Urinary bladder cancer risk factors in Egypt: a multicenter case-control study

Unveiling an Association between Waterpipe Smoking and Bladder Cancer Risk: A Multicenter Case-Control Study in Iran

BACKGROUND

Limited data exist for the association between bladder cancers and waterpipe smoking, an emerging global public health concern.

METHODS

We used the IROPICAN database in Iran and used multivariable logistic regression, adjusting for cigarette smoking, opium use, and other confounding factors. In addition, we studied the association between exclusive waterpipe smoking and bladder cancer.

RESULTS

We analyzed 717 cases and 3,477 controls and a subset of 215 patients and 2,145 controls who did not use opium or cigarettes. Although the OR adjusted for opium, cigarettes, and other tobacco products was 0.92 [95% confidence interval (CI), 0.69-1.20], we observed a statistically significant elevated risk in exclusive waterpipe smokers (OR = 1.78; 95% CI, 1.16-2.72) compared with non-users of opium or any tobacco. Associations were strongest for smoking more than two heads/day (OR = 2.25; 95% CI, 1.21-4.18) and for initiating waterpipe smoking at an age less than 20 (OR = 2.73; 95% CI, 1.11-6.72). The OR for urothelial bladder cancer was higher in ex-smokers (OR = 2.35; 95% CI, 1.24-4.42) than in current smokers (OR = 1.52; 95% CI, 0.72-3.15). All observed associations were consistently higher for urothelial histology.

CONCLUSIONS

Waterpipe smoking may be associated with an increased risk of bladder cancer, notably among individuals who are not exposed to cigarette smoking and opium.

IMPACT

The study provides compelling evidence that waterpipe smoking is a confirmed human carcinogen, demanding action from policymakers. See related In the Spotlight, p. 461.

Modifiable risk factors for cancer in the middle East and North Africa: a scoping review

PURPOSE

This scoping review examines controllable predisposing factors attributable to cancer in the Middle East and North Africa (MENA) region's adult population, highlighting opportunities to enhance cancer prevention programs.

DESIGN

We systematically searched the PubMed, Science Direct, and CINAHL, EMBASE, and Cochrane Library databases from 1997 to 2022 for articles reporting on the impact of modifiable risk factors on adult patients with cancer in the MENA region.

RESULTS

The review identified 42 relevant articles, revealing that tobacco consumption, obesity, physical inactivity, and diet are significant modifiable risk factors for cancer in the region. Tobacco smoking is a leading cause of lung, bladder, squamous cell carcinoma, and colorectal cancer. A shift towards a westernized, calorie-dense diet has been observed, with some evidence suggesting that a Mediterranean diet may be protective against cancer. Obesity is a known risk factor for cancer, particularly breast malignancy, but further research is needed to determine its impact in the MENA region. Physical inactivity has been linked to colorectal cancer, but more studies are required to establish this relationship conclusively. Alcohol consumption, infections, and exposure to environmental carcinogens are additional risk factors, although the literature on these topics is limited.

CONCLUSION

The review emphasizes the need for further research and the development of targeted cancer prevention strategies in the MENA region.

Risk of urinary tract cancers following arsenic exposure and tobacco smoking: a review

Bladder cancer, prostate cancer, and kidney cancer, due to their high morbidity and mortality rates, result in significant economic and health care costs. Arsenic exposure affects the drinking water of millions of people worldwide. Long-term exposure to arsenic, even in low concentrations, increases the risk of developing various cancers. Smoking is also one of the leading causes of bladder, prostate and kidney cancers. Accordingly, this research reviews the relationship between arsenic exposure and smoking with three kinds of urinary tract cancers (bladder cancer, prostate cancer, and kidney cancer) due to their widespread concern for their negative impact on public health globally. In this review, we have gathered the most current information from scientific databases [PubMed, Scopus, Google Scholar, ISI web of science] regarding the relationship between arsenic exposure and tobacco smoking with the risk of bladder, prostate, and kidney cancer. In several studies, a significant relationship was determined between the incidence and mortality rate of the above-mentioned cancers in humans with arsenic exposure and tobacco smoking. The decrease or cessation of smoking and consumption of arsenic-free water significantly declined the incidence of bladder, prostate, and kidney cancers.

Family cancer history and smoking habit associated with sarcoma in a Japanese population study

Sarcoma is a rare cancer, and little is known about the etiology, lifestyle epidemiology, and actual circumstances of treatment in hospitals in Japan. Understanding these issues is essential for the effective prevention and treatment of sarcoma. We therefore investigated the incidence of a personal and family cancer history in a total of 1320 sarcoma patients at the National Cancer Center Hospital. In addition, obesity, hypertension, dyslipidemia, diabetes mellitus, drinking, smoking, age and sex were compared in a descriptive study of 1159 of these sarcoma patients who were ≥ 20 years of age, and 7738 controls derived from the National Health and Nutrition Examination Survey in Japan. A total of 8% of sarcoma patients had a personal history of another cancer, and 30% of soft tissue sarcoma patients had a family cancer history in a first-degree relative (malignant peripheral nerve sheath tumor, 52%; leiomyosarcoma, 46%). A smoking habit was associated with the development of sarcoma (odds ratio [OR], 2.05; 95% confidence interval, 1.78-2.37; p < 0.01). According to the histology, the ORs for undifferentiated pleomorphic sarcoma (UPS) of bone, UPS of soft tissue, and liposarcoma were 5.71, 3.04, and 2.92, respectively. A family cancer history may be associated with certain soft tissue sarcomas, and a smoking habit was significantly associated with the development of sarcomas; however, further studies are necessary.

