Disparities in Bladder Cancer Outcomes Based on Key Sociodemographic Characteristics - Beyond the Abstract

In the published literature, as well as in the clinical vernacular, differences in bladder cancer outcomes based on race and gender have been described where a complex picture of delays in care, differences in treatments received, and disparate oncologic outcomes emerge. Other key sociodemographic factors that have been shown to impact outcomes in other malignancies, such as socioeconomic status and rurality, are less frequently mentioned in the bladder cancer literature. Our article intended to describe, in a narrative fashion, how certain key factors affect bladder cancer survival outcomes based on a systematic review of the literature.

In several large national database reviews, female gender has been associated with lower overall and disease-specific survival. This may be due to females typically presenting with higher-stage disease, as they often experience longer delays to treatment. Females have also been found to have higher recurrence rates. Another factor may be more biological, in the difference in how carcinogens are metabolized, which leads to females having increased urothelial exposure to carcinogens. Interestingly, non-urothelial variants of bladder cancer, which are typically more deadly, are more common in females as well. Overall, the data on gender and survival outcomes is mixed and contradictory.

Poorer survival outcomes amongst Black patients as compared to White patients are more consistent in the literature. There have been similar studies of large national databases reporting less treatment, and importantly, less timely interventions, in Black patients. Moreover, Black patients are less likely to receive care in high-volume centers, which in certain aspects of the bladder cancer care continuum, such as radical cystectomy, have been associated with superior outcomes.

The association between marital status and bladder cancer outcomes has been evaluated in several large studies, which found that marriage was protective, although most of the married subjects were White males. The single group was mostly female. However, the marriage benefit remained after controlling for age, gender, race, and disease stage.

Lastly, socioeconomic status, in terms of income and education levels, has been linked to bladder cancer outcomes in a limited number of studies. Lower income, education, and insurance status have generally been associated with higher stage disease at presentation and worse overall survival. The effect of rurality is understudied, with studies reporting rates of pelvic lymph node dissections, readmissions, receipt of neoadjuvant chemotherapy, partial cystectomy, or continent diversions, but none evaluating survival outcomes.

Overall, the effects of sociodemographic factors on bladder cancer outcomes are varied and remain unclear. The majority of available data is from large population-based datasets, which are of powerful size but limited granularity. Institutional databases have more detail but significant heterogeneity in how variables are defined and collected. The published data could be better assessed with rigorous meta-analyses.

Written by: Wesely Yip, MD, Resident of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, and Sumeet K. Bhanvadia, MD, Assistant Professor of Clinical Urology, Keck School of Medicine, University of Southern California, Los Angeles, California

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