Female bladder cancer: incidence, treatment, and outcome

Are androgen receptor agonists a treatment option in bladder cancer?

Sex-related differences in bladder cancer incidence and progression infer a role for sex hormones and their cognate receptors in this disease. In part due to the oncogenic role of androgen receptor signaling in prostate cancer, the focus of most preclinical and clinical research to-date has been on the potential pro-tumorigenic action of androgens in urothelial cancers. However, clinical studies of androgen receptor antagonism have yielded minimal success. In this review, we explore the tumor suppressor role of androgen receptor in bladder cancer and discuss how it might be harnessed therapeutically.

Correlation between androgen and estrogen receptor expression and clinicopathologic features in carcinoma urinary bladder

INTRODUCTION

The molecular mapping of cancers by the Cancer Genome Atlas Project has accelerated the quest for new therapeutic targets for urinary bladder cancer, including sex steroid receptors. Previous studies have demonstrated conflicting results on their relationship with bladder cancer, and there is sparse data on their expression in the Indian population. The aim of our study is to examine the expression of androgen receptors (AR) and estrogen receptors (ERα and ERβ) in patients with bladder cancer and their correlation with clinicopathologic features.

MATERIALS AND METHODS

In this retrospective cohort study, a total of 132 patients, who were surgically managed for urinary bladder mass by transurethral resection or radical cystectomy in our institute, with transitional cell carcinoma on histopathology and with at least two years of follow-up were included. Their demographic and treatment details were obtained, histopathology blocks were retrieved and immunohistochemical staining for androgen and estrogen receptors was performed. Then, the relationship between their expression and clinicopathologic features was studied.

RESULTS

A total of 3.79% of patients showed estrogen receptor alpha positivity, 51.52% estrogen receptor beta positivity and 63.64% androgen receptor positivity. No statistically significant correlation was found between age of patients (p = 0.75/0.52/0.87), tumour stage and grade (0.71/0.3/0.21), pathological variant (p = 1/0.58/0.38) and overall survival (p = 0.70/0.052/0.45 for NMIBC and p = 0.82/0.36/0.22) and estrogen receptor alpha, estrogen receptor beta and androgen receptor-positive status, respectively. Estrogen receptor beta positivity was significantly higher in patients with unifocal (p = 0.015) and small tumours (< 5 cm) (p = 0.03), and its expression was associated with better disease-free survival (DFS) (p = 0.046) in patients of non-muscle invasive bladder cancer (NMIBC).

CONCLUSION

Our study has the largest sample size conducted on Indian population with results differing from previous studies conducted on western population. Estrogen receptor beta expression was significantly associated with small unifocal tumours and better DFS. Estrogen receptor alpha and androgen receptor expression were not found to be associated with the clinicopathologic features of the study population.

The Inequality of Females in Bladder Cancer

Urinary bladder cancer is worldwide one of the most diagnosed and costly types of cancer. One puzzle in the bladder cancer diagnosis is the disproportional relationship between genders. Males are more likely to be diagnosed with bladder cancer whereas females typically are diagnosed with more adverse disease and worse prognosis, which has led to speculation of the potential role of sex hormones and their receptors in this disease. Estrogen receptors are present in the human bladder, and their role in bladder cancer oncogenesis is increasingly becoming a focus for researchers around the world. This mini-review aims to give a brief overview of the status of female bladder cancer, and to which extend the sex hormones receptors play a role in this. A literature search was performed and included all female original studies on bladder cancer and hormone receptors. Estrogen-receptor alpha seems to be anti-oncogenic whereas estrogen-receptor beta is exhibiting its function pro-oncogenic. The receptor functions may be exercised through mRNA transcriptions and enzymes. Epidemiological studies indicate a potential increase in incidence of bladder cancer for females with earlier age at menopause, and clinical trials are investigating Tamoxifen as a potential treatment in bladder cancer. Increasing evidence supports the theory of bladder cancer development and progression as being partly hormone-dependent. This can lead to a change in conceptual background of bladder cancer etiology and development in the future. Further studies are required to more precise map the use of anti-hormonal drugs in the treatment of this cancer.

