Sex differences in treatment patterns for non-advanced muscle-invasive bladder cancer: a descriptive analysis of 3484 patients of the Netherlands Cancer Registry

Abstract

Purpose Bladder cancer (BC) is a common malignancy with well-established differences in incidence, clinical manifestation and outcomes between men and women. It is unknown to what extent disparities in outcomes are influenced by differences in treatment approaches. This paper describes treatment patterns among men and women with muscle-invasive BC focusing on curative treatment (radical cystectomy or trimodal therapy). Methods A retrospective population-based cohort study was performed with data from the Netherlands Cancer Registry. All patients newly diagnosed with muscle-invasive, non-advanced BC (MIBC, cT2-4a, N0/X, M0/X) in the years 2018, 2019 and 2020 were identified. Patient and tumor characteristics and initial treatment were compared between men and women with descriptive statistics and multivariable logistic regression analyses. Results A total of 3484 patients were diagnosed with non-advanced MIBC in 2018–2020 in the Netherlands, of whom 28% were women. Women had higher T-stage and more often non-urothelial histology. Among all strata of clinical T-stage, women less often received treatment with curative intent (radical cystectomy [RC] or trimodality treatment). Among RC-treated patients, women more often received neoadjuvant treatment (except for cT4a disease). After adjustment for pre-treatment factors, odds ratios were indicative of women having lower probability of receiving curative treatment and RC specifically, and higher probability to receive NAC when treated with RC then men, although not statistically significant. Conclusions Considerable differences in treatment patterns between men and women with MIBC exist. A more considerate role of the patient’s sex in treatment decisions could help decrease these differences and might mitigate disparities in outcomes.

Atypical B cells mediate poor response to Bacillus Calmette Guérin immunotherapy in non-muscle invasive bladder cancer

“…Despite the lower incidence, women generally present with advanced stage tumors and experience shorter progression free survival. [3][4][5][6] Following transurethral resection of bladder tumor (TURBT), patients categorized as intermediate or high-risk NMIBC are treated with intravesical bacillus Calmette-Guérin (BCG) immunotherapy. 7 The treatment regimen involves an induction phase of 6 weekly instillations after tumor resection, followed by a maintenance schedule of 3 weekly instillations every 3-6 months for over 1-3 years depending on risk stratification.…”

Radical cystectomy and urinary diversion in women

“…The need for removing the complete urethra has been challenged by various investigations showing urethral recurrence being a rare event and preserving it in the absence of bladder neck involvement does not compromise oncological safety (5)(6)(7). While the risk for developing bladder cancer is about four-fold higher in men than in women, women more often present with more advanced disease at the time of diagnosis (8,9). This delay largely seems to be caused by a diagnostic delay due to misinterpreting hematuria as a symptom of urinary tract infection not performing the necessary diagnostics to rule out cancer (9).…”

“…While the risk for developing bladder cancer is about four-fold higher in men than in women, women more often present with more advanced disease at the time of diagnosis (8,9). This delay largely seems to be caused by a diagnostic delay due to misinterpreting hematuria as a symptom of urinary tract infection not performing the necessary diagnostics to rule out cancer (9). The gender disparity is also recognized regarding survival, where women compared to men have an excess mortality during the first two post treatment years.…”

“…The gender disparity is also recognized regarding survival, where women compared to men have an excess mortality during the first two post treatment years. It is assumed, that tumor biology, choice and efficacy of treatments and again delay in sufficient treatment account for impaired survival (9).…”

“…Looking at treatment modalities for MIBC a recent study on a contemporary European series in The Netherlands between 2018 and 2020 of interest, showed no significant differences between women and men (9). Concerning reconstruction, a significant difference was observed regarding the choice of urinary diversion.…”