Disinfection By-Products in Drinking Water and Bladder Cancer: Evaluation of Risk Modification by Common Genetic Polymorphisms in Two Case-Control Studies

BACKGROUND

By-products are formed when disinfectants react with organic matter in source water. The most common class of disinfection by-products, trihalomethanes (THMs), have been linked to bladder cancer. Several studies have shown exposure-response associations with THMs in drinking water and bladder cancer risk. Few epidemiologic studies have evaluated gene-environment interactions for total THMs (TTHMs) with known bladder cancer susceptibility variants.

OBJECTIVES

In this study, we investigated the combined effect on bladder cancer risk contributed by TTHMs, bladder cancer susceptibility variants identified through genome-wide association studies, and variants in several candidate genes.

METHODS

We analyzed data from two large case-control studies-the New England Bladder Cancer Study (n/n=989 cases/1,162 controls), a population-based study, and the Spanish Bladder Cancer Study (n/n=706 cases/772 controls), a hospital-based study. Because of differences in exposure distributions and metrics, we estimated effects of THMs and genetic variants within each study separately using adjusted logistic regression models to calculate odds ratios (ORs) and 95% confidence intervals (CI) with and without interaction terms, and then combined the results using meta-analysis.

RESULTS

Of the 16 loci showing strong evidence of association with bladder cancer, rs907611 at 11p15.5 [leukocyte-specific protein 1 (LSP1 region)] showed the strongest associations in the highest exposure category in each study, with evidence of interaction in both studies and in meta-analysis. In the highest exposure category, we observed OR=1.66 (95% CI: 1.17, 2.34, p-trend=0.005) for those with the rs907611-GG genotype and p-interaction=0.02. No other genetic variants tested showed consistent evidence of interaction.

DISCUSSION

We found novel suggestive evidence for a multiplicative interaction between a putative bladder carcinogen, TTHMs, and genotypes of rs907611. Given the ubiquitous exposure to THMs, further work is needed to replicate and extend this finding and to understand potential molecular mechanisms. https://doi.org/10.1289/EHP9895.

Cigarette smoking and risk of bladder cancer: a dose-response meta-analysis

INTRODUCTION

The disease burden of bladder cancer is increasing worldwide; therefore, to deal with this situation, many studies on bladder cancer have been carried out extensively. Among these studies, the risk factors studies may provide a possible way to reduce the incidence of bladder cancer. Meta-analyses and original researches have confirmed that smoking is a risk factor of bladder cancer. However, the specific dose-response relationship between smoking and bladder cancer risk was still unclear. This meta-analysis addresses this research gap by summarizing the accumulated evidences, quantitatively.

METHODS

Relevant studies were obtained by searching PubMed, Embase and Web of Science database since inception until August 10, 2021, without restrictions. To obtain more comprehensive data, reference lists of identified articles were also browsed. Studies that reported risk estimates (relative risks (RR) or odds ratio (OR)) with 95% confidence intervals (CIs) focusing on the association between cigarette smoking and risk of bladder cancer were included in a dose-response meta-analysis.

RESULTS

A non-linear dose-response relationship was confirmed between cigarette smoking and risk of bladder cancer on the basis of 8 cohorts and 44 case-control studies. The summary relative risk of developing bladder cancer for 1 more cigarettes/day (7 cohorts and 24 case-control studies) was 1.039 (95% CI 1.038-1.040, I² = 0%), for 1 more pack-year (3 cohorts and 21 case-control studies) was 1.017(95% CI 1.016-1.019, I² = 0%) and for 1 more year of exposure (16 case-control studies) was 1.021 (95% CI 1.020-1.023, I² = 0%).

CONCLUSION

A positive non-linear dose-response relationship is confirmed between all smoking intensity, pack-years of smoking, smoking duration(years) and the risk of bladder cancer, but the plateau only occurred when smoking intensity reached 20 cigarettes/day. Further studies should report more detailed results, including those for subtypes of gender, age, region and be stratified by other risk factors to rule out residual confounding.

Waterpipe Smoking among Bladder Cancer Patients: A Cross-Sectional Study of Lebanese and Jordanian Populations

Background

Bladder cancer (BC) is the second most reported cancer in Lebanon and the fifth in Jordan. Its risk factors are mainly smoking and occupational exposure to aromatic amines. In these countries where smoking and bladder cancer are highly prevalent, the role of waterpipe smoking (WPS) in bladder cancer is less investigated. We aim to compare two sets of patients between Lebanon and Jordan, focusing on their smoking habits, WP use, occupational exposure, and the grade/invasiveness of their bladder cancer.

