(Urotoday.com) The 2023 American Society of Clinical Oncology Genitourinary (ASCO GU) cancers symposium held in San Francisco, CA between February 16th and 18th was host to a prostate cancer and urothelial carcinoma poster session. Dr. Abhishek Tripathi presented the result of his group’s study evaluating the association of race and payer status with the choice of urinary diversion among patients with localized bladder cancer undergoing a cystectomy.
Dr. Tripathi began by noting that previous studies have identified significant disparities in urinary diversion choice for patients with localized bladder cancer undergoing cystectomy. While there is no known association between the choice of diversion and oncologic outcomes, continent urinary diversions are associated with lower rates of in-hospital complications and mortality, but at higher costs.1 Known predictors of undergoing a continent urinary diversion include:2
- Male gender
- White race
- Higher income
The investigators utilized the California Office of Statewide Health Planning and Development (OSHPD) database to evaluate potential barriers to continent urinary diversions in patients with bladder cancer undergoing a radical cystectomy.
Patients undergoing a radical cystectomy between January 2012 and December 2018 were identified using current procedural terminology (CPT) and the international classification of diseases (ICD)-9/10 codes. The authors collected information regarding the type of urinary diversion and demographic data such as race and payer status. The association between demographic variables and continent urinary diversion use were assessed using univariable and multivariable analyses.
The investigators identified 9,342 patients who underwent a radical cystectomy, with 3,061 having urinary diversion data available. 13.2% of such diversions were continent and 86.2% were incontinent. On univariable analysis, the following variables predicted increased odds of continent urinary diversion use:
- White patients (14.1%) compared to Asian (12.8%), Hispanic (9.5%), or Black (5%) patients (p=0.01)
- Private insurance (23.2%) versus Medicare (10.2%) or indigent (MediCal/Medicaid: 8.6%) coverage (p<0.001)
On multivariable analysis adjusting for comorbidities and care setting, Black (OR: 0.30, 95% CI: 0.13 - 0.69) and Hispanic (OR: 0.57, 95% CI: 0.38 - 0.86) races were associated with lower odds undergoing a continent urinary diversion.
Conversely, male patients (OR: 1.88, 1.31 - 2.71) and those receiving care at academic centers (OR: 3.10, 2.38 - 4.05) had increased odds of receiving a continent urinary diversion. Payer status was not significantly associated with choice of diversion. As expected, the presence of chronic kidney disease was associated decreased odds of undergoing a continent diversion (OR: 0.61, 95% CI: 0.43 - 0.85).
The authors concluded that Black or Hispanic race and female gender were associated with lower odds of undergoing continent urinary diversions when controlling for other factors. They hypothesized that the higher costs for continent diversions, communication barriers, especially with non-English speakers, comorbidities, and a potential lack of cultural humility could lead to an unconscious bias from the healthcare team. Further research aimed at understanding and addressing these disparities is planned.
Presented by: Abhishek Tripathi, MD, City of Hope Comprehensive Cancer Center, Duarte, California
Written by: Rashid Sayyid, MD, MSc – Society of Urologic Oncology (SUO) Clinical Fellow at The University of Toronto, @rksayyid on Twitter during the 2023 Genitourinary (GU) American Society of Clinical Oncology (ASCO) Annual Meeting, San Francisco, Thurs, Feb 16 – Sat, Feb 18, 2023.
References:
- Farber NJ et al. Disparities in the Use of Continent Urinary Diversions after Radical Cystectomy for Bladder Cancer. 2018;4(1):113-120.
- Barocas DA et al. Racial variation in the quality of surgical care for bladder cancer. Cancer 2014;120(7):1018-1125.