Disparities in Bladder Cancer Care Persist Despite Years of Evidence

Shaakir Hasan, DO

In bladder cancer, the socioeconomic disparities the correlate with diagnosis and treatment have been studied previously but are not well described. Investigators utilized health database information to create a snapshot of how race, gender, and insurance status impact the field.

A prospective study of the data obtained through the National Cancer Database that was presented during the American Society of Clinical Oncology (ASCO) Genitourinary Cancers (GU) Symposium found that certain groups, such as Black patients, women, those on Medicaid, and the uninsured, are more likely to be diagnosed with a more severe disease. These groups are also less likely to receive the standard of care. It is believed to be the largest study of its kind.

The investigators looked at cases of urothelial carcinoma. Cases were classified by the National Comprehensive Cancer Network (NCCN) guidelines. Investigators identified 331,714 early cases, 72,154 muscle invasive cases, 15,579 locally advanced cases and 15,161 metastatic cases.

Results from the analysis showed one of the strongest predictors for a muscle invasive, locally advanced, and metastatic disease was Black race with hazard ratios (HRs) of 1.19 (95% CI, 1.15-1.23), 1.49 (95% CI, 1.40-1.59), and 1.66 (95%CI, 1.56-1.76), respectively. Being female was another strong predictor for these disease settings at with an HR of 1.21 (95% CI, 1.18-1.21) for muscle invasive bladder cancer, 1.16 (95% CI, 1.12-1.20) for locally advanced bladder cancer, and 1.34 (95% CI, 1.29-1.38) metastatic bladder cancer. Additionally, these groups among others were less likely to receive cancer-directed therapies. Black patients and female patients were also found to be the only 2 demographic groups that experienced reduced survival, according to a multivariable Cox regression analysis.

In an interview with Targeted Oncology, Shaakir Hasan, DO, an oncologist at New York Proton Center, discussed the results found when diagnostic and treatment information from patients with bladder cancer was prospectively assessed. He also discussed future work on disparities in health care in an interview with Targeted Oncology.

TARGETED ONCOLOGY: Can you provide an overview of what you presented on the matter of bladder cancer disparities at ASCO GU?

HASAN: What we did is we looked at the National Cancer Database, which captures about 70% of cancer diagnoses in the country. We have data going back for about 10 years, and we wanted to do focus on bladder cancer, and specifically disparities within bladder cancer.

For a lot of these studies, because there's so much data, we usually focus in on a particular question, and it's usually a clinical question. We looked a bit more broadly, particularly when we're looking at disparities. The 2 big questions we were looking at were, as far as diagnosis, when can you diagnose this cancer and how early? We also asked, how does that differ among different demographic groups? Then within each group, are there any discrepancies between certain groups receiving the standard of care? If not, how are they being treated?

Going into it, there really wasn't a focus on African Americans, the uninsured, or women. We wanted to let the data speak for itself and see what those differences were. The null hypothesis is that there are no differences among groups. And one thing I want to add just as an additional background measure is that with bladder cancer, in the vast majority of patients, we can detect it early because of blood in the urine and things like that signal the disease. So, it's kind of more important to figure out among different groups who is detected earlier and who is detected later.

What we did find is that the African American race as well as the uninsured, or Medicaid patients, these are the two strongest factors that correlate to later diagnosis. Meaning that relative to White patients or Asian patients, for example, a black patient is more likely to be diagnosed with a muscle-invasive disease, which is more locally advanced or metastatic disease, as opposed to early-stage disease. What we also found is that only exclusively with African Americans do we find that as you progress further along with the disease, as the disease is more advanced, that gap widens, so you're more likely to find black patients with advanced disease and then even more likely with metastatic disease. So that was kind of striking.

And it wasn't the only factor like I said there was uninsured, Medicaid patients, and women as well, that’s the case that they're diagnosed at later stages. But one thing to note there is that anatomically, there is a difference. With females, there are plenty of other ailments like hematuria, or blood in the urine, that could be related to infections or menstruation cycles, things like that. So, we tend to miss these diagnoses in women compared to men where it's more abnormal, and we're more likely to work it up. However, when you break it down by race, if you control for gender, you still see significant difference when it comes to the African American race. The second part of what we found were how about the treatments that patients are getting once they are diagnosed?