Methods

This is a cross-sectional study that compares the smoking culture between two sets of populations with bladder cancer, from two different countries. We recruited 274 bladder cancer patients over the 18 years of age at the American University of Beirut Medical Center (AUBMC), and 158 bladder cancer patients over the age of 18 years at the King Hussein Cancer Center (KHCC).

Results

7.7% of Lebanese patients had significantly more positive family history of bladder cancer compared to 13.9% of Jordanian patients (p = 0.045). Another significant finding is that the majority of Lebanese patients 70.7% reported being frequently exposed to secondhand smoking, mainly cigarettes, versus only 48.6% of Jordanian patients (p < 0.001). The increasing smoking trend among Lebanese females is remarkably the highest in the region, which contributed to the overall increase in smoking rates in the country. 17.1% of the Lebanese smoking patients are mainly but not exclusively WP smokers of which 6.3% are daily WP smokers, similarly 17.1% of the Jordanian patients of which 3.2% are daily WP smokers. There were 71.5% of Lebanese patients who had a noninvasive BC versus 40% of Jordanian patients (p < 0.001), and more than one-third reported an occupational exposure to one of the risk factors of BC in both groups.

Conclusions

Bladder cancer incidence is on the rise in both Jordan and Lebanon along with different smoking types. It is necessary to impose prevention policies to prevent and control the high smoking prevalence. Bladder cancer invasiveness is higher in Jordan compared to universal data.

Stratification of urinary bladder carcinoma based on immunohistochemical expression of CK5, CK14 and CK20

Molecular subtyping of urothelial carcinoma (UC) is similar to that of breast cancer and is based on the developmental biology approach. The aim of the present study is to assess the prognostic impact of CK5, CK14, and CK20 expression in urinary bladder cancer (UBC) with the potential to stratify them into different subtypes. The current study examined the immunohistochemical expression of CK5, CK14, and CK20 in 90 specimens of UBC. CK5 was expressed in 81.1% of the cases and was significantly associated with old age, muscle invasion, presence of bilharziasis, and tendency for poor overall survival. CK20 was expressed in 47.8% of the cases and was associated with nonmuscle invasion and pure UC while 50% of the cases expressed CK14 that were associated with muscle invasion and perineural invasion. Most squamous cell carcinoma and those associated with bilharziasis were belonged to Ck5+/CK20- subgroup while pure UC and those lacked bilharziasis were located in the Ck5+/CK20+ subgroup. The basal group (Ck5+/CK14+/CK20-) showed high proliferative features compared to the intermediate group (Ck5+/CK14-/CK20-). Generally, presence of CK5 is associated with adverse features especially in the group lacking CK20; however, basal and intermediate subgroups share CK5 expression but they show different proliferative capacities, so their distinction by CK14 is helpful.

Urinary hyaluronic acid: a versatile marker of bladder cancer

PURPOSE

To evaluate the role of urinary hyaluronic acid (HA) as a diagnostic marker in urothelial carcinoma (UCC), squamous cell carcinoma (SCC), and adenocarcinoma (ADC) of urinary bladder and compare it with urine cytology.

METHODS

HA was estimated in 170 subjects divided into three groups. Group I: UCC 88 patients, 28 with SCC and 12 with ADC; group II: 34 patients with benign bladder tumors; and group III: 10 healthy bladders. HA was estimated in urine and then readjusted to creatinine (HA/Cr) and protein (HA/Pr) in urine. Urine cytology was evaluated.

RESULTS

The mean ± SD level HA was higher in UCC (589 ± 72), SCC (637 ± 45), and ADC (526 ± 30) as compared with benign (476 ± 92) and normal (277 ± 44) groups regardless the grade of tumor (p < 0.0001). A cutoff value of 490 ng/ml was calculated to detect malignancy with sensitivity of 98% and specificity of 66%. PPV, NPV, and ACC were 88.6%, 94.1%, and 90%, respectively. Urine cytology showed sensitivity of, specificity, PPV, NPV, and ACC of 52.6%, 90%, 90.45, 50%, and 65.5%, respectively. HA/Pr and HA/Cr, cutoff values for detection of malignancy were 84.9 and 9.6 but with less predictive values. Histopathological type was the only independent factor affecting level of HA on multivariate analysis, (p = 0.012, Exp (B) 14.98, 95% CI 1.8-121).

CONCLUSION

Combination of urinary HA and urine cytology provides reliable marker of bladder cancer.

Schistosomiasis and Bladder Cancer in Egypt: Truths and Myths

BACKGROUND

The gathered archeopathological evidence has confirmed that Schistosomiasis has been endemic in Ancient Egypt for over 500 decades. The association between Schistosoma hematobium and increase bladder cancer risk is also well acknowledged. However, over the years, there is a proved changing pattern of bladder cancer that needs to be investigated.

AIM

We aim to discuss the truths and myths about bladder cancer and its association with Schistosomiasis in Egypt.

METHODS

A cross-sectional, case-control study was performed to collect recent data on the topic.

