and 2015 underwent definitive treatment, suggesting that “a substantial proportion” of patients in the state did not receive appropriate treatment over this time, the investigators stress. Insurance was associated with differences in definitive management. For patients who underwent either radical or partial cystectomy, 37% and 49%, respectively, were covered by private insurance and Medicare, respectively. Patients who underwent trimodal therapy were more likely to be covered by Medicare (77%) than by private insurance (15%). More patients with stage T2 or T3 disease at diagnosis underwent cystectomy, whereas more with stage ≤2 disease received trimodal therapy. Of the total 1,156 patients who underwent radical cystectomy, 25% received neoadjuvant chemotherapy.

Applying multivariable logistic regression models, Dr Shah and his colleagues found that patients older than 80 years were less likely to undergo definitive therapy than younger patients. Patients older then 70 years who did receive definitive management were less likely to undergo cystectomy and, when they did, were less likely to receive neoadjuvant chemotherapy beforehand. Female patients were less likely to undergo cystectomy as definitive therapy. Patients who were uninsured were less likely to receive definitive therapy and patients with Medicare were less likely to undergo cystectomy as part of definitive therapy compared to privately insured patients. For patients who underwent either radical or partial cystectomy, 37% and 49% were covered by private insurance and Medicare, respectively. Patients who underwent trimodal therapy were more likely to be covered by Medicare rather than private (77% vs 15%).

Patients at highest socioeconomic disadvantage, as measured by Area Deprivation Index (ADI), were less likely to receive definitive treatment, and when receiving it, were also less likely to undergo cystectomy, and when undergoing cystectomy, were less likely to receive neoadjuvant chemotherapy. The researchers note that rates of neoadjuvant chemotherapy are increasing for patients in both the most and least disadvantaged ADI groups, but that “a large and persistent disparity by socioeconomic status remains.”

Dr Shah and his colleagues point out that their findings about reflect those of other studies that have shown a significant association between age, gender, insurance status, socioeconomic status, and use of cancer screening services, cancer stage at diagnosis, and survival outcomes. Lower socioeconomic status impacted therapy disposition, including receiving definitive therapy or not; and within patients who received definitive therapy, cystectomy or not; and in patients who did undergo cystectomy, whether or not those patients received neoadjuvant chemotherapy.

Lack of insurance potentially leads to decreased access to care and hence, to suboptimal treatment, they explain. This also suggests that lower-income patients probably more often present with later-stage disease, so that definitive treatment is not an option. The lack of definitive therapy in these patients could also be due to lower rates of follow-up, they submit. Adjustment of protocols to reduce delays could have important clinical implications and reduce the overall cost of care, Dr Shah and his colleagues point out, noting that bladder cancer is the most expensive malignancy. They urge state agencies and hospital systems to implement policies and programs to improve the health status of underserved populations.

David Ambinder, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include surgical education, GU oncology and advancements in technology in urology. A significant portion of his research has been focused on litigation in urology. 

References 

  1. Shah AA, Sun Z, Eom KY, et al. Treatment disparities in muscle-invasive bladder cancer: Evidence from a large statewide cancer registry. Urol Oncol. Published online January 10, 2022. DOI: 1016/j.urolonc.2021.12.004
  2. Gild P, Wankowicz SA, Sood A, et al. Racial disparity in quality of care and overall survival among black vs. white patients with muscle-invasive bladder cancer treated with radical cystectomy: a national cancer database analysis. Urol Oncol. 2018;36(10):469 e1- e11. DOI: 1016/j.urolonc.2018.07.012
  3. Fletcher SA, Cole AP, Lu C, et al. The impact of underinsurance on bladder cancer diagnosis, survival, and care delivery for individuals under the age of 65 years. Cancer. 2020;126(3):496–505. DOI: 1002/cncr.32562
  4. Mungan NA, Aben KK, Schoenberg MP, van Dijck JA, van der Poel HG. Gender differences in stage-adjusted bladder cancer survival. Urology. 2000;55(6):876–880.DOI: 1016/s0090-4295(99)00481-1
  5. Hasan S, Lazarev S, Garg M, et al. social disparities in the diagnosis and management of bladder cancer. J Clin Oncol. 2021;39(6 suppl): Abstract 403. DOI: 1200/JCO.2021.39.6_suppl.403