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Bladder Cancer Diagnosis in Women Is Often Delayed

Zosia Chustecka

Medscape Medical News 2009. © 2009 Medscape

January 16, 2009 — A majority of patients with bladder cancer have a delay in diagnosis because of a lack of urgency in urologic evaluation for hematuria, according to an editorial published in the January 1 issue of Cancer.

Although blood in the urine is often a sign of a urinary tract infection, "it's crucial for doctors to consider bladder cancer as a potential cause right from the start," said Edward Messing, MD, from the University of Rochester Medical Center, in New York, one of the authors of a study published in the same issue.

This is particularly important for women. Dr. Messing and colleagues report that women with bladder cancer have worse cancer-specific survival rates than men, even though the incidence of bladder cancer is 3 times higher in men.

Bladder cancer is not even in the differential diagnosis.

"Earlier diagnosis is crucial for bladder cancer survival," the editorialists, Mark H. Katz, MD, and Gary D. Steinberg, MD, both from the University of Chicago Medical Centre, in Illinois, write, but they add: "It is our impression that, all too often, bladder cancer is not even in the differential diagnosis when women present to primary-care physicians complaining of hematuria or a change in voiding symptoms."

Elaborating in an interview with Medscape Oncology, Dr. Steinberg said that bladder cancer needs to be in the differential diagnosis.

"In my own practice, which is a referral practice, I see a lot of women with bladder cancer with very advanced disease," he said, "and I think partly this is because they have been having symptoms and blood in their urine and have been treated with antibiotics for a period of 10, 12, or 14 months before the ever get seen by a urologist." This happens even in women who have gross hematuria, he said, who may be sent to the gynecologist for suspected uterine bleeding, or a gastroenterologist for suspected gastrointestinal bleeding, but are often not sent to a urologist for a urine analysis.

Urology is a very general topic, and most medical students get very little urology training, Dr. Steinberg commented. "There are little bits and pieces that they remember from lectures, like the fact that bladder cancer is more common in men than in women," he said, "but then that gets extrapolated to bladder cancer being seen only in men and never in women, and so women are not diagnosed."

More women die from bladder cancer than from cervical cancer each year in the United States, he pointed out, "yet no doctor in the [United States] would ever dream of not routinely recommending Pap smears to patients, but are they getting urine analysis when they present with blood in their urine?"

"I have no trouble with internists treating women for urinary tract infections, but certainly it would be nice to have a urine analysis that shows bacteria and white blood cells in a urine culture before . . . these women are treated with antibiotics," he said.

Gross hematuria, for whatever reason, needs to be evaluated by a urologist because of the potential for a urologic cancer.

"The message has to be loud and clear that gross hematuria, for whatever reason, needs to be evaluated by a urologist because of the potential for a urologic cancer, the most common of which is bladder cancer," Dr. Steinberg said.

Sex and Racial Differences in Outcomes

In addition to sex differences, Dr. Messing and colleagues found a racial difference in bladder cancer outcomes, with African American patients showing worse survival than white patients, even though whites are nearly twice as likely to have bladder cancer. Of all patients, African American women fared the worst.

The findings come from an analysis of records in the Surveillance, Epidemiology and End Results (SEER) database for 101,249 patients who were diagnosed with bladder cancer between 1990 and 2003. In the first year after diagnosis, women were 80% to 114% more likely to die from their disease than their male counterparts, the researchers found. During the first 2 years after diagnosis, African American women were about 73% to 103% more likely to die from the disease than their white counterparts.

These differences are "compelling and corroborate several previous population-based reports," say the editorialists. Although previous studies have shown similar findings, the editorialists note that — to their knowledge — this is the first study that controlled for multiple tumor characteristics and still quantified a significant sex and racial disparity.

The authors speculate that possible contributing factors include access to healthcare, delay in diagnosis and therapy, choice of treatment options, host factors, and differences in tumor substaging.

In discussing these possibilities, the editorial highlights 2 recent studies that show differences in diagnosis and treatment between the sexes. One of these studies (Urology 2008;72:498-503) showed a striking difference in referral rates. Upon presentation with new onset or recurrent hematuria, men were 65% more likely to be referred to a urologist than women. The second study (Urology 2006;67:288-293) followed 15,000 patients who underwent radical cystectomy in the United States, and found that women had a longer stay in hospital than men, and that African American patients had a longer stay in hospital and greater inpatient mortality than whites. These findings suggest unequal or inferior treatment as a possible cause of the sex and racial inequalities, they say.

Together, these 2 studies began to demonstrate a trend toward inferior quality of care for women and African American patients, the editorialists comment. "Greater public awareness and better medical-student and primary-care-physician education are critically important to improve the earlier diagnosis and to standardize all treatments for patients with bladder cancer," they conclude.

The analysis performed by Dr. Messing and colleagues was funded by the Ashley Family Foundation. The researchers have disclosed no relevant financial relationships.

Cancer. 2009;115:10-12, 68-74. Abstract, Abstract