Interruptions in bladder cancer care during the COVID-19 public health emergency.

BACKGROUND: Academic and community urology centers participating in a pragmatic clinical trial in non-muscle-invasive bladder cancer completed monthly surveys assessing restrictions in aspects of bladder cancer care due to the COVID-19 Public Health Emergency. Our objective was to describe pandemic-related restrictions on bladder cancer care. METHODS: We invited 32 sites participating in a multicenter pragmatic bladder cancer trial to complete monthly surveys distributed through REDCap beginning in May 2020. These surveys queried sites on whether they were experiencing restrictions in the use of elective surgery, transurethral resection of bladder tumors (TURBT), radical cystectomy, office cystoscopy, and intravesical bacillus Calmette-Guerin (BCG) availability. Responses were collated with descriptive statistics. RESULTS: Of 32 eligible sites, 21 sites had at least a 50% monthly response rate over the study period and were included in the analysis. Elective surgery was paused at 76% of sites in May 2020, 48% of sites in January 2021, and 52% of sites in January 2022. Over those same periods, coinciding with COVID-19 incidence waves, TURBT was restricted at 10%, 14%, and 14% of sites, respectively, radical cystectomy was restricted at 10%, 14%, and 19% of sites, respectively, and cystoscopy was restricted at 33%, 0%, and 10% of sites, respectively. CONCLUSIONS: Bladder cancer care was minimally restricted compared with more pronounced restrictions seen in general elective surgeries during the COVID-19 pandemic.

Geriatric assessment-derived deficit accumulation and patient-reported treatment burden in older adults with bladder cancer.

BACKGROUND: When a person's workload of healthcare exceeds their resources, they experience treatment burden. At the intersection of cancer and aging, little is known about treatment burden. We evaluated the association between a geriatric assessment-derived Deficit Accumulation Index (DAI) and patient-reported treatment burden in older adults with early-stage, non-muscle-invasive bladder cancer (NMIBC). METHODS: We conducted a cross-sectional survey of older adults with NMIBC (≥65 years). We calculated DAI using the Cancer and Aging Research Group's geriatric assessment and measured urinary symptoms using the Urogenital Distress Inventory-6 (UDI-6). The primary outcome was Treatment Burden Questionnaire (TBQ) score. A negative binomial regression with LASSO penalty was used to model TBQ. We further conducted qualitative thematic content analysis of responses to an open-ended survey question ("What has been your Greatest Challenge in managing medical care for your bladder cancer") and created a joint display with illustrative quotes by DAI category. RESULTS: Among 119 patients, mean age was 78.9 years (SD 7) of whom 56.3% were robust, 30.3% pre-frail, and 13.4% frail. In the multivariable model, DAI and UDI-6 were significantly associated with TBQ. Individuals with DAI above the median (>0.18) had TBQ scores 1.94 times greater than those below (adjusted IRR 1.94, 95% CI 1.33-2.82). Individuals with UDI-6 greater than the median (25) had TBQ scores 1.7 times greater than those below (adjusted IRR 1.70, 95% CI 1.16-2.49). The top 5 themes in the Greatest Challenge question responses were cancer treatments (22.2%), cancer worry (19.2%), urination bother (18.2%), self-management (18.2%), and appointment time (11.1%). CONCLUSIONS: DAI and worsening urinary symptoms were associated with higher treatment burden in older adults with NMIBC. These data highlight the need for a holistic approach that reconciles the burden from aging-related conditions with that resulting from cancer treatment.

Performance Characteristics of a Rule-Based Electronic Health Record Algorithm to Identify Patients with Gross and Microscopic Hematuria.

