NEW ORLEANS, LA USA (UroToday.com) - Women experience longer delays in diagnosis of urinary tract infection (UTI) compared to men. But in both women and men initially presenting with UTI, evidence points to a link between delays in diagnosis, adverse pathology, and ultimately risk of death from bladder cancer. Among older individuals especially, symptoms of UTI may be a “harbinger” of bladder cancer, and misdiagnosis may lead to inferior oncologic outcomes, according to Kyle Richards, MD, from the University of Wisconsin, who presented these data to an audience at the American Urological Association Annual Meeting, May 14-19 in New Orleans, LA.
“When we talk about sex disparities in bladder cancer, it is important for people to understand that the disparity is in survival. Women traditionally have worse outcomes compared to their male counterparts. And, there is a longer time to bladder cancer diagnosis in women than in men, from what appear to be a prolonged time to workup and treatment of urinary tract infections among women compared to men,” Dr. Richards said.
In a novel study of factors that have not been evaluated before, or examined with sufficient thoroughness, Dr. Richard and colleagues undertook to assess the impact of presentation with urinary tract infection on time to diagnosis in a retrospective cohort study of the Surveillance, Epidemiology and End Results (SEER) Medicare population. The investigators hypothesized that presenting symptoms would have an impact on the time of diagnosis.
In particular, the researchers hypothesized that if women within the Medicare population were stratified by hematuria or urinary tract infection (UTI), they would experience a prolonged time to diagnosis (versus men) and that this lag time would have a direct impact on their pathologic and oncologic outcomes.
From the SEER data, Dr. Richards identified patients aged 66 and older who were diagnosed with bladder cancer from the years 2007-2009. Impacts of sex, demographic data, and clinical factors on time from initial symptom claim to bladder cancer diagnosis, as well as the impact of sex and symptom claims on delay in diagnosis, pathologic, and oncologic outcomes.
The study had strict inclusion/exclusion criteria. Patients were required to have had hematuria or a UTI claim within 1 year preceding their bladder cancer claim as well as 2 years of pre-index data, “…to ensure that there weren’t any other claims for hematuria, UTI, or bladder cancer within this precedent period.”
Of a much larger cohort of potential study subjects, a total of 12 195 patients (9 326 men and 2 869 women) met the inclusion criteria. Outcome measures included time to bladder cancer diagnosis from initial symptoms.
The data were examined using two different sample definitions, Dr. Richards explained. The first sample definition was hematuria—patients with blood in urine within 1 year without a preceding UTI claim. The second sample allowed for sub-stratification by symptom at presentation – hematuria or UTI—whichever came first within the first year.
For sample one—the hematuria sample—there was no difference in time to diagnosis. However, as Dr. Richards said, “If you add the UTI as a presenting symptom, for sample two, there was an increase in time to diagnosis for both men and women, with a greater effect on women.”
After applying models to look at predictors of advanced stage disease, the investigators determined that if a woman presented with UTI, she had two-fold greater odds of advanced stage, and node positivity—both negative prognostic signs.
A similar model was applied in men presented with UTI who also had a greater odds of advanced stage, although the effect was not as strong as in women. Time to diagnosis in men was not predictive of advanced stage disease in men.
After an analysis of the data using logistic regression and Cox proportional modeling to assist for outcomes, the researches confirmed that the mean time from initial symptom claim to a bladder cancer claim was significantly prolonged for women (72.2 days) compared to men (58.9 days, p < 0.001).
Using a multinomial logistic regression model, the investigators identified the most important predictors of pT4 pathology as women (OR 2.79, 95% CI 2.04-3.83) and men (OR 2.08, 95% CI 1.56-2.79) with UTI as an initial diagnosis. In a Cox proportional hazards analysis assessing risk factors for bladder cancer specifically, and overall mortality identified an increased risk of death in the women that presented with UTI (HR 1.72, 95% CI 1.46-2.03, and HR 1.41, 95% CI 1.28-1.56) compared to the men with hematuria as referent group.
In results with clear clinical implications, Dr. Richard’s data strongly indicate that, symptoms of UTI in older patients, especially women, should be regarded as a possible harbinger of bladder cancer. An accurate diagnosis is thus critical to avoid inferior oncologic outcomes.
Reference:
PD23-10: Urinary tract infection is associated with worse bladder cancer outcomes in the Medicare population: Implications for sex disparities
Kyle Richards*, Madison, WI, Sandra Ham, Joshua Cohn, Gary Steinberg, Chicago, Il
Presented by Kyle Richards, MD at the American Urological Association (AUA) Annual Meeting - May 15 - 19, 2015 - New Orleans, LA USA
University of Wisconsin, Madison, WI USA