Physical activity and risk of bladder cancer among postmenopausal women

Physical activity is associated with decreased risk for many cancers. Studies on the association between physical activity and risk of bladder cancer are limited, and findings are inconsistent. Postmenopausal women (mean age = 63.3) were recruited into the Women's Health Initiative from 1993 to 1998. Self-reported baseline information on physical activity and other covariates were available in 141 288 participants. Incident bladder cancer cases were collected through 2018 and centrally adjudicated. Hazard ratios (HRs) and 95% confidence intervals (CIs) were determined by Cox proportional hazard regression models. Effect modification due to smoking was assessed. During an average of 18.5 years of follow-up, 817 bladder cancer cases were identified. Compared to physically inactive women, those who engaged in ≥15 MET-hours/week of total physical activity, ≥8.75 MET-hours/week of walking or ≥11.25 MET-hours/week of moderate to vigorous physical activity had lower risk of bladder cancer (HR = 0.74, 95% CI: 0.59-0.94, P for linear trend = .02; HR = 0.79, 95% CI: 0.63-0.98, P for linear trend = .03; and HR = 0.76, 95% CI: 0.61-0.94, P for linear trend = .02, respectively). No effect modification was found by smoking status (P for interaction = .06, 0.91 and 0.27, respectively). We found that total physical activity, walking and moderate to vigorous physical activity were inversely associated with bladder cancer incidence among postmenopausal women in a dose-response manner. Physical activity may play a potential role in the primary prevention of bladder cancer. Further studies with objective measurements of physical activity are needed to confirm these findings.

Blood transfusions during neoadjuvant chemotherapy for muscle-invasive urinary bladder cancer may have a negative impact on overall survival

Objective: To evaluate the extent and plausible effects of blood transfusions given during cisplatin-based neoadjuvant chemotherapy (NAC) on overall survival in patients with muscle-invasive urothelial bladder cancer (MIBC) undergoing NAC and radical cystectomy (RC).Background: Several studies have demonstrated a decreased survival for MIBC patients receiving allogenic peri- and postoperative blood transfusions in conjunction with RC. No studies have previously investigated the effects of blood transfusions during NAC.Materials and methods: 120 patients with MIBC (cT2-T4aN0M0) undergoing NAC and RC between 2008 and 2014 at four Swedish cystectomy centers were retrospectively evaluated. Clinicopathological data were obtained, including data of allogenic blood administration. Survival data was analyzed by Kaplan-Meier plotting and Cox regression.Results: One third of the cohort received blood transfusions during the period of NAC. In univariate analysis, blood transfusions during NAC, nodal stage and advanced tumor stage (pT >2) were negative prognostic factors for survival. In multivariate analysis, only pNx and pT >2 remained significant negative prognostic factors. In a subgroup analysis consisting of patients with localized tumors without dissemination (n = 96), patients that received transfusions during NAC showed an 18.5% absolute risk increase of death at five years of observation, although without statistical significance (p = .197).Conclusions: This is the first time that the extent and plausible effects of allogenic blood transfusions during NAC is examined in MIBC. Data suggest that there may be an association between blood transfusion and poor pathological and oncological outcome. Firm conclusions are difficult to draw due to few study participants and the retrospective nature of the study.

Smoking Cessation and the Risk of Bladder Cancer among Postmenopausal Women

Smoking is the strongest established risk factor for bladder cancer. Former smokers have a lower risk of bladder cancer compared with current smokers, but findings on the dose-response relationship between years after quitting and the risk of bladder cancer are inconsistent. A total of 143,279 postmenopausal women from the Women's Health Initiative Study were included. Cox proportional hazards regression models were applied for estimating age- and multivariable-adjusted HRs and their 95% confidence intervals (CI). There were 870 bladder cancer cases identified over an average of 14.8 years of follow-up. After adjusting for pack-years of smoking, bladder cancer risk among former smokers declined by 25% within the first 10 years of cessation and continued to decrease as cessation time increased but remained higher than never smokers after 30 years of quitting (HR, 1.92; 95% CI, 1.43-2.58). Smokers who quit smoking had a lower risk of bladder cancer compared with current smokers (HR, 0.61; 95% CI, 0.40-0.94). We conclude that among postmenopausal women, there is a significant reduction in the risk of bladder cancer after quitting smoking. In addition to primary prevention, smoking cessation is critical to prevent the incidence of bladder cancer in older women.