Most are getting the "standard of care." Now one thing that's a little bit controversial here is that the standard of care per the NCCN guidelines can be either a cystectomy, you just complete removal of the of the bladder with chemotherapy, or you can do bladder preservation with chemoradiation. A lot of urologist will likely tell you that the standard of care has to be cystectomy. And there are even papers looking at demographic factors about who is getting the "standard of care" when it is only considered surgery or cystectomy. But if you look at the guidelines, you can actually kind of include both. What we did is we included either chemo radiation or surgery as a standard of care, we looked at both of those. And relative to just palliation.

Even then, we do find that consistently African Americans were necessarily offered cystectomy but ended up having less therapeutic options, or were called cancer directed therapies, at every single stage, whether it's early muscle invasive, locally advanced, or metastatic disease relative to white and Asian counterparts. Those were the 2 biggest things that were that were highlighted here.

One of the things I want to mention is that this is not a novel study in that the idea of looking at disparities, which is actually going on throughout a lot of disease sites, including bladder. But this is kind of the newest, and it does have updated data. And if you actually look about 10 years ago, there was a paper published using Surveillance, Epidemiology, and End Results Program (SEER) data, which uses Medicare data, and they actually had about two decades of data before ours started. So, they were looking at the 70s, 80s, 90s and we looked at around 2000, up to 2017. And unfortunately, the numbers are actually quite similar. They had similar proportions of Black patients being diagnosed later. And, with the same thing that we're seeing now. So there didn't seem to be much improvements, if you're kind of comparing those 2.

I guess one last point I would want to make is that it is important to note that any correlations that we see here, do not necessarily mean causation. That's a very fundamental statistical principle which everybody would understand. But it is important to kind of highlight that here. Just note that what these correlations are, but then if you were to try to connect the dots and explain why that's where you're going to have it's going to be a lot more difficult to do.

TARGETED ONCOLOGY: Why does this disparity exist?

HASAN: The "why" is going to be speculative, so let's start with that. The “why” we would say this is that we have to consider everything. We don't want to jump to conclusions, and we have to explore. It is very important to ask that question and dive in and try to figure it out.

We do see some disease sites that certain races have a predilection to maybe having more aggressive disease. But then we can always kind of re-examine those cases and find that might not be the case.

As an example, I treat a lot prostate cancer. In prostate cancer, we've traditionally learned that African Americans have more aggressive disease. We still keep that in the back of our mind when we think of treatment options. But if you look at a lot of the work being done more recently, if we control for everything else, and just isolate the race, there isn't a difference. It might be that the outcome is more related to health disparities and access to health care when they were diagnosed, the treatment that they received. That might be a greater explanation as to why we see these differences in outcome, and the same might be here.

In the older SEER study that I mentioned, they pointed out that African Americans tend to have a higher-grade disease, meaning more aggressive disease at the outset. And so, they were saying that might be a possibility, maybe just naturally, with the race. You have a higher degree of aggressiveness and that's why you catch it later, and it has nothing to do with health care disparities or things like that. We did control for that and made sure to isolate the grade and factored into our model that we use here.

We still saw a considerable discrepancy when it when it comes to a diagnosis and outcomes for African Americans. But I just wanted to use that as an example, that there could be some clinical factors, things we don't know about that we can't control for in these models that can explain some of these discrepancies that may not be related to actual access to health care or quality of care, etc. We also have to definitely look at the mirror and look at the healthcare system itself and say, okay, whatever the cause is, something's not right here there is an equity that we have to address. We have to look at ourselves, look at the clinical factors, but also look at ourselves to figure out what we can do about it.

TARGETED ONCOLOGY: Were there any key recommendations made based on the data that you found? How you can move forward and maybe close the gap?

HASAN: I would exercise a little bit of caution and say, we have to further investigate and do more studies to see the why. We have to figure out the why before you can go into solutions. But I would say, look, if I'm working up a potential bladder cancer case, or in my case, I'm going to call just so we already know the diagnosis. But as part of the workup, if you have an African American that has blood in the urine, I'm going to be the label is going to come out a little bit quicker, and I'm going to be a little bit more aggressive and try to really work that up and not dismiss it, right. If I have this study, if I know this data, in the back of my mind I'm going to be a lot less likely to dismiss an early symptom because this is something that's in the back your mind. It was a trigger to go, okay, there could be something else going on. Regardless of the race, you want to do that. But we probably do have a history, unfortunately, of oftentimes dismissing a lot of symptoms we see in African American patients in general, kind of globally. That's something we have to be more cognizant of. I think it starts there to really take every patient seriously, but especially notice the Black patients and really make sure that you're doing the appropriate workup.

