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Urology Update

Study reveals strong correlation between geriatric conditions and treatment burden in older adults diagnosed with non-muscle-invasive bladder cancer

The American Cancer Society estimates that by the end of 2022, more than 81,000 new cases of bladder cancer will be diagnosed in the United States. About 90% of these patients are over the age of 55, with 73 being the average age at diagnosis – the highest age at diagnosis for all cancer types1.

A team of researchers, led by Dr. Tullika Garg, urologic surgeon at Penn State Health Milton S. Hershey Medical Center and associate professor of urology at Penn State College of Medicine, conducted a study that sought to evaluate the treatment burden for older adults diagnosed with non-muscle-invasive bladder cancer (NMIBC), which accounts for about 75% of all newly diagnosed bladder cancers.

While NMIBC carries a low risk of death, the recurrence rate is as high as 70% and requires frequent health care visits for treatment and surveillance.2 The study, published in the Journal of Geriatric Oncology, found that patients with existing geriatric conditions experienced a greater treatment burden during the year following diagnosis of NMIBC, with patients in rural areas impacted most.

“We found that each type of geriatric condition was associated with a higher rate of health system contact, except for dementia,” Garg said. “Multimorbidity had the greatest effect of all of the geriatric conditions we looked at. This corroborates the literature on the belief that people with two or more chronic conditions tend to experience greater burdens in their care.”

Researchers defined treatment burden as the number of times a patient had contact with the health care system, including clinic visits, lab draws, emergency room visits and hospitalizations. Geriatric conditions were selected based on a guideline released by the American Society of Clinical Oncology (ASCO)3 and included functional dependency, mobility impairment, depression, dementia, weight loss and multimorbidity, as well as urinary incontinence. Researchers described multimorbidity as two or more chronic conditions as defined in the U.S. Department of Health and Human Services framework.4

Unexpected and notable results

Researchers evaluated data of Medicare patients 66 years or older diagnosed with NMIBC between January 2001 and September 2014. According to the study, the average number of days patients made contact with the health care system was 8.9 in the year following diagnosis. Patients with multimorbidity had the largest effect size, with a mean of 12 days of health care contact. Overall, each additional chronic condition was linked to a 13% increase in treatment burden.

Finding that multimorbidity raised patient burden confirmed the researchers’ beliefs, while other results were unexpected. They also examined disparities in treatment burden for rural versus urban populations and learned that rural patients had a higher rate of contact with the health care system for each additional chronic condition than urban patients.

“This finding was quite surprising because we thought that rural patients might stack their appointments or even not attend as many appointments,” Garg said. “However, rural populations are aging more quickly than urban populations, and younger people are moving to the urban areas. Because being older correlates with having more chronic conditions, this finding makes sense.”

Garg said this could also be due to rural patients having more advanced disease. “Rural patients tend to have higher severity of their chronic conditions, which could lead to a need for a higher amount of care.”

Another unforeseen finding was that patients with high functional dependency tended to have lower health system contact specifically for bladder cancer.

“This could be a sign that physicians may be tailoring care for those frailer patients to try to reduce some of the burden,” Garg said. “Seeing that pattern within a large, national data set was something that was really surprising and interesting.”

Ongoing research and new strategies

This retrospective study focused on national trends, and now the team is taking the research a step further by collecting more detailed data.

“While the first study defined treatment burden as the number of health care encounters a patient had, we know that definition might be different than what a patient perceives as a burden,” Garg said. “For example, going to appointments might not be burdensome to some older people because of the social aspect of these visits. We’re hoping to gain more perspective from patients and caregivers themselves.”

To accomplish this, the team conducted a cross-sectional survey using a validated questionnaire to measure patient and caregiver perceptions of treatment burden. Researchers are in the final stages of analyzing the data and will be submitting their findings for publication before the end of the year.

Garg hopes the study results can be used by physicians to help develop strategies that would reduce burdens on older adults diagnosed with cancer.

“What underpins my research are the stories that patients and their caregivers tell me in the clinic about the many challenges they face,” Garg said. “A lot of these stories center around the burden of care, whether that is finding transportation to appointments, managing multiple medications or having difficulties with mobility.”

She believes physicians can help meet the needs of these patients by measuring baseline geriatric conditions.

“Determining a patient’s baseline can help us understand what additional burdens they may have besides just what we focus on within our specialty,” Garg said. “This can be done with simple survey-based measures and can help us take a more patient-centered and comprehensive approach to cancer care.”

In addition, having conversations with patients about their goals over time can help physicians provide more personalized care.

“We should strive to have these conversations with patients at each decision point,” Garg said. “This is because patient goals and preferences might evolve as health status evolves.”

A head-and-shoulders photo of Tullika Garg, MD, MPH

Tullika Garg, MD, MPH

Associate Professor of Urology, Penn State College of Medicine
Phone: 717-531-1132
Fellowship: Urologic oncology, Memorial Sloan Kettering Cancer Center, New York City
Residency: Urology, Medical College of Wisconsin, Milwaukee
Medical School: Baylor College of Medicine, Houston
Connect with Tullika Garg, MD, MPH, on Doximity


  1. American Cancer Society. Key statistics for bladder cancer. American Cancer Society Website. Accessed May 25, 2022.
  2. Garg T, Johns A, Young A, et al. Geriatric conditions and treatment burden following diagnosis of non-muscle-invasive bladder cancer in older adults: A population-based analysis. Journal of Geriatric Oncology. 2021 May; 12(7): 1022–1030. doi: 10.1016/j.jgo.2021.04.005
  3. Mohile SG, Dale W, Somerfield MR, et al. Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. Journal of Clinical Oncology. 2018 Aug; 36(22): 2326–2347. doi: 10.1200/JCO.2018.78.8687
  4. Parekh AK and Goodman RA. The HHS Strategic Framework on multiple chronic conditions: genesis and focus on research. Journal of Comorbidity. 2013 Dec; 3: 22–29.

The Department of Urology at Penn State Health offers expert diagnosis and treatment of diseases and conditions involving the urinary tract. Our fellowship-trained surgeons and skilled advanced practice providers offer individualized care for cancer, kidney stones, infertility, impotence and other complex urologic concerns.

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