Stesura Seveso Archivio Italiano di Urologia e Andrologia 2024; 96(1):12305 1 ORIGINAL PAPER early stage when they can be treated. However, about 25% of BCs are diagnosed at an advanced stage (2). The progno- sis depends on many factors (1). SM survival varies signifi- cantly according to stage, in both non-invasive and invasive cases. The percentage of non-invasive cancers is relatively high. Stage, age, and histology associated with survival (5). The probability of accumulated survival at the end of 1, 3, 5, and 10 years in patients with BC is 0.8989, 0.7132, 0.5752, and 0.2459, respectively. There are significant dif- ferences in survival rates between age groups and types of treatment (6). The stage and extent of the cancer are impor- tant factors in determining the best treatment for BC (7). Continuity Cancer survival is generally lower for resi- dents of more socio-economically disadvantaged areas. Socio-economic inequality decreases survival due to cer- tain factors (8). In addition, health insurance is the deter- minant of patient treatment. The burden of cancer sur- vival also affects healthcare systems and society (9). In- hospital mortality can occur in patients with BC. The objective of this study was to determine the relationship between income, health insurance, and employment sta- tus as prognostic indicators of bladder cancer. MATERIALS AND METHODS Study design The largest tertiary referral hospital in East Java, Indonesia, Dr. Soetomo General Academic Hospital, carried out a retrospective observational study for patients with bladder cancer. Hospitalized BC patients were the subject of the research, which ran for five years, from January 2019 to December 2023. Adult BC patients were includ- ed, and patients with missing data met the exclusion cri- teria. The Dr. Soetomo General Academic Hospital's ethical review board granted approval for the research, which was carried out under the Declaration of Helsinki (approval number: 1527/ LOE/ 301. 4. 2/ XI/ 2023). Data collection The following socioeconomic data were extracted for analy- sis: income, employment status, and health insurance. Patients were divided by income below 4 million Rupiah or more than 4 million Rupiah, according to the basic salary in Background: Bladder Cancer (BC) is one of the health problems. Socioeconomic status (SES) may correlate with patient treatment, possibly impacting patient prognosis. This study aimed to determine the relation- ship between income, health insurance, and employment status as prognostic indicators of BC. Methods: A retrospective observational study for patients diag- nosed with BC in a hospital during the 5-year period between January 2019 and December 2023. Kaplan-Meier test analysis was used to generate overall survival curves stratified by income, employment status, and health insurance. Multivariate Cox proportional-hazards regression was used to identify fac- tors associated with worse overall survival. Results: The results of the analysis on 219 patients showed no difference in patient survival based on income (p > 0.05), while employment status and health insurance showed significant dif- ference in patient survival (p < 0.05). Moreover, there were 99 (45.2%) patients died, with the average patient being 58 years old and dominant in male patients. Conclusions: Prevention of poor outcomes in patients needs to pay attention to certain characteristics, particularly for the low- economic patients without appropriate national health insurance coverage. KEY WORDS: Bladder cancer; Insurance; Outcomes; Income; Employment. Submitted 23 January 2024; Accepted 3 February 2024 INTRODUCTION Bladder cancer (BC) is a neoplasm that arises from the bladder and is the most common type of urinary tract neoplasm (1). This cancer is included in one of the 10 most common cancers worldwide and has a high mortal- ity rate (2). BC accounts for 3% of global cancer diag- noses and is particularly common in developed countries. This case is mainly found in people aged 55 years, who are found in as many as 90% of diagnoses, and the dis- ease is four times more common in men than women (3). The incidence rate is twice as high in developing coun- tries than in developed countries (1). Treatment of bladder cancer tends to be significant and expensive (4). Diagnosis relies mainly on cystoscopy, an invasive and costly procedure. Most BCs are diagnosed at an The relationship between income, health insurance, and employment status as prognostic indicators of bladder cancer: A survival analysis Wahjoe Djatisoesanto 1, 2, Yufi Aulia Azmi 1, 2, 3, Ida Bagus Gde Tirta Yoga Yatindra 1, 2 1 Department of Urology, Faculty of Medicine, Universitas Airlangga; 2 Dr. Soetomo General-Academic Hospital, Surabaya, East Java, Indonesia; 3 Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. DOI: 10.4081/aiua.2024.12305 Summary Archivio Italiano di Urologia e Andrologia 2024; 96(1):12305 W. Djatisoesanto, Y. Aulia Azmi, I. Bagus Gde Tirta Yoga Yatindra 2 Indonesia. They were divided by type of health insurance as patients with National Health Insurance (Jaminan Kesehatan Nasional/JKN) or private insurance. Mortality in this insur- ance system was defined as death during the hospital stay. Statistical analysis Survival analysis was done for patients whose income, work status, and health insurance were known. Time in months from diagnosis to death from any cause was the primary outcome. For every variable, descriptive epi- demiological and survival statistics were computed. The overall survival curves were stratified by income, job sta- tus, and health insurance using Kaplan-Meier test analy- sis. Log-rank tests were used to analyze survival differ- ences. To find the variables linked to a lower overall sur- vival rate, multivariate Cox proportional-hazards regres- sion was used. Hazard ratios (HR) and accompanying 95% confidence intervals (CI) were utilized. We also ana- lyzed the regression to predict sepsis and metastases as strata. The