Introduction:

While various factors, such as gender and insurance, have been evaluated in relation to bladder cancer diagnostic evaluation, the impact of racial disparities has not been well described. Our objective was to assess the impact of racial and gender disparities in the evaluation of hematuria using the All of Us prospective clinico-genomic database, which is primarily composed of underrepresented populations.

Methods:

To include a group of patients who were evaluated for hematuria, we included patients with >3 RBC/HPF on urinalysis or those with a diagnosis code of gross hematuria in the database. We excluded patients with other likely causes, i.e., those who were pregnant at the time of urinalysis, had a UTI at urinalysis, or had a prior history of bladder, kidney, or ureter cancer or urolithiasis before the urinalysis was completed. Patients were categorized based on the current 2020 AUA guidelines: low risk (3-10 RBC on urinalysis), moderate risk (11-25 RBC on urinalysis), and high risk (>25 RBC on urinalysis or a diagnosis code of gross hematuria). All possible genitourinary (GU) imaging was included: CT urogram, MRI urogram, and renal/bladder ultrasound. Univariate logistic regression was utilized for these groups.

Results:

A total of 34,042 patients were eligible for inclusion: 54% White, 18% Black, 26% Hispanic, 2.4% Asian; 32% male and 68% female. Of 11,638 hematuria patients with imaging, 44% had a CT urogram, 23% an MRI urogram, and 63% a renal/bladder ultrasound. Across all patients with hematuria, 11.1% had a cystoscopy, 32.1% GU imaging, and 8.5% both. Women had lower screening rates than men for cystoscopy (OR = 0.36, CI: [0.34, 0.39]), GU imaging (OR = 0.55, CI: [0.52, 0.57]), and both (OR = 0.56, CI: [0.52, 0.6]). Minorities had lower overall screening rates for cystoscopy, imaging, and combined modalities. While more severe hematuria increased testing overall, minorities in the high-risk group had lower screening rates than White patients, with Asians and Hispanics having the lowest rates.

Conclusion:

All minorities appear to face disparities in the evaluation of hematuria compared to White patients. These disparities are more evident in high-risk patients with a higher degree of hematuria. In these high-risk patients, Hispanics and other minorities are less likely to undergo initial diagnostic tests or a comprehensive evaluation with both cystoscopy and imaging. These findings may explain racial and gender differences in bladder cancer stage and clinical outcomes.

Funding: N/A