Martha K. Terris, MD, FACS,is Professor and Chair of the Department of Urology, holding the Witherington Distinguished Chair in Urology at the Medical College of Georgia at Augusta University.

Closing the Gap: Understanding Gender Disparities in Bladder Cancer Care, hosted by Martha K. Terris, MD, FACS, is a limited series spotlighting unique considerations for bladder cancer diagnosis and treatment among women. Dr Terris is department chair and a professor in the Department of Urology, the Witherington Distinguished Chair in Urology, and co-director of the Cancer Center at the Medical College of Georgia at Augusta University.

In the final part of this 3-part series, Dr Terris discussed how the early diagnosis of bladder cancer presents a significant challenge, particularly in female patients, who are frequently diagnosed at a later stage of the disease and subsequently respond less favorably to treatment modalities. A crucial component of early detection is the rigorous evaluation of hematuria, she emphasized. Microhematuria is defined strictly by microscopy. Reliance solely on a dipstick test is insufficient; any positive dipstick result necessitates a microscopic examination, she explained. Furthermore, patients currently receiving anticoagulation therapy do not bypass the standard workup, she noted. If hematuria is identified alongside a urinary tract infection or gynecological issue, the urine should be rechecked once the co-existing problem has cleared, she advised.

Risk assessment must consider both common and less-recognized factors, particularly in women, according to Terris. Standard risks include exposure to cyclophosphamide or ifosfamide, Lynch syndrome, chronic indwelling Foley catheters, benzene/aromatic amine exposure, and smoking, she added. However, uro-oncologists must actively assess female patients for occupational exposures not traditionally associated with bladder cancer, she said.

Patients presenting with microhematuria should be stratified into low-, intermediate-, or high-risk groups, Terris continued. The gold standard evaluation for high-risk patients is a cystoscopy and CT urogram, she reported. The CT urogram involves cross-sectional imaging of the abdomen and pelvis with and without contrast, incorporating delayed images to optimally visualize the renal pelvis and ureters for potential filling defects, she noted. If patients cannot tolerate contrast, an MR urogram is the primary alternative, she stated. If neither CT nor MR urogram can be performed, the default workup is non-contrast CT combined with cystoscopy and retrograde pyelograms, although this requires general anesthesia, she explained. Given that women are often diagnosed with bladder cancer late and face poor outcomes with advanced disease, maintaining a heightened awareness and low threshold for investigation is critical, Terris concluded.

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Dr Terris discusses how the early diagnosis of bladder cancer presents a challenge, particularly in female patients, who are frequently diagnosed later.

Distinct Risk Factors for Bladder Cancer in Women Necessitate Diligent Early Detection Strategies: With Martha K. Terris, MD, FACS

In part 2 of this 3-part series, Dr Terris discussed the disparities in treatment and outcomes for women with bladder cancer. Although bladder cancer is less common in females than in males, female patients tend to have significantly worse outcomes, Terris explained. Delayed diagnosis is a contributing factor, but the exact reasons for the poorer prognosis are not fully understood, she emphasized.

Treatment difficulties begin surgically, according to Terris. From a surgical perspective, she noted that, performing a cystectomy on a woman is more challenging due to factors like pelvic varicosities and differing fat distribution, which complicate stoma creation.

In terms of medical treatment, Terris also explained that women exhibit worse tolerability and higher rates of discontinuation of immunotherapy, and that they often experience poor efficacy outcomes regardless of whether they complete the course of treatment. These differences between men and women may be linked to factors such as hormonal influences or antibody introduction during pregnancy. Conversely, classic cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy have been shown to have similar overall survival and disease-free survival in eligible female and male patients.

Biologically, Terris also reported that tumors in women may exhibit more effective immune escape mechanisms, possibly connected to differences in the bladder microbiome. The presence of bacteria in bladder tumors has been found to be enriched in patients who did not respond to neoadjuvant chemotherapy, which is relevant as women are more prone to bladder colonization, she added. Overall, Terris emphasized that oncologists must be aggressive in treating women with bladder cancer, despite surgical complexities, and highlighted that early detection is key.

Dr Terris discusses disparities in treatment and outcomes for women with bladder cancer and summarized reasons for this poor prognosis. 

Unique Challenges Characterize Treatment Outcomes for Women With Bladder Cancer: With Martha K. Terris, MD, FACS

Closing the Gap: Understanding Gender Disparities in Bladder Cancer Care

, hosted by Martha K. Terris, MD, FACS, is a limited series spotlighting unique considerations for bladder cancer diagnosis and treatment among women. Dr Terris is department chair and a professor in the Department of Urology, the Witherington Distinguished Chair in Urology, and co-director of the Cancer Center at the Medical College of Georgia at Augusta University.

In part 1 of this 3-part series, Dr Terris discussed the prevalence of bladder cancer in women, as well as reasons for diagnostic disparities that contribute to poor treatment outcomes. She noted that this disease is often diagnosed at later stages in women than in men, often resulting in diagnoses of more advanced disease and translating to poorer outcomes. She added that although female patients represent a minority of those with urothelial carcinoma, retrospective data indicate that women tend to be diagnosed at later stages and consequently experience worse survival rates, regardless of the disease stage.

Dr Terris identified several theories explaining why this diagnosis delay occurs. One possible reason is patient-related: women may be less likely than men to consult a physician when they notice blood in their urine because they may be conditioned to dismiss blood if they experience menstrual bleeding. However, physician behavior and bias also contribute to diagnostic disparities, Terris said. Women with suspected hematuria typically receive fewer imaging tests, she continued. Additionally, physicians may be biased, attributing hematuria to uterine bleeding, menstruation, or other benign causes.

Overall, Terris emphasized that early detection is key. If there is any suspicion of a malignancy, patients should be referred directly to a urologist, she stated. Urologists should be willing to work up cases that might ultimately be recurrent urinary tract infections or radiation cystitis to avoid undiagnosed cases of bladder cancer in women, she concluded.

Martha K. Terris, MD, FACS, discusses unique considerations for bladder cancer diagnosis and treatment among women

Martha K. Terris, MD, FACS

Articles

Distinct Risk Factors for Bladder Cancer in Women Necessitate Diligent Early Detection Strategies: With Martha K. Terris, MD, FACS

Unique Challenges Characterize Treatment Outcomes for Women With Bladder Cancer: With Martha K. Terris, MD, FACS

Bladder Cancer Symptom Awareness and Testing Are Crucial for Early Detection in Women: With Martha K. Terris, MD, FACS