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274 Background: Single-dose administration of intravesical gemcitabine is a common part of clinical practice following transurethral resection (TURBT) of non-muscle invasive bladder cancer (NMIBC). Although the side effect profile for gemcitabine is well characterized in systemic and local therapy, rare side effects continue to be identified with ongoing use. Here we identify several cases of treatment-related alopecia with adjuvant single dose intravesical administration for NMIBC after TURBT. Methods: Using our single-institutional IRB-approved Cysview registry database, we identified patients who underwent TURBT for NMIBC and received a single dose of intravesical gemcitabine post-TURBT between January 2020 and June 2023 at Keck Hospital of USC. Patients with a history of low grade NMIBC or those undergoing their first TURBT received 2g of gemcitabine dissolved in 100 cc of saline 1h after tumor resection. We reviewed patient-reported adverse events and included patients who reported alopecia following gemcitabine instillation. Patients were questioned on the degree and length of hair loss and information was collected from patient charts. Results: Overall, 9 patients (2 male, 7 female) reported hair loss following single dose intravesical gemcitabine after the TURBT. One patient had an autoimmune disease. The hair loss started within a few days of gemcitabine instillation and resolved spontaneously. The table shows the clinicopathologic characteristics of this cohort in detail. Three patients experienced severe hair loss. The resection extent during TURBT was classified as small (<2 cm), medium (2-5 cm), or large (>5 cm). Three patients had a large resection, 2 patients a medium one and 3 patients a small resection. None of the patients had previous intravesical gemcitabine; however, 2 patients had a history of intravesical BCG and 1 had intravesical mitomycin before. Conclusions: This study demonstrates that hair loss is a rare but possible adverse effect of intravesical gemcitabine after TURBT. Prior to surgery, patients should be counseled regarding this potential side-effect. Additional research and multicenter studies are required to describe the occurrence and cause of this adverse event. Demographic, clinical, and pathologic characteristics of patients. Patient ID Age Sex History of other IVT Pathology of TURBT Number of prior TURBT Resection extent Severity of hair loss Prior UBC 1 73 M None LGTa 1 large moderate LGTa 2 88 M MMC LGTa multiple large severe LGTa 3 76 F BCG CIS multiple small moderate HGT1 in upper tract, HGTa & LGTa in bladder 4 56 F BCG HGTa multiple large severe LG+HGTa 5 66 F None HGTa none small moderate None 6 84 F None LGTa none small severe None 7 62 F None LGTa 1 medium moderate LGTa 8 68 F None HGTa multiple medium mild LGTa 9 64 F None LGTa none medium severe None LG= Low Grade, HG = High Grade. [ABSTRACT FROM AUTHOR]

Neoadjuvant chemotherapy followed by radical cystectomy (RC) and Transurethral Resection of Bladder Tumor (TURBT) followed by concurrent chemoradiation therapy (trimodal therapy, TMT) are both evidence-based approaches to the management of muscle-invasive bladder cancer, and no randomized evidence conclusively supports the use of one treatment over another. Literature suggests that increasing distance to radiation therapy (RT) facilities reduces the likelihood that patients will receive RT, though this has not been evaluated in bladder cancer. We hypothesize that greater travel time between a patient's home and their closest RT facility is associated with a lower likelihood of undergoing TMT. Clinical data and the locations of patient residences and surgical facilities performing RC were obtained from the California Cancer Registry. RT facility locations were compiled from state regulatory databases and dosimetric accrediting bodies. Travel time was identified using the Google Distance Matrix API. California patients diagnosed with T2-4N0 bladder cancer in 2018-2019 who underwent TMT (> = 55Gy) or RC were included in this analysis. Chi-square tests, Kruskal-Wallis tests, and univariate and multivariate logistic regressions were performed to assess factors associated with an increased likelihood of receipt of TMT, and to compare travel times for patients receiving TMT vs RC. A total of 536 patients met inclusion criteria, and 27.1% underwent TMT. Patients receiving TMT were more likely to be older, White, male, and live further from their nearest RT facility. After adjusting for age, sex, and race/ethnicity, patients undergoing TMT were more likely than RC patients to live more than 30 minutes away from the nearest RT facility (OR 1.53, p = 0.21, ref<15 minutes). On multivariate analysis, patients receiving TMT were less likely than surgical patients to live 30-60 minutes or >60 minutes from their treatment facility ((OR 0.5, p-value<0.01, and OR 0.23, p-value <.001), ref: <30 minutes). Only 26.2% of patients who received TMT were treated at their nearest RT facility, while 13.3% of patients undergoing RC were treated at their nearest surgical facility. In a modern cohort of bladder cancer patients in California, about a quarter of T2-4N0 patients are undergoing bladder preservation. Patients undergoing TMT lived further from their nearest RT facility than patients undergoing surgery. Surgical patients were more likely to live >30 minutes from their treating facility than TMT patients. A minority of patients underwent treatment at the facility nearest to them, regardless of treatment modality chosen. Taken together, this suggests that proximity to the nearest RT facility may not be associated with a higher likelihood of undergoing TMT. Examination of actual treatment facilities (as opposed to the closest facility) shows that patients are traveling further for surgical care than TMT. [ABSTRACT FROM AUTHOR]

• About 45% of patients with high grade non-muscle invasive bladder cancer (NMIBC) received intravesical therapy within 6 months of diagnosis. • Underutilization of Bacillus Calmette-Guérin (BCG) was most pronounced in the elderly and patients from the lowest socioeconomic status areas. • Paradoxically, non-Hispanic black (NHB) patients were more likely to receive BCG despite known disparities in survival. Among patients diagnosed with non-muscle invasive bladder cancer (NMIBC), those with high risk disease have the greatest risk of recurrence and disease progression. The underutilization of intravesical immunotherapy with Bacillus Calmette-Guérin (BCG) has been a longstanding concern in clinical practice. This study aimed to determine the disparities present in receipt of adjuvant intravesical chemotherapy and immunotherapy in treatment of patients with high grade NMIBC following initial transurethral resection of a bladder tumor (TURBT). The California Cancer Registry data was used to identify 19,237 patients diagnosed with high grade NMIBC who underwent TURBT. Treatment variables include re-TURBT, re-TURBT and intravesical chemotherapy (IVC) and/or BCG. Independent variables include age, sex, race/ethnicity, neighborhood socioeconomic status (nSES), primary insurance payer and marital status at diagnosis. Multiple logistic regression and multinomial regression models were used to examine variation in the treatments received following TURBT. The proportion of patients receiving TURBT followed by BCG was similar across all racial and ethnic groups (28%–32%). BCG therapy was higher in patients belonging to the highest nSES quintile (37% for highest vs. 23%–26% for the 2 lowest quintiles). In multiple variable analyses, receipt of any intravesical therapy (IVT) was influenced by nSES, age, marital status, race/ethnicity, and insurance type. Patients in the lowest nSES quintile had a 45% less likelihood of receiving IVT compared to the highest nSES group (OR [95%CI]: 0.55[0.49, 0.61]). Race/ethnicity differences in receipt of any adjuvant therapy were noted in the middle to lowest nSES quintile for Hispanic and Asian/Pacific Islander patients when compared to non-Hispanic White patients. When comparing variation in treatment by insurance type at diagnosis, those with Medicare or other insurance were 24% and 30% less likely to receive BCG after TURBT compared to those with private insurance, (OR [95%CI]: 0.76 [0.70, 0.82] and 0.70[0.62, 0.79]) respectively. In patients with a diagnosis of high risk NMIBC, disparities in utilization of BCG are seen based on SES, age, and insurance type. [ABSTRACT FROM AUTHOR]