Histopathological and prognostic significance of the expression of sex hormone receptors in bladder cancer: A meta-analysis of immunohistochemical studies

Objective

Emerging preclinical evidence suggests the involvement of sex hormones and their receptor signals in the development and progression of bladder cancer. Meanwhile, previous studies have demonstrated conflicting results on the relationship between the status of sex hormone receptors in urothelial tumors and histopathological characteristics of the tumors or patient outcomes. We therefore conducted this meta-analysis to assess the clinicopathological impact of the expression of androgen receptor (AR) and estrogen receptors (ERs) in bladder cancer.

Methods

A comprehensive literature search in databases (i.e. PubMed, Web of Science, Cochrane) was performed for all immunohistochemical studies stained for AR, ERα, and/or ERβ in surgically resected bladder cancer specimens and analyzed for patient outcomes. We selected eligible studies in accordance with the PRISMA guidelines and analyzed data using R software.

Results

A total of 2,049 patients from 13 retrospective studies were included in this meta-analysis. The difference in ERα expression between non-tumors and tumors was significant [odds ratio (OR) = 0.412; P<0.001], while those of AR (OR = 3.256; P = 0.336) or ERβ (OR = 0.580; P = 0.674) were not statistically significant. AR positivity in tumors was strongly correlated with gender (male vs. female: OR = 0.658; P = 0.027) or tumor grade (low-grade vs. high-grade: OR = 0.575; P<0.001). ERβ positive rates were significantly higher in high-grade (OR = 2.169; P<0.001) and muscle-invasive (OR = 3.104; P<0.001) tumors than in low-grade and non-muscle-invasive tumors, respectively. Survival analysis in patients with non-muscle-invasive bladder cancer revealed associations between AR expression and better recurrence-free survival [hazard ration (HR) = 0.593; P = 0.006) as well as between ERβ expression and worse recurrence-free (HR = 1.573; P = 0.013) or progression-free (HR = 4.148; P = 0.089) survivals.

Conclusions

These data suggest down-regulation of ERα expression in bladder tumors, compared with non-neoplastic urothelial tissues. AR or ERβ expression was down- or up-regulated, respectively, in high-grade and/or muscle-invasive bladder cancers. Moreover, immunohistochemistry of AR/ERβ in surgical specimens may serve as prognosticators in patients with non-muscle-invasive bladder tumor.

Falling bladder cancer incidence from 1990 to 2009 is not producing universal mortality improvements

Objective

The objective of this article is to obtain up-to-date epidemiological statistics of bladder cancer in England.

Methods

We collected incidence from the National Cancer Data Repository (NCDR), survival from the national Cancer Information System (CIS), ethnicity information from the Hospital Episode Statistics (HES), mortality and smoking rates from the Office for National Statistics (ONS).

Results

Incidence of bladder cancer has fallen continuously. Mortality has reduced less, leading to worsening survival. Bladder cancer mainly affects men, the most deprived, and the elderly. The gender gap is decreasing, and the deprivation gap is unchanged. Mortality is unchanged in the youngest, oldest and least deprived females. Mortality has recently increased in the oldest males. The highest incidence and mortality is found in industrial areas. This study is limited by i) its retrospective design using existing databases, allowing identification of associations and statistical differences, but not causation; and ii) very restricted ethnicity data.

onclusion

Reductions in bladder cancer incidence and mortality in England coincide with a decrease in high-risk occupations and public health measures to reduce smoking. Some risk factors in modern living may as yet be unidentified. It remains paramount to ensure equity of access and treatment regardless of gender, age, region and social deprivation to further improve mortality.

Steroid Hormone Receptor Signals as Prognosticators for Urothelial Tumor

There is a substantial amount of preclinical or clinical evidence suggesting that steroid hormone receptor-mediated signals play a critical role in urothelial tumorigenesis and tumor progression. These receptors include androgen receptor, estrogen receptors, glucocorticoid receptor, progesterone receptor, vitamin D receptor, retinoid receptors, peroxisome proliferator-activated receptors, and others including orphan receptors. In particular, studies using urothelial cancer tissue specimens have demonstrated that elevated or reduced expression of these receptors as well as alterations of their upstream or downstream pathways correlates with patient outcomes. This review summarizes and discusses available data suggesting that steroid hormone receptors and related signals serve as biomarkers for urothelial carcinoma and are able to predict tumor recurrence or progression.