RESULTS

Of the reported cancer cases, 79.3% were transitional cell carcinoma (TCC), an additional 6% showed associated squamous features. Squamous cell carcinoma (SCC) constituted only 13.8% of cancer cases. Schistosomiasis was histologically confirmed in 19 cancer cases, only one was SCC. The relative frequency of TCC is increasing, while SCC is decreasing. There is no evidence that this pattern is related to smoking or environmental factors, as the incidence of lung cancer, is not proportionately increasing.

CONCLUSION

The old concept that Schistosomiasis is associated with SCC should be revaluated as most cases are associated with TCC. Relying on the histopathology for confirmation of Schistosomiasis in our research studies appears to be non-accurate and leads to irrelevant results.

Body mass index modifies bladder cancer risk associated with low estrogen exposure among Egyptian women after menopause

PURPOSE

Investigators have reported inconsistent findings regarding associations between body mass index (BMI) and bladder cancer risk, and they have postulated that sex steroids mediate such associations. We assessed the impact of BMI on the relationship between bladder cancer risk and combinations of age at first childbirth, parity, and age at menopause, among Egyptian women.

METHODS

We used data from our multicenter case-control study of 419 cases and 786 controls in logistic regression models to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) of such associations.

RESULTS

Age > 18 years at first childbirth and parity ≤ 6 were significantly associated with bladder cancer risk, which was higher when both factors (AOR = 2.31, 95% CI = 1.55-3.43) and age at menopause < 45 years (AOR = 3.51, 95% CI = 1.88-6.55) were present. Early menopause was associated with higher bladder cancer risk in obese (AOR = 2.90, 95% CI = 1.40-5.98) but not normal weight women (AOR = 0.98, 95% CI = 0.58-1.65; P_interaction = 0.11), and the risk was greatest when both first childbirth at age > 18 years and parity ≤ 6 were present (AOR = 7.60, 95% CI = 1.84-31.35); however, overweight and obesity were associated with significantly lower bladder cancer risk (AOR = 0.59, 95% CI = 0.43-0.81, and AOR = 0.26, 95% CI = 0.18-0.38, respectively).

CONCLUSION

Body mass index appears to modify bladder cancer risk in Egyptian women after menopause by slightly enhancing the risk associated with low estrogen exposure among the obese only. Longitudinal studies of the BMI role in bladder malignancy in this distinctive population are required.

Bladder Cancer in Lebanon: Incidence and Comparison to Regional and Western Countries

Lebanon has one of the highest estimated age-standardized incidence rate (ASR(w)) of bladder cancer (BC) worldwide. The aim of this study is to analyze the incidence rates for BC in Lebanon over a period of 7 years and to compare them to the rates in other countries. Data were obtained from the Lebanese National Cancer Registry for the currently available years 2005 to 2011. The calculated ASR(w) and age-specific rates were expressed as per 100 000 population. From 2005 to 2011, BC has been ranked as the third most common cancer in Lebanon. It accounted for 9.0% of all newly diagnosed cancer cases excluding nonmelanoma skin cancer. It ranked second in males and ninth in females. The average ASR(w) over this period was 31.2 in men and 7.3 in women. These incidence rates are among the highest worldwide across all age groups in both sexes. This study shows that the incidence of BC in Lebanon is high and it is among the highest worldwide. It is important to reduce the risk of BC through tobacco control and by decreasing exposure to avoidable environmental and occupational risk factors.

Secondhand smoking increases bladder cancer risk in nonsmoking population: a meta-analysis

Background

Tobacco smoking has been widely acknowledged to be the most important risk factor for bladder cancer. However, whether secondhand smoking (SHS) increases the risk of bladder cancer still remains uncertain. We conducted a meta-analysis about the risk of bladder cancer and lifetime SHS and childhood SHS.

Materials and methods

We searched PubMed, EMBASE, Web of Science, and Chinese National Knowledge Infrastructure (CNKI) up to March 12, 2018, and checked references of the retrieved articles and relevant reviews to include 14 studies. Relative risk (RR) and 95% confidence interval (CI) were used to assess this risk.

Results

The pooled RR of 14 eligible studies based on the retrieved articles and relevant reviews illustrated a significantly increased risk of bladder cancer with RR 1.22, 95% CI 1.06–1.4. No heterogeneity or publication bias was found. But we need more evidence to prove a more reliable association between childhood SHS and bladder cancer.

Conclusion

There was a statistically significant 22% increased risk of bladder cancer for lifetime SHS exposure in nonsmoking patients compared with unexposed nonsmoking population. But the association between childhood SHS exposure compared with unexposed nonsmoking population was unclear. Further research should be conducted to confirm our findings and reveal the potential biological mechanisms.

Understanding Urogenital Schistosomiasis-Related Bladder Cancer: An Update

Infection with Schistosoma haematobium leads to urogenital schistosomiasis, which has been correlated with the occurrence of bladder cancer. However, mechanisms responsible for this association have not yet been clearly identified. In this short review, we provide an update, highlighting the most recent studies on schistosome-associated bladder cancer, including those that focus on identifying changes in host biology during S. haematobium infection, as well as studies for the identification of potentially pro-carcinogenic parasite molecules, and we offer a discussion on some possible mechanisms driving schistosomal bladder cancer.

