Purpose Men are diagnosed with bladder cancer at three times the rate of women. However, women present with advanced disease and have poorer survival, suggesting delays in bladder cancer diagnosis. Hematuria is the presenting symptom in a majority of cases. Our objective was to assess gender differences in hematuria evaluation in older adults with bladder cancer. Materials and Methods Using the Surveillance, Epidemiology and End Results cancer registry linked with Medicare claims, we identified Medicare beneficiaries aged 66 years or older diagnosed with bladder cancer between 2000 and 2007 with a claim for hematuria in the year prior to diagnosis. We examined the impact of gender and demographic and clinical factors on time from initial hematuria claim to urology visit; and time from initial hematuria claim to hematuria evaluation including cystoscopy, upper urinary tract imaging, and urine cytology. Results Of 35,646 patients with a hematuria claim in the year preceding bladder cancer diagnosis, 97% had a urology visit claim. The mean time to urology visit was 27 days (range 0-377), and the time to urology visit was longer for women than for men (adjusted hazard ratio 0.9, 95% CI 0.87-0.92). Women were more likely to undergo delayed (after > 30 days) hematuria evaluation (adjusted odds ratio 1.13, 95% CI 1.07-1.21). Conclusion We observed longer time to a urology visit for women than for men presenting with hematuria. These findings may explain stage differences in bladder cancer diagnosis and inform efforts to reduce gender disparities in bladder cancer stage and outcomes.

Objective To determine the association between preoperative serum albumin and mortality and postoperative complications after radical cystectomy and urinary diversion. Patients and Methods We conducted a retrospective review of 1097 radical cystectomies performed for the treatment of bladder cancer between 1992 and 2005. All data were entered prospectively into a hospital-based complications database. We used multivariable logistic regression to assess the association between preoperative serum albumin and complications and mortality within 90 days of surgery, while controlling for preoperative patient and disease characteristics. Results Low preoperative serum albumin was identified in 14% of the cohort. Preoperative serum albumin was a predictor of postoperative complications (adjusted odds ratio [OR] per unit increase in albumin: 0.61, 95% confidence interval [CI] 0.42–0.90) and 90-day mortality (OR 0.33, 95% CI 0.14–0.75) when controlling for sex, race, age-adjusted Charlson score, body mass index, prior history of abdominal surgery, clinical stage, and neoadjuvant chemotherapy. As serum albumin decreased, the risk of complications and mortality increased. Conclusions In addition to age-adjusted Charlson score, low preoperative serum albumin is a significant predictor of complications and mortality after radical cystectomy. Serum albumin testing can be used to identify individuals at high-risk for morbidity and mortality.

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IMPORTANCEExisting recommendations for the diagnostic testing of hematuria range from uniform evaluation of varying intensity to patient-level risk stratification. Concerns have been raised about not only the costs and advantages of computed tomography (CT) scans but also the potential harms of CT radiation exposure.OBJECTIVE To compare the advantages, harms, and costs associated with 5 guidelines for hematuria evaluation. DESIGN, SETTING, AND PARTICIPANTSA microsimulation model was developed to assess each of the following guidelines (listed in order of increasing intensity) for initial evaluation of hematuria: Dutch, Canadian Urological Association (CUA), Kaiser Permanente (KP), Hematuria Risk Index (HRI), and American Urological Association (AUA). Participants comprised a hypothetical cohort of patients (n = 100 000) with hematuria aged 35 years or older. This study was conducted from August 2017 through November 2018.EXPOSURES Under the Dutch and CUA guidelines, patients received cystoscopy and ultrasonography if they were 50 years or older (Dutch) or 40 years or older (CUA). Under the KP and HRI guidelines, patients received different combinations of cystoscopy, ultrasonography, and CT urography or no evaluation on the basis of risk factors. Under the AUA guidelines, all patients 35 years or older received cystoscopy and CT urography. MAIN OUTCOMES AND MEASURESUrinary tract cancer detection rates, radiation-induced secondary cancers (from CT radiation exposure), procedural complications, false-positive rates per 100 000 patients, and incremental cost per additional urinary tract cancer detected. RESULTSThe simulated cohort included 100 000 patients with hematuria, aged 35 years or older. A total of 3514 patients had urinary tract cancers (estimated prevalence, 3.5%; 95% CI, 3.0%-4.0%). The AUA guidelines missed detection for the fewest number of cancers (82 [2.3%]) compared with the detection rate of the HRI (116 [3.3%]) and KP (130 [3.7%]) guidelines. However, the simulation model projected 108 (95% CI, 34-201) radiation-induced cancers under the KP guidelines, 136 (95% CI, 62-229) under the HRI guidelines, and 575 (95% CI, 184-1069) under the AUA guidelines per 100 000 patients. The CUA and Dutch guidelines missed detection for a larger number of cancers (172 [4.9%] and 251 [7.1%]) but had 0 radiation-induced secondary cancers. The AUA guidelines cost approximately double the other 4 guidelines ($939/person vs $443/person for Dutch guidelines), with an incremental cost of $1 034 374 per urinary tract cancer detected compared with that of the HRI guidelines. CONCLUSIONS AND RELEVANCEIn this simulation study, uniform CT imaging for patients with hematuria was associated with increased costs and harms of secondary cancers, procedural complications, and false positives, with only a marginal increase in cancer detection. Risk stratification may optimize the balance of advantages, harms, and costs of CT.

Urology patients are older and more medically complex, especially those with urological cancer than primary care patients. These data may inform care redesign to reduce the treatment burden and improve care coordination in urological cancer cases.

PurposeThe clinical utility of screening unselected individuals for pathogenic BRCA1/2 variants has not been established. Data on cancer risk management behaviors and diagnoses of BRCA1/2-associated cancers can help inform assessments of clinical utility.MethodsWhole-exome sequences of participants in the MyCode Community Health Initiative were reviewed for pathogenic/likely pathogenic BRCA1/2 variants. Clinically confirmed variants were disclosed to patient–participants and their clinicians. We queried patient–participants’ electronic health records for BRCA1/2-associated cancer diagnoses and risk management that occurred within 12 months after results disclosure, and calculated the percentage of patient–participants of eligible age who had begun risk management.ResultsThirty-seven MyCode patient–participants were unaware of their pathogenic/likely pathogenic BRCA1/2 variant, had not had a BRCA1/2-associated cancer, and had 12 months of follow-up. Of the 33 who were of an age to begin BRCA1/2-associated risk management, 26 (79%) had performed at least one such procedure. Three were diagnosed with an early-stage, BRCA1/2-associated cancer—including a stage 1C fallopian tube cancer—via these procedures.ConclusionScreening for pathogenic BRCA1/2 variants among unselected individuals can lead to occult cancer detection shortly after disclosure. Comprehensive outcomes data generated within our learning healthcare system will aid in determining whether population-wide BRCA1/2 genomic screening programs offer clinical utility.

Older adults with cancer have increasing needs in physical, cognitive, and emotional domains, and they can experience decline in all domains with the diagnosis and treatment of cancer. Social support plays a key role in supporting these patients, mitigating negative effects of diagnosis and treatment of cancer, and improving cancer outcomes. We review the importance of social support in older adults with cancer, describe the different components of social support and how they are measured, discuss current interventions that are available to improve social support in older adults, and describe burdens on caregivers. We also highlight Dr. Arti Hurria's contributions to recognizing the integral role of social support to caring for older adults with cancer.

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