Sex Differences of ≥pT1 Bladder Cancer Survival in Austria: A Descriptive, Long-Term, Nation-Wide Analysis Based on 27,773 Patients

Introduction: In recent days, the relationship between gender, tumour stage and survival of bladder cancer has attracted interest. Materials and Methods: The Austrian cancer registry was linked to the national death statistics. All patients with urothelial cancer of the urinary bladder with stages pT1, pT2, pT3 and pT4 diagnosed between 1983 until 2012 were followed for up to 15 years. Overall and cancer-specific mortality were estimated by cumulative incidence. Results: A total of 27,773 patients were analysed. The male:female ratio declined from 3:1 for stage pT1-tumours (n = 16,416) to 2.6:1 for pT2 (n = 6,548), 2.1:1 for pT3 (n = 3,111) and 1.9:1 for pT4 (n = 1,698). The 5 years cumulative overall death rate for pT1 tumours was slightly lower for women (0.31 vs. 0.32; p = 0.016). The opposite was observed for more advanced tumour stages: pT2: women 0.66, men: 0.60 (p = 0.0001); pT3: women 0.76, men 0.72 (p = 0.0004) and for pT4: women 0.90, men 0.85 (p = 0.0001). Cancer-specific survival was identical for pT1-tumours in both sexes, while women had a worse cancer-specific survival in both age cohorts (<70 years and ≥70 years) with higher tumour stages. Conclusions: This population-based study demonstrates that (1) a rise of advanced bladder cancer stages in women and (2) that women with tumour stages >pT1 have a shorter cancer-specific and overall survival.

Urologist referral delay and its impact on survival after radical cystectomy for bladder cancer

BACKGROUND

Evidence shows that wait times before bladder cancer surgery have been increasing, and wait time can negatively affect survival. We aimed to determine if a long delay caused by an indirect referral before a first urologist visit affects the survival of patients undergoing radical cystectomy for bladder cancer.

METHODS

We analyzed data from 1271 patients who underwent surgery for bladder cancer during the decade 2000-2009. The cohort was obtained by linking two administrative databases in the province of Quebec. Patients were considered to have been directly referred to a urologist if they had 5 or fewer visits with a general practitioner before their first urologist visit; otherwise, they were considered to have been indirectly referred. The effect on survival after surgery of a longer delay before a first urologist visit was assessed using Cox regression models.

RESULTS

Median referral delay for the study population was 30 days (56 days for women, 23 days for men; p < 0.0001). Indirect referral was observed for 49% of women and 33% of men. Compared with patients who were directly referred, those who were indirectly referred after first symptoms of bladder cancer experienced poorer survival (hazard ratio: 1.29; 95% confidence interval: 1.10 to 1.52). Women who were indirectly referred had a significant 47% greater risk of death after radical cystectomy. Men who were indirectly referred also experienced decreased survival (adjusted hazard ratio: 1.25; 95% confidence interval: 1.03 to 1.51).

CONCLUSIONS

Patients indirectly referred to a urologist had an increased risk of mortality after surgery. Compared with men, women had longer wait times and poorer survival.

Prognostic value of sex-hormone receptor expression in non-muscle-invasive bladder cancer

PURPOSE

We investigated sex-hormone receptor expression as predicting factor of recurrence and progression in patients with non-muscle invasive bladder cancer.

MATERIALS AND METHODS

We retrospectively evaluated tumor specimens from patients treated for transitional cell carcinoma of the bladder at our institution between January 2006 and January 2011. Performing immunohistochemistry using a monoclonal androgen receptor antibody and monoclonal estrogen receptor-beta antibody on paraffin-embedded tissue sections, we assessed the relationship of immunohistochemistry results and prognostic factors such as recurrence and progression.