Prevention of bladder cancer incidence and recurrence: tobacco use

PURPOSE OF REVIEW

To summarize the current knowledge about smoking carcinogenesis in bladder cancer (BCa), individual susceptibility and impact of smoking on incidence and outcomes of nonmuscle invasive BCa (NMIBC) and muscle-invasive BCa (MIBC). To assess the impact of smoking cessation on oncological outcomes.

RECENT FINDINGS

Smoking pattern, intensity, and duration are responsible for an increased risk of developing BCa and for worse tumor features at presentation. Tobacco consumption is associated with a higher risk of recurrence in NMIBC and with an impaired intravesical therapy efficacy. To date, the impact of smoking on oncological outcomes after radical surgery remains unclear.

SUMMARY

Smoking cessation decreases the risk of BCa and may also allow benefits on treatment outcomes. Nonetheless, the magnitude of the effect remains unclear and prospective series with the specific aim of weighing smoking cessation on outcomes are needed. Because even a 5-min counseling in the urology setting may be sufficient to significantly enhance smoking cessation rates, adequate knowledge of links between tobacco and BCa, from its molecular pathophysiology and its harms to benefits of cessation is paramount for urologists and for everyday clinical practice.

Screening for human urinary bladder carcinogens: two-year bioassay is unnecessary

Screening for carcinogens in general, and for the urinary bladder specifically, traditionally involves a two-year bioassay in rodents, the results of which often do not have direct relevance to humans with respect to mode of action (MOA) and/or dose response. My proposal describes a multi-step short-term (90 day) screening process that characterizes known human urinary bladder carcinogens, and identifies those reported in rodent two-year bioassays. The initial step is screening for urothelial proliferation, by microscopy or by increased Ki-67 labeling index. If these are negative, the agent is not a urinary bladder carcinogen. If either of these is positive, an MOA and dose response analysis are performed. DNA reactivity is evaluated. If the chemical is non-DNA reactive, evaluation for cytotoxicity is performed. This involves examination of the urothelium and urine, the latter to identify the generation of urinary solids (e.g. calculi). If urinary solids are the cause of cytotoxicity, the MOA is not relevant to human cancer, but dose response becomes essential for evaluating potential toxicity to humans. If cytotoxicity occurs but no urinary solids are detected, urinary concentrations of the chemical and its metabolites are evaluated, and compared to in vitro cytotoxicity against rodent and human immortalized urothelial cell lines. Based on this process, a screen for urinary bladder carcinogenicity is reliable, and more importantly, can be based on MOA and dose response analyses useful in the overall risk assessment for possible human bladder cancer. The proposed procedure is shorter, less expensive and more relevant than the two-year bioassay.

The effects of waterpipe tobacco smoking on health outcomes: an updated systematic review and meta-analysis

Background and aims

A systematic review conducted in 2008 found significant associations between waterpipe tobacco smoking and lung cancer, respiratory disease, periodontal disease and low birthweight. Since then, a number of relevant studies have been published. The objective of this study was to update the systematic review on the effects of waterpipe tobacco smoking on health outcomes.

Methods

In May 2015 we electronically searched the following databases with no date restrictions: MEDLINE, EMBASE and the ISI Web of Science using a detailed search strategy with no language restrictions. We also screened the references' lists of the included studies. We included cohort, case-control and cross-sectional studies, and excluded case reports, conference abstracts, editorials and reviews. We excluded studies not conducted in humans, assessing physiological outcomes, not distinguishing waterpipe tobacco smoking from other forms of smoking or not reporting association measures. We assessed risk of bias for each included study and conducted meta-analyses for each of the outcomes of interest.

Results

We identified 50 eligible studies. We found that waterpipe tobacco smoking was significantly associated with: respiratory diseases [COPD; odds ratio (OR) = 3.18, 95% confidence interval CI = 1.25, 8.08; bronchitis OR = 2.37, 95% CI = 1.49, 3.77; passive waterpipe smoking and wheeze OR) = 1.97, 95% CI = 1.28, 3.04]; oral cancer OR = 4.17, 95% CI = 2.53, 6.89; lung cancer OR = 2.12, 95% CI = 1.32, 3.42; low birthweight (OR = 2.39, 95% CI = 1.32, 4.32); metabolic syndrome (OR 1.63-1.95, 95% CI = 1.25, 2.45); cardiovascular disease (OR = 1.67, 95% CI = 1.25, 2.24); and mental health (OR 1.30-2.4, 95% CI = 1.20, 2.80). Waterpipe tobacco smoking was not significantly associated with: oesophageal cancer (OR = 4.14, 95% CI = 0.93, 18.46); worse quality of life scores [standardized mean difference (SMD) = -0.16, 95% CI = -0.66, 0.34]; gastric carcinoma (OR = 2.16, 95% CI = 0.72, 6.47); bladder cancer (OR = 1.25, 95% CI = 0.99, 1.57); prostate cancer (OR = 7.00, 95% CI = 0.90, 56.90); hepatitis C infection (OR = 0.98, 95%0.80, 1.21); periodontal disease (OR = 3.00, 5.00); gastro-oesophageal reflux disease (OR = 1.25, 95% CI = 1.01, 1.56); nasopharyngeal carcinoma (OR = 0.49, 95% CI = 0.20, 1.23); bladder cancer (OR = 1.25, 95% CI = 0.99, 1.57); infertility (OR = 2.50, 95% CI = 1.00, 6.30); and mortality (OR = 1.15, 95% CI = 0.93, 1.43).

