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.