BACKGROUND: Two million patients per year are referred to urologists for hematuria, or blood in the urine. The American Urological Association recently adopted a risk-stratified hematuria evaluation guideline to limit multi-phase computed tomography to individuals at highest risk of occult malignancy. OBJECTIVES: To understand population-level hematuria evaluations, we developed an algorithm to accurately identify hematuria cases from electronic health records (EHRs). METHODS: We used International Classification of Diseases (ICD)-9/ICD-10 diagnosis codes, urine color, and urine microscopy values to identify hematuria cases and to differentiate between gross and microscopic hematuria. Using an iterative process, we refined the ICD-9 algorithm on a gold standard, chart-reviewed cohort of 3,094 hematuria cases, and the ICD-10 algorithm on a 300 patient cohort. We applied the algorithm to Geisinger patients ≥35 years (n = 539,516) and determined performance by conducting chart review (n = 500). RESULTS: After applying the hematuria algorithm, we identified 51,500 hematuria cases and 488,016 clean controls. Of the hematuria cases, 11,435 were categorized as gross, 26,658 as microscopic, 12,562 as indeterminate, and 845 were uncategorized. The positive predictive value (PPV) of identifying hematuria cases using the algorithm was 100% and the negative predictive value (NPV) was 99%. The gross hematuria algorithm had a PPV of 100% and NPV of 99%. The microscopic hematuria algorithm had lower PPV of 78% and NPV of 100%. CONCLUSION: We developed an algorithm utilizing diagnosis codes and urine laboratory values to accurately identify hematuria and categorize as gross or microscopic in EHRs. Applying the algorithm will help researchers to understand patterns of care for this common condition.

Demographic and Practice Trends of Rural Urologists in the U.S.: Implications for Workforce Policy.

INTRODUCTION: There is a shortage in the number of urologists needed to satisfy the needs of an aging U.S. POPULATION: The urologist shortage may have a pronounced impact on aging rural communities. Our objective was to describe the demographic trends and scope of practice of rural urologists using data from the American Urological Association Census. METHODS: We conducted a retrospective analysis of American Urological Association Census survey data over a 5-year period (2016-2020), including all U.S.-based practicing urologists. Metropolitan (urban) and nonmetropolitan (rural) practice classifications were based on rural-urban commuting area codes for the primary practice location zip code. We conducted descriptive statistics of demographics, practice characteristics and specific rural-focused survey items. RESULTS: In 2020, rural urologists were older (60.9 years, 95% CI 58.5-63.3 vs 54.6 years, 95% CI 54.0-55.1) and were in practice longer (25.4 years, 95% CI 23.2-27.5 vs 21.2 years, 95% CI 20.8-21.5) than urban counterparts. Since 2016, mean age and years in practice increased for rural urologists but remained stable for urban urologists, suggesting an influx of younger urologists to urban areas. Compared with urban urologists, rural urologists had significantly less fellowship training and more frequently worked in solo practice, multispecialty groups and private hospitals. CONCLUSIONS: The urological workforce shortage will particularly impact rural communities and their access to urological care. We hope our findings will inform and empower policymakers to develop targeted interventions to expand the rural urologist workforce.

Urologic oncology workforce diversity: A first step in reducing cancer disparities.

Urologic cancer disparities based on race/ethnicity and gender are well-documented across the cancer continuum. Patients cared for by physicians of similar race/ethnicity and gender report better communication, patient satisfaction, and care adherence which has the potential to translate into better health outcomes. We believe that ensuring a diverse Urologic Oncology workforce is an important first step toward eliminating cancer disparities due to the downstream effects of improved communication between concordant patient-physician dyads. In this essay, we review the demographics of the Urologic cancer patient population and Urologic Oncology workforce; describe current evidence supporting healthcare workforce diversity, especially related to race and gender-based concordant patient-physician relationships; and make recommendations for individual and institutional strategies to develop and support a diverse workforce in Urologic Oncology.

Innovative Strategies to Facilitate Patient-Centered Research in Multiple Chronic Conditions.

Multiple chronic conditions (MCC) are one of today's most pressing healthcare concerns, affecting 25% of all Americans and 75% of older Americans. Clinical care for individuals with MCC is often complex, condition-centric, and poorly coordinated across multiple specialties and healthcare services. There is an urgent need for innovative patient-centered research and intervention development to address the unique needs of the growing population of individuals with MCC. In this commentary, we describe innovative methods and strategies to conduct patient-centered MCC research guided by the goals and objectives in the Department of Health and Human Services MCC Strategic Framework. We describe methods to (1) increase the external validity of trials for individuals with MCC; (2) study MCC epidemiology; (3) engage clinicians, communities, and patients into MCC research; and (4) address health equity to eliminate disparities.

Geriatric conditions and treatment burden following diagnosis of non-muscle- invasive bladder cancer in older adults: A population-based analysis.