Conclusions

There is accumulating evidence about the association of waterpipe tobacco smoking with a growing number of health outcomes.

A Stratified Meta-Analysis of the Association between Exposure to Environmental Tobacco Smoke during Childhood and Adulthood and Urothelial Bladder Cancer Risk

Background: Active smoking is a major risk factor for urothelial bladder cancer (UBC). However, the evidence that exposure to environmental tobacco smoke (ETS) either in childhood or adult life is also associated with UBC risk is ambiguous. With this meta-analysis, we aim to summarise how exposure to ETS is associated with UBC risk. Methods: In total, 11 studies (3 cohort studies, 8 case-control studies) were included in this meta-analysis and summary odds ratios (SORs) for UBC risk were calculated for never smokers who were exposed to ETS during childhood at home, during adulthood at home, or during adulthood in a work environment compared to never smokers who were never exposed to ETS. Sensitivity analyses were conducted to test the robustness of findings. Results: Never smokers exposed to ETS during childhood (SOR = 1.04, 95% confidence interval (CI) = 0.82-1.26), during adulthood at work (SOR = 0.98, 95% CI = 0.78-1.18) or at home (SOR = 0.99, 95% CI = 0.83-1.15) were at a similar risk of UBC compared to never smokers who were never exposed to ETS. Results for males and females were similar. Also, when pooling all estimates during both childhood and adulthood, no effect was observed (SOR = 1.00, 95% CI = 0.89-1.10). Conclusions: Although measurement of exposure to ETS was imprecise, there does not seem to be an association between UBC risk and exposure to ETS during childhood or adulthood. However, the current body of evidence mostly overlooks the duration and intensity of exposure to ETS.

Urinary Bladder Cancer in Egypt: Are There Gender Differences in Its Histopathological Presentation?

We investigated gender differences in the histopathologic presentation of bladder cancer cases in Egypt, where both urothelial cell carcinoma (UC) and squamous cell carcinoma (SCC) types are highly prevalent. We used logistic regression to estimate the unadjusted (OR) and adjusted odds ratio (AOR) and 95% confidence interval (CI) of the associations between gender and different histopathologic and sociodemographic parameters of 2,186 confirmed cases of primary bladder cancer (1,775 males and 411 females; 784 SCC and 1,402 UC). There were no statistically significant gender differences in tumor grade, stage, mucosal ulcer, or inflammatory cystitis, regardless of the cancer type, but men were less likely than women to have undergone cystectomy with pelvic lymphadenectomy. Having Schistosoma haematobium (SH) ova in the bladder tissue was significantly associated with male gender in the fully adjusted model of either SCC (AOR (95% CI) = 2.12 (1.15-3.89)) or UC cases (3.78 (1.89-7.55)). Compared to females, male cases were significantly older at time of diagnosis and smokers. In Egypt, regardless of the type of bladder cancer (SCC or UC), male more than female cases had evidence of SH infection, but not other histopathologic differences, in bladder tissue specimens.

NAT1 genotypic and phenotypic contribution to urinary bladder cancer risk: a systematic review and meta-analysis

N-acetyltransferase 1 (NAT1), a polymorphic Phase II enzyme, plays an essential role in metabolizing heterocyclic and aromatic amines, which are implicated in urinary bladder cancer (BCa). This systematic review investigates a possible association between the different NAT1 genetic polymorphisms and BCa risk. Medline, PubMed, EMBASE, Scopus, Web of Science, OpenGrey, and BASE databases were searched to identify eligible studies. The random-effect model was used to calculate pooled effects estimates. Statistical heterogeneity was tested with Chi-square and I². Twenty case-control studies, including 5606 cases and 6620 controls, met the inclusion criteria. Pooled odds ratios (OR) analyses showed a statistically significant difference in NAT1*10 versus non-NAT1*10 acetylators in the total sample (OR: 0.87; 95% CI: 0.79-0.96) but was borderline among Caucasians (OR: 0.88 with 95% CI: 0.77-1.01). No statistically significant differences in BCa risk were found for: NAT1*10 versus NAT1*4 wild type (OR: 0.97; 95% CI: 0.78-1.19), NAT1 'Fast' versus 'Normal' acetylators (OR: 1.03; 95% CI: 0.84-1.27), and NAT1 'Slow' versus 'Fast' (OR: 2.32; 95% CI: 0.93-5.84) or 'Slow' versus 'Normal' acetylators (OR: 1.84; 95% CI: 0.92-3.68). When stratifying by smoking status, no statistically significant differences in BCa risk were found for NAT1*10 versus non-NAT1*10 acetylators among the different subgroups. Our study suggests a modest protective role for NAT1*10 and a possible risk contributory role for slow acetylation genotypes in BCa risk. Further research is recommended to confirm these associations.