We speculate that independently, African Americans are diagnosed later and probably did not receive the standard of care. We saw the same thing with Medicare patients and Medicaid patients. That to me suggests that there is an intersectionality of access to health care. So, it's not just that it's racially motivated, economically motivated, or just access in general. But there probably is, to some degree, intersectionality where we have to work on access to health care. I think once you provide more of that, you're probably going to see the gap closed a little bit more.

The last thing might just be education. It might just be as simple as how many patients How many of them are aware of potential things to talk to their physician about? This is something that we can't account for in our study or in our model. But, maybe you havng blood in the urine is not something that you care to get worked up, or you can't get worked up, or whatever the case may be. I think that kind of public outreach to talk about these things and get people to see their primary care physicians or urologist if there's worsening symptoms would be important.

It’s multifactorial. I think the reason the results that we're seeing are definitely going to be several facets, but I do think, number 1, we as healthcare experts have to pay more attention. We have to do our job as far as getting these patients in and taking care of them. Number 2, access to health care, make sure that patients, meaning everyone, but especially the underserved communities, have access so they can work up things if there are any issues. Number 3, educate the masses. Everyone should be aware of what's going on and understand what they are prone to get and what they can do about it if they have any issues. I think these are some starting points that can help maybe close the gap.

TARGETED ONCOLOGY: Are there is there any plans to further this research? Are you aware of any other studies that are looking at something similar?

HASAN: This research has been going on. it has certainly accelerated in the past 4 or 5 years probably. The, this past summer we kind of had, an “awakening,” we saw a lot of the racial equality protests. That does seem to be like a catalyst really to do more research like this. You would like to think that it would have been done before, certainly, and it has been. But I think that it has been accelerated recently. ASCO has put out calls to publish more disparities papers as well. 

I think that we are going to see a lot more of this. So, yes, we do want to investigate this further. Now that we have seen this correlation, we want to figure out, as you asked earlier, why? What's going on? What can we look at? Now, maybe we'll see how do these patients present with symptoms? What risk factors are there? These questions are important. There are other additional risk factors for bladder cancer that we can't capture in this database and how does that correlate with different minority groups?

Also, just addressing the access portion, if we can explore the access portion and see those that have access? What is the gap there, and it's going to be a lot smaller. So, We have to kind of dissect the data that we do have, because like I said, it's quite broad.

I treat mostly genitourinary cancers. I'm a radiation oncologist at the New York Proton Center and that's what I focus on. But certainly, this concept can be applied to everything. We do see a lot of data already with things like prostate cancer and breast cancer, because those are the 2 most common cancers. But bladder is not that far behind. So, what I would say is that I think we’re going to see many more studies.

TARGETED ONCOLOGY: Do you have any final thoughts about this topic?

HASAN: I am thankful to everyone who is paying attention this topic. I think it is certainly important that we keep moving forward with it. I think it's probably not enough for us to simply diagnose the problem, which is what we're doing with our project is identifying what's out there.

I think oftentimes, in the past, we'll kind of look at something say, “yes, that makes sense and I've seen that in my practice. But it's probably not enough to do that. We have to take the next step. Like I mentioned, they did a similar study to this 10 years ago, looking at data 30 and 40 years earlier and it's kind of the same. The fact that we haven't really made improvements since then is kind of discouraging. We've made a lot of improvements with medicine. We've made a lot of improvements with diagnosis, and outcomes. But the gap is still there and that's a problem. We have some work to do.

^REFERENCE:

^{Hasan S, Lazarev S. Garg M, et al. Social disparities in the diagnosis and management of bladder cancer. J Clin Oncol. 2021;39 (suppl 6). doi: 10.1200/JCO.2021.39.6_suppl.403https://meetinglibrary.asco.org/record/194827/abstract}