Editorial Comment to Urinary tract infection-like symptom is associated with worse bladder cancer outcomes in the Medicare population: Implications for sex disparities.

Abstract

Compared with men, women present at a higher stage of bladder cancer and have worse survival outcomes.1 Richards et al. hypothesized that a delay in diagnosis as a result of presumptive urinary tract infection (UTI) could account for this disparity in oncological outcomes.2 Using Surveillance, Epidemiology and End Results-Medicare, they found a 13-day delay in diagnosis in women compared with men, and in a multivariate model found that both female sex and a UTI-like presentation (as compared with hematuria presentation) were associated with all-cause and bladder cancer-specific mortality. The authors should be commended for their insight and study design. Despite the author's rigor, there are several pitfalls with using this dataset to study this question. The lack of urine culture data for the majority of patients is a major weakness that limits this study's ability to differentiate between several possible associations between UTI and bladder cancer. These potential associations are namely: (i) patients with true UTI have worse outcomes from bladder cancer due to a biological interaction of infection and carcinogenesis; (ii) patients with higher-stage disease, carcinoma in situ, bladder neck or trigonal invasion might present with irritative symptoms initially thought to be UTI; (iii) patients with large bulky tumors and a degree of bladder outlet or ureteral obstruction might develop UTI secondary to urinary stasis; or (iv) coding errors leading to spurious diagnosis of UTI cause an artifactual association. Although the present study is unable to answer which of these possibilities is the driver of this association, it does support the fact that clinicians must be vigilant in their work-up of elderly patients with irritative voiding symptoms, particularly in the face of negative urine culture. None declared.