Strong associations between chromosomal aberrations in blood lymphocytes and the risk of urothelial and squamous cell carcinoma of the bladder

Chromosomal aberrations (CAs) in blood lymphocytes have been shown to be associated with overall cancer risk and aging. However, their relationship to bladder cancer risk remains to be elucidated. In a case-control study of bladder cancer in Egypt, we examined the relationship between the increased frequency of CAs in blood lymphocytes and bladder cancer risk. High frequency of CAs was significantly associated with an increased risk of bladder cancer [adjusted odds ratios (OR) = 3.90, 95% confidence interval (CI) = 2.65-5.73]. The associations were somewhat stronger in squamous cell carcinomas (SCC, OR = 4.90) than in urothelial carcinomas (UC, OR = 3.62). We also identified chromosome specific CAs for chromosomes 3, 4, 5, 8, 9, 10, 11, 12, 17, 19 that were significantly associated with an increased risk of bladder cancer. We observed particularly strong associations between aberrations of chromosomes 12, 13, 17 and risk of SCC (OR = 7.06, 6.91 and 6.23, respectively).

CONCLUSION

increased frequency of chromosomal aberrations in blood lymphocytes was significantly associated with bladder cancer risk. Overall and chromosome specific aberrations in blood lymphocytes may be a unique set of biomarkers for risk assessments of SCC and UC.

Molecular factors regulating E-cadherin expression in urothelial bladder cancer and their correlations with the clinicopathological features

This study aimed to assess the expression of S100A4, Twist and E-cadherin (mRNA and protein) in urothelial bladder cancer, investigate the correlation between them and evaluate their association with the clinicopathological features of the disease. The study included 54 patients diagnosed as urothelial bladder cancer of different stages and grades. The expression levels of S100A4, Twist and E-cadherin (mRNA and protein) in tissue samples were determined by quantitative RT-PCR and immunohistochemistry. The expression of S100A4 and Twist was significantly upregulated while E- cadherin was significantly downregulated in urothelial bladder cancer tissues compared to the adjacent surrounding normal bladder tissues at both mRNA and protein levels (p < 0.001). Expression levels of S100A4 and Twist were significantly higher in recurrent tumor than in non-recurrent tumors (p < 0.001) while the expression level of E-cadherin was significantly lower in recurrent tumors than in non-recurrent tumors at both mRNA and protein levels (p < 0.001). There was a significant positive correlation between S100A4 and Twist expressions (r = 0.875, p < 0.001) while significant negative correlations were found between E- cadherin and S100A4 expressions(r=- 0.803, p < 0.001) and between E-cadherin and Twist (r = -0.809, p < 0.001). Up-regulation of S100A4 and Twist and down-regulation of E-cadherin in urothelial bladder cancer tissues compared to adjacent normal tissues were observed. There was a significant negative correlation between S100A4 and E- cadherin and between E- cadherin and Twist expression. However, there was a significant positive correlation between S100A4 and Twist expressions. Furthermore, the alterations in the gene expression were associated with disease stage and grade.

High Coexpression of Runt-related Transcription Factor 2 (RUNX2) and p53 Independently Predicts Early Tumor Recurrence in Bladder Urothelial Carcinoma Patients

Conventional prognostic factors for bladder cancer are inadequate to predict tumor recurrence and/or progression successfully; thus, the identification of adjunctive novel prognostic biomarkers is of paramount importance. In this study, the immunohistochemical expression patterns and clinical significance of RUNX2, WWOX, and p53 were investigated in a tissue microarray of 87 primary urothelial carcinomas and 17 control cases. We found that RUNX2, WWOX, and p53 were significantly correlated and overexpressed in urothelial carcinoma cases compared with the control group. RUNX2 and p53 were significantly upregulated in association with high-grade, nonpapillary pattern, and bilharziasis. Muscle-invasive tumors significantly overexpressed RUNX2. WWOX overexpression was significantly associated with high-grade tumors and inversely correlated with age. In a bivariate analysis, the risk of early tumor recurrence and progression was significantly associated with RUNX2 and p53 overexpression and bilharziasis. A multivariate Cox regression analysis proved that RUNX2 and p53 were independent predictors of early tumor recurrence. The ROC curve analysis showed that combined RUNX2 and p53 high expression (scores >3 and >5, respectively) had the highest accuracy (73.6%) for the prediction of early tumor recurrence. We conclude that RUNX2 and p53 might be functionally related and are likely involved in bladder tumor carcinogenesis and aggressiveness, which provides a new perspective for targeted therapy. RUNX2 and p53 independently predict early tumor recurrence in bladder carcinoma patients, with the highest prediction accuracy being achieved on their combined high expression. The role of WWOX in bladder urothelial carcinoma and its relationship with RUNX2 and p53 remains unclear and warrants further investigation.