INTRODUCTION: Treatment burden is emerging as an important patient-centered outcome for older adults with cancer who concurrently manage geriatric conditions. Our objective was to evaluate the contribution of geriatric conditions to treatment burden in older adults with non-muscle invasive bladder cancer (NMIBC). METHODS: We identified 73,395 Medicare beneficiaries age 66+ diagnosed with NMIBC (Stage

Genetic Analysis Reveals Rare Variants in T-Cell Response Gene MR1 Associated with Poor Overall Survival after Urothelial Cancer Diagnosis.

Urothelial carcinoma of the bladder (UC) is the fifth most common cancer in the United States. Germline variants, especially rare germline variants, may account for a portion of the disparity seen among patients in terms of UC incidence, presentation, and outcomes. The objectives of this study were to identify rare germline variant associations in UC incidence and to determine its association with clinical outcomes. Using exome sequencing data from the DiscovEHR UC cohort (n = 446), a European-ancestry, North American population, the complex influence of germline variants on known clinical phenotypes were analyzed using dispersion and burden metrics with regression tests. Outcomes measured were derived from the electronic health record (EHR) and included UC incidence, age at diagnosis, and overall survival (OS). Consequently, key rare variant association genes were implicated in MR1 and ADGRL2. The Kaplan-Meier survival analysis reveals that individuals with MR1 germline variants had significantly worse OS than those without any (log-rank p-value = 3.46 × 10-7). Those with ADGRL2 variants were found to be slightly more likely to have UC compared to a matched control cohort (FDR q-value = 0.116). These associations highlight several candidate genes that have the potential to explain clinical disparities in UC and predict UC outcomes.

Leclercia adecarboxylata urinary tract infection in a patient with bladder cancer and recurrent hematuria.

Leclercia adecarboxylata is an rare human pathogen, mostly affecting immunocompromised individuals or as one microbe in polymicrobial infections in immunocompetent patients. L. adecarboxylata is rarely isolated from the urinary tract. We describe a case of pan-sensitive L. adecarboxylata isolated from a polymicrobial urinary tract infection from an immunocompetent older adult with recently diagnosed bladder cancer.

Women in Leadership in Urology: The Case for Increasing Diversity and Equity.

There is a persistent male gender predominance in urology, especially with respect to female representation in leadership. We review the current status of women in urology leadership, discuss challenges women face in leadership positions, present the case for adopting inclusive practices that increase diversity and gender equity in urology leadership, and review the potential benefits of such an expansion. We discuss practical strategies to grow the role of women in urologic leadership, including increasing mentorship, modifying academic promotion criteria, and addressing implicit bias, while presenting a roadmap toward achieving equity and diversity at the highest ranks of urologic leadership.

Predicting risk of multiple levels of recurrence and progression after initial diagnosis of nonmuscle-invasive bladder cancer in a multisite, community-based cohort.

BACKGROUND: Nonmuscle-invasive bladder cancer (NMIBC) has heterogeneous recurrence and progression outcomes. Available risk calculators estimate recurrence and progression but do not predict the recurrence stage or grade, which may influence downstream treatment. The objective of this study was to predict risk-stratified NMIBC recurrence and progression based on recurrence tumor classification and grade. METHODS: In total, 2956 patients with NMIBC (

Association between metabolic syndrome and recurrence of nonmuscle-invasive bladder cancer in older adults.

BACKGROUND: Nonmuscle-invasive bladder cancer (NMIBC) disproportionately affects older adults who often have coexisting chronic conditions such as metabolic syndrome (MetS). Although prior research suggests that MetS is a risk factor for NMIBC, limited data exists on whether MetS is associated with NMIBC recurrence. Our objective was to evaluate the association between MetS and recurrence in older adults treated for NMIBC. METHODS: We identified 1,485 older (age ≥60 years) NMIBC patients (American Joint Committee on Cancer Stage ≤1) from 2community-based health systems. Using data from the health systems' electronic medical record, MetS was defined as the presence of three of the following: diagnosis codes indicating hypertension, hyperlipidemia, diabetes, or body mass index >30. Follow up time was determined by date of the last follow up in the tumor registry and censored at 10 years. Cox proportional hazards regression of time to recurrence that accounts for the competing risk of death included adjustment for age, sex, smoking status, health system, NMIBC stage/grade, tumor size, and number of specimens with cancer. RESULTS: Overall, 341 patients (23%) met MetS criteria. Median follow up was 5.9 years and 582 patients (39.2%) died. Patients with MetS were more frequently male (84.2%), and mostly current/former smokers (82.6%). By 10 years, 34.1% of the cohort had experienced a recurrence. After accounting for the competing risk of death, there was no association between MetS and time to recurrence (adjusted hazard ratio, 0.88, 95% confidence interval 0.70-1.11, P = 0.28). Patients without MetS had more 0a/low grade recurrences (49.1% vs. 41.4%), though differences were not significant. CONCLUSION: We found no association between MetS and risk of NMIBC recurrence in this large, multisite cohort of older adults with NMIBC. In order to design personalized care for older NMIBC patients, future research is needed to evaluate associations between common chronic conditions and a variety of oncologic outcomes.