RESULTS

A total of 169 patients with bladder cancer were evaluated in this study. Sixty-threepatients had expressed androgen receptors and 52 patients had estrogen receptor beta. On univariable analysis, androgen receptor expression was significant lower in recurrence rates (p=0.001), and estrogen receptor beta expression was significant higher in progression rates (p=0.004). On multivariable analysis, significant association was found between androgen receptor expression and lower recurrence rates (hazard ratio=0.500; 95% confidence interval, 0.294 to 0.852; p=0.011), but estrogen receptor beta expression was not significantly associated with progression rates.

CONCLUSION

We concluded that the possibility of recurrence was low when the androgen receptor was expressed in the bladder cancer specimen and it could be the predicting factor of the stage, number of tumors, carcinoma in situ lesion and recurrence.

Comparative Analysis of Gender-Related Differences in Symptoms and Referral Patterns prior to Initial Diagnosis of Urothelial Carcinoma of the Bladder: A Prospective Cohort Study

Objective: To analyze gender-specific differences regarding clinical symptoms, referral patterns and tumor biology prior to initial diagnosis of urothelial carcinoma of the bladder (UCB). Methods: A consecutive series of patients with an initial diagnosis of UCB was included. All patients completed a questionnaire on demographics, clinical symptoms and referral patterns. Results: In total, 68 patients (50 men, 18 women) with newly diagnosed UCB at admission for transurethral resection of bladder tumors were recruited. Dysuria was more often observed in women (55.6 vs. 38.0%, p = 0.001). Direct consultation of the urologist was conducted by 84.0% of males and 66.7% of females (p = 0.120). One third of the women saw their general practitioner and/or gynecologist once or twice (p = 0.120) before referral to the urologist. Furthermore, women were significantly more often treated for urinary tract infections than men (61.1 vs. 20.0%, p = 0.005). Cystoscopy at first presentation to the urologist was more often performed in men than women (88.0 vs. 66.7%, p = 0.068), with a more favorable tumor detection rate at first cystoscopy in men (96.0 vs. 50.0%, p < 0.001). Conclusions: Delayed referral patterns might lead to deferred diagnosis of UCB and consequently to adverse outcome. Thus, primary care physicians might consider referring patients with bladder complaints to specialized care earlier.

A review on thiazolidinediones and bladder cancer in human studies

There is a concern of an increased risk of bladder cancer associated with the use of thiazolidinediones, a class of oral glucose-lowering drugs commonly used in patients with type 2 diabetes with a mechanism of improving insulin resistance. Human studies on related issues are reviewed, followed by a discussion on potential concerns on the causal inference in current studies. Pioglitazone and rosiglitazone are discussed separately, and findings from different geographical regions are presented. Randomized controlled trials designed for primarily answering such a cancer link are lacking, and evidence from clinical trials with available data for evaluating the association may not be informative. Observational studies have been reported with the use of population-based administrative databases, single-hospital records, drug adverse event reporting system, and case series collection. Meta-analysis has also been performed by six different groups of investigators. These studies showed a signal of higher risk of bladder cancer associated with pioglitazone, especially at a higher cumulative dose or after prolonged exposure; however, a weaker signal or null association is observed with rosiglitazone. In addition, there are some concerns on the causal inference, which may be related to the use of secondary databases, biases in sampling, differential detection, and confounding by indications. Lack of full control of smoking and potential biases related to study designs and statistical approaches such as prevalent user bias and immortal time bias may be major limitations in some studies. Overlapping populations and opposing conclusions in studies using the same databases may be of concern and weaken the reported conclusions of the studies. Because randomized controlled trials are expensive and unethical in providing an answer to this cancer issue, observational studies are expected to be the main source in providing an answer in the future. Furthermore, international comparison studies using well-designed and uniform methodology to clarify the risk in specific sexes, ethnicities, and other subgroups and to evaluate the interaction with other environmental risk factors or medications will be helpful to identify patients at risk.

Sex disparities in diagnosis of bladder cancer after initial presentation with hematuria: a nationwide claims-based investigation

BACKGROUND

Women have disproportionately higher mortality rates relative to incidence for bladder cancer. Multiple etiologies have been proposed, including delayed diagnosis and treatment. Guidelines recommend ruling out malignancy in men and women presenting with hematuria. This study sought to determine the difference in timing from presentation with hematuria to diagnosis of bladder cancer in women versus men.

