88 96
multivariate analysis, we
identified that only tumour stage,
grade,
and
size,
patient
age,
and
smoking
exposure were
predictors
of
outcome when
adjusted
for pathway
delays.
These
reinforce
observations
from
randomised
controlled
trials of bladder cancer treatment, and suggest that gender-
related
disparities
arise,
at
least
in
part,
from
a
disease
stage/grade migration
due
to
diagnostic
delay.
A major
limitation
of
our
study
is
a
lack
of
delay
data
downstream
from
TURBT.
However,
classification
and
interpretation
of
such
data
could
be
challenging
(eg,
classifying
the
time
to
definitive
treatment
of MIBC
in
the
setting of chemoradiotherapy or neoadjuvant chemotherapy/
cystectomy), whereas
TURBT
remains
the
first
intervention
for
all
cases of UBC
[11,12].
It
could
also be
suggested
that
our
outcome
data
are
not
applicable
to modern
practice
(although
outcomes
from UBC
have
remained
unchanged
for
>
30
yr
[3]).
For
example,
there
appear
to be high
rates
of UBC-specific death
for patients with Ta and T1
tumours;
in
1991
these
patients may
have
been
understaged
and
undertreated
in
an
era
when
repeat
TUR
was
rare
and
utilisation
of
intravesical
therapies
was
uncommon.
Furthermore,
disease
surveillance
was
according
to
na-
tional guidelines and may have
limited generalisability
for
other health
care
systems. Given
the nature of multicentre
cohort studies,
it
is also
likely
that
there was heterogeneity
in
both
treatment
and
surveillance
strategies
among
participating units. Finally,
the gathering of more
compre-
hensive
smoking
and
occupation
data
would
have
been
more
illuminating
than
the
limited
categorical
data
presented
here.
The
strengths
of
the
study
include
its
prospective
nature,
its mature
and
long-term
follow-up,
and
the
completeness
of
data
for
a
large
cohort.
5.
Conclusions
Our data
demonstrate
a
stage migration
to MIBC
in
female
patients
at
presentation.
The
relationships
among
gender,
outcomes,
delays,
and UBC
aetiology
are
complex.
Female
patients
experience
a
significantly
longer
total
delay
than
male patients,
the majority of which
results
from a delay
in
GP
referral
to
secondary
care/urological
assessment,
and
may
contribute
to
stage migration. GPs
should
be
particu-
larly
vigilant
regarding
symptoms
that
are
associated
with UBC,
especially
in
female patients;
visible haematuria
always
requires
urgent
referral
to
secondary
care
for
urological
assessment.
Author
contributions:
James W.F. Catto had
full
access
to
all
the data
in
the
study
and
takes
responsibility
for
the
integrity
of
the
data
and
the
accuracy
of
the
data
analysis.
Study
concept
and
design:
Dunn,
Bathers, Wallace.
Acquisition
of
data:
Bathers, Wallace.
Analysis
and
interpretation
of
data:
Bryan,
Evans,
Dunn,
Iqbal,
Bathers,
Collins,
James,
Catto, Wallace.
Drafting
of
the manuscript:
Bryan,
Evans,
Dunn,
Iqbal,
Bathers,
Collins,
James,
Catto, Wallace.
Critical
revision of
the manuscript
for
important
intellectual
content:
Bryan,
Evans, Dunn,
Iqbal,
James,
Catto.
Statistical
analysis:
Evans, Dunn,
Iqbal.
Obtaining
funding:
Dunn, Wallace.
Administrative,
technical,
or material
support:
Dunn,
Bathers.
Supervision:
Bryan, Wallace.
Other:
None.
Financial
disclosures:
James
W.F.
Catto
certifies
that
all
conflicts
of
interest,
including
specific
financial
interests
and
relationships
and
affiliations
relevant
to
the
subject matter
or materials
discussed
in
the
manuscript
(eg,
employment/affiliation,
grants
or
funding,
consultan-
cies, honoraria,
stock
ownership
or options,
expert
testimony,
royalties,
or
patents
filed,
received,
or
pending),
are
the
following:
Nicholas
D.
James
has
previously
received
honoraria
from
Pierre
Fabre.
Richard
T.
Bryan
has
previously
contributed
to
advisory
boards
for
Olympus
Medical
Systems
in
relation
to
narrow
band
imaging
cystoscopy.
The
remaining
authors
have
nothing
to
disclose.
Funding/Support
and
role
of
the
sponsor
:
This
study was
supported
by
the University
of
Birmingham.
The
sponsor
played
a
role
in
the
design
and
conduct
of
the
study,
and
in
collection, management,
analysis,
and
interpretation
of
the
data.
Appendix
A.
Supplementary
data
Supplementary
data
associated with
this
article
can
be
found,
in
the
online
version,
at
http://dx.doi.org/10.1016/ j.euf.2015.01.001.
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