Racial and gender disparities are well documented in Black individuals who need cancer-related care. According to the American Cancer Society, Black women have the second highest incidence of bladder cancer (6.4 per 100,000), but the highest death rate (2.3 per 100,000).¹ Prior literature suggests this discordance may stem from limitations in access to care that lead to delays in evaluation, diagnosis, and treatment, all of which negatively impact prognosis.^2-4 We examined more recent data to determine whether these disparities persist and to evaluate differences in outcomes after cystectomy.

The National Cancer Database Hospital Comparison Benchmark Report provided information on all women diagnosed with bladder cancer in the United States from 2011 to 2020. We stratified this cohort by race to compare demographic and clinical characteristics between White and Black women. To assess surgical outcomes, the American College of Surgeons National Surgical Quality Improvement Program database was queried to identify the cohort of White and Black women who received a cystectomy between 2016 and 2020 (Current Procedural Terminology codes: 51570, 51575, 51580, 51585, 51590, 51595, 51596). Similar comparison of demographics, preoperative comorbidities, complications, and 30-day outcomes were performed.

From the National Cancer Database, we identified 634,900 patients with bladder cancer. Women made up 24.1% (n=152,729) of this cohort, of which 85.1% (n=129,967) were White and 8.3% (12,639) were Black. Black women made up a greater proportion of all Black individuals with bladder cancer compared to White women and all White individuals (33.4% vs 23.4%, P < .001; see Figure). Black women were more likely to have Medicaid (8.6% vs 3.2%, P < .001), live in areas with the highest high school dropout rates (27.0% vs 9.3%, P < .001), have a Charlson comorbidity score of 2 or more (16.4% vs 11.3%, P < .001), and receive care locally (<10 miles traveled; 52.5% vs 40.1%, P < .001). A significantly higher proportion of Black women had stage IV disease at presentation compared to White women (13.1% vs 8.2%, P < .001).

Within the National Surgical Quality Improvement Program analysis, 2,002 women underwent a cystectomy from 2016 to 2020. Of these, 1,813 (90.6%) were White and 189 (9.4%) were Black. Black women were found to be younger (66 years old vs 69 years old, P = .001) with a higher BMI (29.8 vs 27.5 kg/m², P < .001) at the time of their procedure. Rates of non–insulin dependent diabetes (18.0% vs 8.9%, P < .001), hypertension (72.0% vs 53.8%, P < .001), and smoking (28.0% vs 21.3%, P = .04) were all higher in Black women. However, no statistically significant differences were observed in any Clavien complications or 30-day outcomes (see Table).

Table. Population Characteristics and Outcomes of Women Undergoing Cystectomy (From 2016 to 2020)

The results from our study show Black women face continued socioeconomic disparities and present with a greater proportion of stage IV bladder cancer compared to White women. Additionally, Black women present for cystectomy at a younger age with more preoperative comorbidities. Despite this, their surgical complications and 30-day outcomes were not statistically different when compared against White women. It is important to note that among women who received a cystectomy, Black women were outnumbered by White women 10 to1(see Table).

Disparities seen in Black women relating to bladder cancer are likely twofold. First, women tend to have delays before undergoing complete workup for hematuria, which is the most common symptom of bladder cancer.⁵ In many instances, benign etiologies, including urinary tract infection and overactive bladder, overlap with the presence of hematuria.⁶ As a result, hematuria in women may not prompt a workup at the same rate as in male patients. Second, Black women continue to face limitations in health care access, education, income, and insurance that all lend to delays in time to diagnosis, which is a crucial factor that affects outcomes.⁴

Mitigating disparities is crucial to achieving equitable care to Black women with bladder cancer. Improving resources allocated to community hospitals and taking a multidisciplinary approach to bladder cancer management have been suggested.⁷ This would allow for improved avenues for Black women to access and receive care in a timely manner. Additionally, early involvement of care navigators can help improve adherence to and affordability of care, ultimately reducing loss to follow-up.⁸

We found that socioeconomic disparities continue to be seen in Black women with bladder cancer; however, surgical outcomes appear to be similar when compared to White women. Continued efforts should be made to explore this topic and target areas of improvement to combat these health inequities.