METHODS

This is a retrospective population-based study examining the timing from presentation with hematuria to diagnosis of bladder cancer, based on data from the MarketScan databases, which include enrollees of more than 100 health insurance plans of approximately 40 large US employers from 2004 through 2010. All study patients presented with hematuria and were subsequently diagnosed with bladder cancer. The primary outcome measure was number of days between initial presentation with hematuria and diagnosis of bladder cancer by sex.

RESULTS

A total of 5416 men and 2233 women met inclusion criteria. Mean days from initial hematuria claim to bladder cancer claim was significantly longer in women (85.4 versus 73.6 days, P < .001), and the proportion of women with >6 month delay in bladder cancer diagnosis was significantly higher (17.3% versus 14.1%, P < .001). Women were more likely to be diagnosed with urinary tract infection (odds ratio = 2.32, 95% confidence interval = 2.07-2.59) and less likely to undergo abdominal or pelvic imaging (odds ratio = 0.80, 95% confidence interval = 0.71-0.89).

CONCLUSIONS

Both men and women experience significant delays between presentation with hematuria and diagnosis of bladder cancer, with longer delays for women. This may be partly responsible for the sex-based discrepancy in outcomes associated with bladder cancer.

Sex differences in incidence and mortality of bladder and kidney cancers: national estimates from 49 countries

OBJECTIVES

In the United States, among patients diagnosed with bladder cancer (BC), women have increased disease-specific mortality compared with men. The main objective of this study was to determine whether this pattern is also present in other countries. For comparison, similar analyses were performed for kidney cancer (KC).

METHODS AND MATERIALS

Data for this study were obtained from the GLOBOCAN 2008 database. A total of 49 countries with available information on BC and KC incidence and mortality were included in the analysis, representing all major geographic regions except Africa. For each country, we computed the sex-specific ratio of the total number of deaths from a given cancer to the total number of diagnoses in the year 2008 (the mortality-to-incidence ratio [MIR]). The relative MIR was computed for each country as a ratio of MIR in women to MIR in men. A relative MIR of more than 1 would indicate that the number of cancer-specific deaths relative to the number of cancer-specific diagnoses is greater in women than in men.

RESULTS

For BC, the relative MIRs were significantly more than 1 in 26 countries (53%), significantly less than 1 in 2 countries (4%), and not significantly different from 1 in 21 countries (43%). The median relative MIR was 1.21 (interquartile range: 1.04-1.41). For KC, the relative MIRs were significantly more than 1 in 4 countries (8%), significantly less than 1 in 3 countries (6%), and not significantly different from 1 in 42 countries (86%). The median relative MIR was 1.00 (interquartile range: 0.94-1.06).

CONCLUSION

Among BC patients, increased disease-specific mortality in women compared with men appears to be a common (although not a universal) phenomenon. This pattern may potentially be explained by differences between the sexes in the biology of disease, time to diagnosis, treatment decisions, and other factors. In contrast, among KC patients, no significant differences in disease-specific mortality were seen between the 2 sexes in the overwhelming majority of the countries.

Bladder cancer: a simple model becomes complex

Bladder cancer is one of the most frequent malignancies in developed countries and it is also characterized by a high number of recurrences. Despite this, several authors in the past reported that only two altered molecular pathways may genetically explain all cases of bladder cancer: one involving the FGFR3 gene, and the other involving the TP53 gene. Mutations in any of these two genes are usually predictive of the malignancy final outcome. This cancer may also be further classified as low-grade tumors, which is always papillary and in most cases superficial, and high-grade tumors, not necessarily papillary and often invasive. This simple way of considering this pathology has strongly changed in the last few years, with the development of genome-wide studies on expression profiling and the discovery of small non-coding RNA affecting gene expression. An easy search in the OMIM (On-line Mendelian Inheritance in Man) database using "bladder cancer" as a query reveals that genes in some way connected to this pathology are approximately 150, and some authors report that altered gene expression (up- or down-regulation) in this disease may involve up to 500 coding sequences for low-grade tumors and up to 2300 for high-grade tumors. In many clinical cases, mutations inside the coding sequences of the above mentioned two genes were not found, but their expression changed; this indicates that also epigenetic modifications may play an important role in its development. Indeed, several reports were published about genome-wide methylation in these neoplastic tissues, and an increasing number of small non-coding RNA are either up- or down-regulated in bladder cancer, indicating that impaired gene expression may also pass through these metabolic pathways. Taken together, these data reveal that bladder cancer is far to be considered a simple model of malignancy. In the present review, we summarize recent progress in the genome-wide analysis of bladder cancer, and analyse non-genetic, genetic and epigenetic factors causing extensive gene mis-regulation in malignant cells.

