Incarcerated Patients Present with More Advanced Bladder Cancer Stage: A Statewide Analysis

Intro: United States has high incarceration rate, with documented racial and socioeconomic disparities in incarceration. Cancer is the leading cause of death in prisons, accounting for nearly one-third of deaths. Prior studies suggest incarcerated patients may present with more advanced disease and worse cancer-specific outcomes. We aimed to assess the association between incarceration status and stage at presentation in bladder cancer. Methods: We used the Michigan Cancer Surveillance Program, a statewide, population-based registry. We included patients diagnosed with bladder cancer between 2004 and 2019. Advanced stage was defined as pathological T stage ≥2, nodal involvement (N+), or distant metastasis (M+). Demographic and clinicopathological variables included were age, sex, race/ethnicity, year of diagnosis, smoking history, histological grade, and tumor stage. Patients were stratified by incarceration status. Univariable and Multivariable logistic regression analyses were performed to assess the association between incarceration status and advanced disease at the diagnosis, after adjusting for relevant covariates. Results: Among 29,429 patients with bladder cancer, 31 (0.1%) were incarcerated at diagnosis. Incarcerated patients were younger (median age 58 vs. 72 years, p<0.001), more frequently Black (16.1% vs. 6.2%), and had a higher proportion of ≥T2 stage disease (32.3% vs. 20.4%). In unadjusted analysis, incarceration was not significantly associated with advanced disease (OR 1.82, 95% CI 0.82-3.77; p=0.12). However, in multivariable analysis adjusting for age, sex, race, smoking and grade, incarceration was associated with higher odds of advanced stage at presentation (OR 2.46, 95% CI 1.01-5.82; p=0.04). Female sex, Black race, smoking status and high-grade tumors were also independently associated with advanced disease. Conclusions: Incarceration at the time of diagnosis was independently associated with higher odds of presenting with advanced-stage bladder cancer. These findings highlight incarceration status as a marker of clinical vulnerability, not fully explained by known risk factors such as smoking or race. Addressing this disparity will require both preventive strategies targeting modifiable risk factors and structural interventions to ensure timely access to cancer diagnosis and care within correctional settings.