For bladder cancer diagnosis and treatment, how can inequities be navigated? Expert Dr. Shaakir Hasan from Beth Israel Lahey Health discusses groups that experience disparities in bladder cancer outcomes, factors that may impact outcomes, and proactive patient advice.

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“…if you see something abnormal, again, going back to the blood and the urine, please, get medical advice, please go, address this with your PCP. Again, it may be nothing, but it’s something that’s definitely worth investigating, because it literally could save your life. And then I hope this doesn’t have to be the case…but you do have to kind of be your own advocate if you do notice that you’re getting dismissed…”

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Transcript:

Lisa Hatfield:

Dr. Hasan, can you explain how race and gender might influence a patient’s experience with bladder cancer, particularly in terms of diagnosis and treatment?

Dr. Shaakir Hasan:

All right, now this is a difficult topic to kind of explore, but a very important one. And the reason why it’s difficult, not just because it has some just the terminology a hot button issue, so to speak because it’s really important that we address all of these hot button topics to kind of get the best outcomes for everyone. But  what makes it complicated is if you look at the data, and this is throughout many cancers, bladder cancer included, you will see that certain ethnic groups, certain communities, they end up doing worse, stage for stage or different stages with whatever cancer that they have. And the reason why it’s complicated is because we can definitely report what’s happening. That’s indisputable. For example, instance, African American patients, regardless of gender do worse. They’re diagnosed later, and they do worse, stage for stage with whatever cancer that they have, including bladder cancer.

That part is not controversial. No one’s going to dispute that. The controversial parts, the two of them are, well, why is that the case? And then what do we do about it? If you look at stage for stage one might say, okay, well do certain ethnicities, are they predisposed to having worse cancers is the cancer themselves, the worse actors, more aggressive? Is it harder to handle? And then others will say, no, it’s the exact same cancer, but they’re just not getting as good care for whatever reason. I do think based on what we see that it is probably more of the latter, but I don’t want to ignore the former, I don’t want to then just dismiss the idea that certain groups, certain people might be predisposed to a worse version of the cancer, because then, maybe I don’t treat as aggressively, and therefore I’m not treating as appropriately.

So it’s a difficult one that we have to have an open mind to really difficult question that we have to have an open mind to truly address appropriately. Let’s tackle gender first. Okay, so independently of race. This is particularly interesting with bladder cancer, because women often can miss this diagnosis, can misreport the initial symptoms. They might be peri-menopausal or premenopausal or even postmenopausal, and they have just an occasional menses or just kind of used to seeing blood in the urine from time to time, and just kind of ignore that symptom. Whereas men see something like that, they’re right away, they’re going to go talk to a, speak to a physician, get that addressed. And I would urge all people to get that addressed, because it is abnormal to have blood in the urine period.

But women might miss it and miss that early diagnosis. Therefore, they’re diagnosed later, and therefore, there is a worse prognosis for women that have bladder cancer. Now stage for stage, it does not appear to be worse. So that does suggest that once it’s diagnosed, women and men are getting the same care, and their prognosis is pretty similar, okay? And that’s a good thing. But it does also say that women are…were missing this diagnosis in a lot of women. So, it’s definitely important to get checked out. Now as far as race goes, and this was an unfortunate finding in our research that we did, but it’s pretty glaring about twice as likely to get diagnosed at any later stage of bladder cancer if you’re an African American versus a non-African American, and I don’t have the why, the answers of why. But I can tell you based on the research that if you’re diagnosed later, certainly your prognosis is worse. Certainly, the chances of cure are worse, and the overall life expectancy is worse.

Is it possible that there might be some biologic components to this, regardless of when one was diagnosed? It is, but in our research we try to isolate these factors. So, for example, grade of tumor, which is the intrinsic aggressiveness of how the cancer might behave. We do tend to see a higher correlation in African Americans in high grade tumors. So, that does suggest that biologically there’s a component here that maybe confers a worse prognosis. However, we also did try to control for that as one of our variables in our multi-variable analysis, meaning we filter that part out, we accounted for that, and we still see that African Americans were diagnosed at a later stage and had a worse prognosis overall. So the answer is kind of a little bit of both when it comes to nature versus nurture type of thing. But at the end of the day, we do, unfortunately, see a worse experience for African Americans when it comes to bladder cancer.

Lisa Hatfield:

Okay. Thank you. And how about an [ACT]IVATION tip for this question?

Dr. Shaakir Hasan:

Yeah, so, it’s probably going to be a consistent theme here,  but if you see something abnormal, again, going back to the blood and the urine, please, get medical advice, please go, address this with your PCP. Again, it may be nothing, but it’s something that’s definitely worth investigating, because it literally could save your life. You do have to kind of be your own advocate if you do notice that you’re getting dismissed for whatever reason if you, because there might be a physician that says, oh, hey, you’ve stayed your period, don’t worry about it. You say, you know what, that’s fine, but I do want to get this checked out. This is abnormal. This just doesn’t happen to me. I do want to understand what’s going on here. So I would, you kind of have to be your own advocate sometimes.