Amanda Myers: Great, thank you. So thank you. Disparities in temporal trends in a referral for bladder cancer diagnosis, a worsening epidemic. So really the impetus for this study was that delayed bladder cancer diagnosis after hematuria has been linked to increased mortality independent of tumor stage or grade. And previous studies have highlighted that women with hematuria have lower referral rates to urology and longer wait times to a urology visit if they are referred. So our goal was really to understand the temporal dynamics of the diagnostic pathway as it's crucial for identifying opportunities to improve timeliness and equity in bladder cancer care. Our objective was to analyze specific delays within the diagnostic pathway and temporal trends using the SEER-Medicare database from 2004 to 2019. So we looked at the time from the patient's initial hematuria claim to the time they actually first saw urologist after that, and then from the time of the urology visit to the time they actually had their cystoscopy performed. From the hematuria claim to the urology visit, we defined a delay as greater than 30 days and a severe delay as greater than 60 days. And then from the urology visit to the cystoscopy, we defined a delay as greater than 14 days and a severe delay as greater than 30 days.
When we looked first at the time from the hematuria diagnosis to urology visit, you can see on the left-hand side, the blue is the delay greater than 30 days over time, and the orange is the delay greater than 60 days over time. So you can see overall, the delay rates were increasing from 2004 up to 2019 with a slight uptick after 2016, starting at about 30%, going all the way up to about 39% in 2019. Now on the right, when we look at males versus females, we can see the females in blue and the males in green. And we can see that the rate of delay was actually much higher for females than it was for males, although both were uptrending. And then we can see towards the end of the graph, there was even an uptick in the annual percentage change of the delay rate among female patients with hematuria and seeing a urologist. When we then went to look at actually a multivariable analysis to see what drivers there were, here we can see female was associated with a delay and as well as your Charlson comorbidity index one or two and other things including the region that you lived in, your race and your ethnicity, and of course the time. When we then wanted to see, well, okay, there's a delay to the urologist. Well, what about the time from the urologist actually performing the cystoscopy to diagnose the bladder cancer? We can see that on the left, we see a delay greater than 14 days in blue and a delay greater than 30 days in yellow.
Now here we also saw that the rates increased over time and how long it was taking patients to have this done. But on the right, when we looked at males versus females, females being in blue and males being in green, we actually noted that there was less delay among the female patients in having the cystoscopy done after the urology visit versus the male patients. And then when we did our multivariable analysis, we saw that being female gendered was actually protective of the time it took from your urology visit to obtaining a cystoscopy. And also that having prior imaging done before your urology visit was protective in terms of the time it would take to get a cystoscopy done and preventing delays. Some other things that were factored in were, of course, the time. We saw things go up with time, and we also saw some differences among different regions and among if the patient had a prior urology visit and their comorbidity index. So in summary, we did observe this worsening trend and delays for urology referral after a hematuria diagnosis from 2005 to 2019, and the female patients really continued to experience a disproportionately delayed urologic referral, and this has actually gotten worse over time. And while they experienced longer delays to a urologist, once they saw urologists, they actually had a less likelihood of experiencing a delay to cystoscopy. And we also noted that pre-urology visit imaging was associated with shorter times to cystoscopy, and we really need to target future interventions on streamlining the initial referral process for patients. Thank you.
Ashish Kamat: Thanks, Amanda. I mean, it's something that we've known women having a delayed presentation, delayed diagnosis, delayed recognition. It was rather disheartening to see that that's gotten worse over time. I think that referral dynamic clearly needs to change because when the patient gets to the urologist, and I don't know why, maybe it's a recognition that it was more delay getting to us than we tend to do the cystoscopy sooner. Share with me a little bit, based on all the deep-dive work that you've done, what do you think some of the drivers, other than what you could see just from the analysis of the database, but what do you think some of the drivers are in today's day and age? People know about it, people recognize it. Why do you think there's that delay?
Amanda Myers: I think one of the biggest factors is that bladder cancer is about 75% males and about 25% females. So as females are less likely to be diagnosed with bladder cancer, their pretest probability is lower and their providers are not thinking bladder cancer when they see these patients. They may be more concerned about having a urinary tract infection, which is very common. And I think primary-care doctors are really the backbone of our healthcare system, and they're increasingly being asked to do more and more and more. So one of the initiatives that we're hoping to start here is to actually create a microscopic hematuria telehealth clinic with our advanced-practice providers to actually take some of that weight off the primary-care doctor and having to triage these patients and determine if they need to see a urologist.
Ashish Kamat: Yeah, those could be my next question. They have implemented strategies like that in the UK where they have hematuria clinics. They've done that at several VAs here in the US as well. So I'm excited to hear that you are planning to do that in Iowa. But just to backtrack a little bit to my earlier question. So do you think that the reason the delays have gotten worse is because there's less primary-care physicians today in the US, there's less people doing that work and there's more work to be done? Do you think that's the main driver?
Amanda Myers: I think that we do ask more and more of our primary-care doctors and they have a lot of things they need to accomplish in one visit. So taking some of that burden off of them would be really helpful for our healthcare system.
Ashish Kamat: Now, in addition to, of course, initiatives such as those that you mentioned that we can do on the physician side or the hospital side, what do you think about patient advocacy and spreading more of this? I mean, Beacon, World Bladder Cancer Patient Coalition, Bladder Cancer, UK, all of them do a good job trying to educate the layperson the importance of hematuria. What else do you think we could do?
Amanda Myers: I do think that the majority of patients do not realize that hematuria is a sign of bladder cancer. And we do a great job of advocating this and teaching our patients, but we really need to have a way to reach patients on a more national level and a way to reach them outside of just within a medical system through advertisements or other things like that.
Ashish Kamat: Any thoughts on if you think that this is going to get even worse nowadays that there's so much more for our primary-care colleagues to do and there's so much more going on when it comes to electronic medical record, just the burden of healthcare. I hope not, but do you think it's going to get worse before it gets better?
Amanda Myers: It could get worse before it gets better. I think it's definitely the time to take action and do something to make a change.
Ashish Kamat: Yeah, I think at least it was encouraging to recognize that once the patients are referred, at least then they have expeditious recognition of the need for a cystoscopy and clearly all the other variables that you showed, imaging, et cetera, help. Amanda, I want to thank you again for taking the time. Congratulations on yet another publication and best of luck with everything else that you're doing.
Amanda Myers: Thank you.