criterion for statistical significance was fixed at P < 0.05. The statistical studies were conducted using IBM Corp.'s SPSS 25 program in Armonk, NY. RESULTS There were 99 (45.2%) patients who died. Results show that the average patient is 58 years old with prevalence of male patients. Our analysis shows that the characteristics of income below 4 million rupiah and education level have significant impact in mortality rates. Sociodemographic characteristics are shown in Table 1. The results of the socio-economic status (SES) data assess- ment show that most patients have an income of more than 4 million rupiahs every month. More than half of the respondents were employed. Most have health coverage. SES data are shown in Table 2. Based on the results of survival analysis using Kaplan Meier (Log-rank), there was no difference in patient survival based on income (p > 0.05) (Figure 1), while there was a difference in patient survival based on employment status and health insurance (p < 0.05) (Figures 2, 3). Table 1. Socioeconomic Status. Component N % P Race Javanese 164 74.9 0.253 Madurese 50 22.8 Chinese 5 2.3 Income ≥ 4 million rupiah 192 87.7 < 0.001 < 4 million rupiah 27 12.3 Employment Status Yes 113 51.6 0.013 No 106 48.4 Farmer Yes 21 10.6 0.002 No 198 89.4 Location Urban 52 23.7 0.812 Rural 167 76.3 Health Insurance National Insurance 174 79.5 0.827 Private Insurance 45 20.5 Education Educated 177 80.8 < 0.001 Non-Educated 42 19.2 Figure 1. Survival analysis of bladder cancer patients with different income. Archivio Italiano di Urologia e Andrologia 2024; 96(1):12305 3 Prognostic indicators of bladder cancer DISCUSSION The results showed that there was no difference in patient survival based on income, while, there were differences in patient survival based on employment status and health insurance. Previous research has found relationship between socioeconomic status and survival, although socioeconomic assessments were carried out with differ- ent standards (10). Other studies have found that cancer survival is often poorer among people from more socioe- conomically disadvantaged areas. For tumors of connec- tive/soft tissue, bladder, and unknown primary origin, socioeconomic differences in survival decrease with increasing age at diagnosis (8). In addition, health insur- ance is the determinant of patient treatment. Finally, the burden of cancer survival also affects healthcare systems and society (9). Figure 2. Survival analysis of bladder cancer patients with different employment status. Figure 3. Survival analysis of bladder cancer patients within different health insurance. Archivio Italiano di Urologia e Andrologia 2024; 96(1):12305 W. Djatisoesanto, Y. Aulia Azmi, I. Bagus Gde Tirta Yoga Yatindra 4 Taylor et al. discovered that characteristics related with a greater chance of bladder cancer presenting at an advanced stage compared to early stages were race, ethnicity, gender, insurance status, one or more comorbidities, and a median household income of less than $63,000 (11). Other researchs have found that lower SES, Medicaid insurance, and no insurance all resulted in a higher tumor stage. Regardless of the stage of the tumor, poorer SES, having Medicaid insurance, and no insurance linked to worse over- all survival (OS) and disease specific survival (DSS) (12). Worse overall survival is related to male gender and sig- nificant prognostic factors of overall survival include gen- der (13). Other studies found that women's risk levels were significantly higher than men's for up to two years after a bladder cancer diagnosis, especially for muscle- invasive cancers. The common belief that the prognosis for bladder cancer is poorer in women compared to men must be reconsidered (14). In Indonesia, National Health Insurance (NHI) significant- ly enhances public health and offers low-income house- holds access to care. Nonetheless, NHI coverage below the federal minimum or the government's guidelines may affect health at all phases and developments. The growth and development of stunted children, immunization rates, and the quality of life for those with non-commu- nicable illnesses may all be negatively impacted by low NHI coverage. Moreover, health insurance is less com- mon among rural homes. The main criterion for eligibili- ty for Indonesia's subsidized and contributory programs is that participants must be employed and live in Java or Bali. Low coverage may also be due to the cost of travel- ing to the health insurance office (15). This burden should be evenly distributed across stake- holders considered in the evaluation of the cost-effective- ness of new anti-cancer drugs (9). Patient survival rates can be enhanced through strategic planning for early detection and screening, as well as proper access to appropriate diagnostic and treatment services, particular- ly in men, considering the significant influence on disease stage at diagnosis (16). CONCLUSIONS There is no difference in patient survival based on income, while there are differences in patient survival based on employment status and health insurance. Health insurance and employment status, specifically being a farmer, might affect the mortality outcomes significantly. ETHICAL APPROVAL The Dr. Soetomo General Academic Hospital’s ethical review board grants approval for this research carried out under the Declaration of Helsinki (approval number: 1527/LOE/301. 4. 2/XI/ 2023). REFERENCES 1. Kaseb H, NR. A. Bladder Cancer. In: StatPearls [Internet]. 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Correspondence Wahjoe Djatisoesanto wahjoe.djatisoesanto@fk.unair.ac.id Yufi Aulia Azmi y.aulia.azmi@umcg.nl, yufiazmi@gmail.com Ida Bagus Gde Tirta Yoga Yatindra tirtayogastudi@gmail.com Department of Urology, Faculty of Medicine, Airlangga University, Soetomo General Academic Hospital Jl. Mayjen Prof. Dr. Moestopo No.6-8, Surabaya, East Java, Indonesia, 60286 Conflict of interest: The authors declare no potential conflict of interest.