Investigators have examined the contribution of low socioeconomic status to the incidence of prostate cancer in AA men [26,27], but there is a paucity of work that characterizes the unique interaction between income inequality and hiv protease inhibitor regarding the delivery of treatment to these men who need it most. In this retrospective cohort study of 102,486 AA and non-Hispanic white men with localized high-risk prostate cancer, AA men were 49% less likely than white men to receive definitive therapy for prostate cancer after adjusting for patient demographics, comorbidity, and cancer prognostic factors. Moreover, this racial disparity in receipt of definitive therapy widened significantly among low-income men. Although high-income AA men were 40% less likely than high-income white men to receive definitive therapy, the treatment disparity expanded to 51%—even more striking—among low-income men.
Although the analyses adjust for regional education, urban/rural residence, and income, it is possible that some of the census-tract-level data does not capture patient-level characteristics that influence patient and provider decisions. Recent work demonstrates significant lack of comprehension of common prostate cancer terms  and barriers to shared decision making  among economically disadvantaged men. Poor communication between patients and providers regarding the efficacy and adverse effects of treatment likely encourages decisional regret among some AA men  and contributes to the prevalence of shared perspectives for or against certain health care interventions within communities. Patient refusal of recommended surgery or radiation is correlated with increased prostate cancer mortality , and it is probable that disproportionately fewer recommendations for primary therapy to AA men likewise contribute to less receipt of therapy and greater prostate cancer mortality.
Although affordable care is a critical component to improving treatment access and outcomes for low-income men, providers must also work to address other factors that limit the quality of care delivered to vulnerable populations, such as communication, transportation, and access to high-volume hospitals [32,33]. Although this study did not evaluate insurance status, Mahal et al.  show that the racial disparity in receipt of primary therapy between AA men and white men narrows with access to insurance, though large socioeconomic treatment disparities continue to exist even in nations with universal health care .
Conflict of interest/disclosures
When the World Health Organization (WHO) published its 2004 guidelines for classification of urothelial carcinoma (UC) and chose to recognize distinct variant histology (VH), one of its aims was increasing identification of these variants on pathology specimens . Better understanding of these VH forms of UC leads to greater knowledge of prognosis and treatment strategies specific to individual variants. Despite initial descriptions of variants more than 20 years ago, molecular pathways for the divergent development of specific VH within primary urothelial bladder carcinoma have not been elucidated [2,3]. Divergent differentiation is poorly understood; although, Cheng et al.  have suggested sarcomatoid urothelial cancer developing as the final common pathway in UC differentiation. The true prevalence of VH has likely not increased over the past decade, although this is difficult to prove retrospectively . Rather, increased pathologic awareness of the possible morphologic variants is likely the driver of increased variant diagnosis.
Using an institutional database, we conducted a retrospective review of all patients who underwent radical cystectomy for UC of the bladder at our institution between 2008 and June 2013 (n = 698). As the current WHO guidelines recommend that patients with any component of small cell histology be managed as primary small cell carcinoma, we eliminated all patients with small cell variant (n = 22). Patients with locoregional metastatic disease that underwent cystectomy after preoperative chemotherapy or with a history of management under a bladder-preservation protocol were excluded (n = 52). Dedicated genitourinary pathologists assigned all UC VH using centralized pathology review, which included regular review of all malignant histology and variant classification to ensure standardization within the group. Outside hospital transurethral resection (TUR) specimens underwent VH reassignment by this same group of genitourinary pathologists. Histologic descriptions of VH are available from prior studies .