Shaakir Hasan, DO, discusses the disparities identified in the bladder cancer space through a real-world prospective study.
Shaakir Hasan, DO, an oncologist at New York Proton Center/Montefiore, discusses the disparities identified in the bladder cancer space through a real-world prospective study.
The socioeconomic disparities the correlate with diagnosis and treatment are an area of active research. Utilizing health database information, Hasan and colleagues created a snapshot of how race, gender, and insurance status impact the field of bladder cancer.
O:07 | 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.
2:05 | 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.
4:44 | 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.
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