Gender-specific differences in cancer-specific survival after radical cystectomy for patients with urothelial carcinoma of the urinary bladder in pathologic tumor stage T4a

BACKGROUND

Bladder cancer (UCB) staged pT4a show heterogeneous outcome after radical cystectomy (RC). No risk model has been established to date. Despite gender-specific differences, no comparative studies exist for this tumor stage.

MATERIALS AND METHODS

Cancer-specific survival (CSS) of 245 UCB patients without neoadjuvant chemotherapy staged pT4a, pN0-2, M0 after RC were analyzed in a retrospective multi-center study. Seventeen patients were excluded from further analysis due to carcinoma in situ (CIS) of the prostatic urethra and/or positive surgical margins. Average follow-up period was 30 months (IQR: 14-45). The influence of different clinical and histopathologic variables on CSS was determined through uni- and multivariate Cox regression analyses. Two risk groups were generated using factors with independent effect in multivariate models. Internal validity of the prediction model was evaluated by bootstrapping.

RESULTS

Eighty-four percent of the patients (n = 192) were male; 72% (n = 165) showed lymphovascular invasion (LVI). The 5-year CSS rate was 31%, and significantly different between male and female (35% vs. 15%, P = 0.003). Multivariate Cox regression modeling, female gender (HR = 1.83, P = 0.008), LVI (HR = 1.92, P = 0.005), and absence of adjuvant chemotherapy (HR = 0.61, P = 0.020) significantly worsened CSS. Two risk groups were generated using these 3 criteria, which differed significantly between each other in CSS (5-year-CSS: 46% vs. 12%, P < 0.001). The c-index value of the risk model was 0.61 (95% CI: 0.53-0.68, P < 0.001).

CONCLUSIONS

Prognosis in UCB staged pT4a is heterogeneous. Female gender and LVI are adverse factors. Adjuvant chemotherapy seems to improve outcome. The present analysis establishes the first risk model for this demanding tumor stage.

Diabetes and risk of bladder cancer: a study using the National Health Insurance database in Taiwan

AIMS/HYPOTHESIS

Studies on the link between diabetes and bladder cancer in Asians are rare. We investigated the association between diabetes and incidence of bladder cancer by using a large national insurance database.

METHODS

A random sample of 1,000,000 individuals covered by the National Health Insurance was recruited. A total of 495,199 men and 503,748 women for all ages and 187,609 men and 189,762 women ≥40 years old and without bladder cancer at recruitment were followed from 2003 to 2005. Cox regression evaluated the adjusted relative risk for all ages and for age ≥40 years old.

RESULTS

The results were similar for all ages and for age ≥40 years. In Cox models, patients with diabetes consistently showed a significantly higher relative risk ranging from 1.36 to 1.51 after adjustment for age, sex and other potential confounders. Age, male sex, nephropathy, urinary tract diseases (infection and stone) and statin use were associated with bladder cancer, but occupation, hypertension, stroke, ischaemic heart disease, peripheral arterial disease, eye disease, dyslipidaemia and medications (oral glucose-lowering agents including sulfonylurea, metformin, acarbose and thiazolidinediones, insulin, fibrates, ACE inhibitors/angiotensin receptor blockers and calcium channel blockers) were not. Chronic obstructive pulmonary disease and living in regions other than Metropolitan Taipei were associated with lower risk.

CONCLUSIONS

Patients with diabetes have a higher risk of bladder cancer. The association with urinary tract diseases suggests a complex scenario in the link between bladder cancer and diabetes at different disease stages.