Management of bladder cancer in older patients: Position paper of a SIOG Task Force.

Median age at bladder cancer (BC) diagnosis is older than for other major tumours. Age should not determine treatment, and patients should be fully involved in decisions. Patients should be screened with Mini-Cog™ for cognitive impairment and the G8 to ascertain need for comprehensive geriatric assessment. In non-muscle invasive disease, older adult patients should have standard therapy. Age does not contraindicate intravesical therapy. Independent of age and fitness, patients with muscle-invasive BC should have at least cross-sectional imaging. Data suggest extensive undertreatment in older adult patients, leading to poor outcomes. Standard treatment for a fit patient differs between countries. Radical cystectomy and trimodality therapy are first-line options. Radical cystectomy patients should be referred to an experienced centre and prehabilitation is mandatory. Older adult patients should be considered for neoadjuvant and adjuvant therapy, according to guidelines. In urinary diversion, avoiding bowel surgery for reconstruction of the lower urinary tract significantly reduces complications. If a patient is unfit for or refuses standard treatment, RT alone, or TURBT in selected cases should be considered. In metastatic BC, older adult patients should receive standard systemic therapy, depending on fitness for cisplatin and prognosis. Efficacy and tolerability of immunotherapy (IO) appears similar to younger patients. Second line IO is standard in platinum pre-treated patients, with benefit and tolerability in the older adult similar to younger patients. The toxicity profile seems to favour IO in the older adult but more data are needed. Patients progressing on IO may respond to further systemic treatment. In metastatic disease, palliative care should begin early.

Social support for older adults with cancer: Young International Society of Geriatric Oncology review paper.

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.

External validation of the EORTC and NCCN bladder cancer recurrence and progression risk calculators in a U.S. community-based health system.

OBJECTIVES: To externally validate the European Organization for the Research and Treatment of Cancer (EORTC) risk calculator and National Comprehensive Cancer Network (NCCN) guidelines in a contemporary population of U.S. non-muscle-invasive bladder cancer (NMIBC) patients treated in a community-based setting and compare our findings to those from another U.S. health system. MATERIALS AND METHODS: We identified 1,491 NMIBC patients with a median follow-up of 2.1 years (recurrence) and 4.1 years (progression). We calculated NCCN risk groupings and EORTC prognostic index for recurrence and progression. We followed Royston and Altman's guidelines for the external validation of prognostic calculators. RESULTS: For predicting recurrence using the EORTC framework, Harrell's C (a measure of discrimination) was smaller in our sample (0.66) than in the European Association of Urology sample (0.61), whereas for progression, Harrell's C was larger in our sample (0.78 vs. 0.75). The EORTC calculator overestimated progression risk in the highest stratum for our sample; calibration and discrimination were adequate for all groups except the highest risk group. For NCCN risk groupings, Harrell's C was 0.54 for recurrence and 0.62 for progression, suggesting poor to fair discrimination in our sample. The NCCN framework had slightly better performance for predicting progression vs. recurrence. CONCLUSIONS: Existing NMIBC risk-stratification frameworks have acceptable accuracy to predict outcomes. However, further innovation in NMIBC care will require predictive tools with more granularity to reflect the differential risks of subgroups of NMIBC recurrence, prior treatment histories, and other prognostic variables.

Comparison of the Harms, Advantages, and Costs Associated With Alternative Guidelines for the Evaluation of Hematuria.

IMPORTANCE: Existing 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 PARTICIPANTS: A 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 MEASURES: Urinary 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. RESULTS: The 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 RELEVANCE: In 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.