George DM, Loffredo CA, Amr S. Nonoccupational exposure to agricultural work and risk of urinary bladder cancer among Egyptian women

This study examined the associations between nonoccupational exposure to agricultural work, through husband or head of household (H/HH) occupation, and urinary bladder cancer risk among Egyptian women. A total of 1,167 women (388 bladder cases and 779 age- and residence-matched, population-based controls) from a multicenter case-control study were included in the analysis. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were estimated using logistic regression. Among married women, those who reported H/HH to be an agricultural worker were at increased risk for bladder cancer as compared to those with H/HH in other occupations, AOR = 1.54, 95% CI [1.09, 2.18]; among unmarried women the risk was not increased, AOR = 0.77, 95% CI [0.45, 1.32]. Nonoccupational exposure to agricultural work, defined as living with an agricultural worker, increased the risk for bladder cancer among married Egyptian women.

Assessing the Effect of Waterpipe Smoking on Cancer Outcome - a Systematic Review of Current Evidence

Background: Waterpipe smoking (WPS) is widely believed to be a safe and hazard-free tobacco habit. However, a number of studies have indicated that exposure to several toxicants and carcinogens through WPS is strongly related to serious health hazards. The current paper presents a narrative review on the effects of WPS on cancer outcome. Methods: The addressed focused question was “Is there an association between waterpipe smoking and cancer outcome?” PubMed, Medline, EMBASE, ISI Web of Science and the Cochrane databases were searched until June 2015 using the key words “Waterpipe”, “Hookah”, “Narghileh”, “Shisha”, “Hubbly Bubbly” “cancer” in various combinations. Letters to the Editor, review articles, case-reports and unpublished articles were excluded. Results: A total of 16 studies were included: six on lung cancer, three on oesophageal cancer, two on gastric cancer, two on bladder cancer, and one each on nasopharyngeal, pancreatic and prostate cancers. Our search did not yield any study that evaluated the risk of oral cancer in WPS users. The available evidence showed a significant association of WPS with lung cancer (UOR 6.0, 95% CI 1.78–20.26); however, no association was observed with bladder, nasopharyngeal, pancreatic and prostate cancers. Gastric (OR 3.4, 95% CI 1.7-7.1) and oesophageal cancers (OR 1.85, 95% CI 1.41-2.44) were observed to have weak associations with WPS. Conclusion: Regardless of the limitations, there is sufficient evidence to suggest associations of WPS with cancer, particularly in the lung. Future well-designed studies are required to identify and quantify with confidence all the health effects of this form of smoking.

International pooled study on diet and bladder cancer: the bladder cancer, epidemiology and nutritional determinants (BLEND) study: design and baseline characteristics

Background

In 2012, more than 400,000 urinary bladder cancer cases occurred worldwide, making it the 7^th most common type of cancer. Although many previous studies focused on the relationship between diet and bladder cancer, the evidence related to specific food items or nutrients that could be involved in the development of bladder cancer remains inconclusive. Dietary components can either be, or be activated into, potential carcinogens through metabolism, or act to prevent carcinogen damage.

Methods/design

The BLadder cancer, Epidemiology and Nutritional Determinants (BLEND) study was set up with the purpose of collecting individual patient data from observational studies on diet and bladder cancer. In total, data from 11,261 bladder cancer cases and 675,532 non-cases from 18 case–control and 6 cohort studies from all over the world were included with the aim to investigate the association between individual food items, nutrients and dietary patterns and risk of developing bladder cancer.

Discussion

The substantial number of cases included in this study will enable us to provide evidence with large statistical power, for dietary recommendations on the prevention of bladder cancer.

Epidemiological evidence on environmental tobacco smoke and cancers other than lung or breast

We reviewed 87 epidemiological studies relating environmental tobacco smoke (ETS) exposure to risk of cancer other than lung or breast in never smoking adults. This updates a 2002 review which also considered breast cancer. Meta-analysis showed no significant relationship with ETS for nasopharynx cancer, head and neck cancer, various digestive cancers (stomach, rectum, colorectal, liver, pancreas), or cancers of endometrium, ovary, bladder and brain. For some cancers (including oesophagus, colon, gall bladder and lymphoma) more limited data did not suggest a relationship. An increased cervix cancer risk (RR 1.58, 95%CI 1.29-1.93, n = 17 independent estimates), reducing to 1.29 (95%CI 1.01-1.65) after restriction to five estimates adjusting for HPV infection or sexual activity suggests a causal relationship, as do associations with nasosinus cancer observed in 2002 (no new studies since), and less so kidney cancer (RR 1.33, 95%CI 1.04-1.70, n = 6). A weaker association with total cancer (RR 1.13, 95%CI 1.03-1.35, n = 19) based on heterogeneous data is inconclusive. Inadequate confounder control, recall bias, publication bias, and occasional reports of implausibly large RRs in individual studies contribute to our conclusion that the epidemiological evidence does not convincingly demonstrate that ETS exposure causes any of the cancers studied.

Strong association between long and heterogeneous telomere length in blood lymphocytes and bladder cancer risk in Egyptian

Although it is widely recognized that telomere dysfunction plays an important role in cancer, the relationship between telomere function and bladder cancer risk is not well defined. In a case-control study of bladder cancer in Egypt, we examined relationships between two telomere features and bladder cancer risk. Telomere fluorescent in situ hybridization was used to measure telomere features using short-term cultured blood lymphocytes. Logistic regression was used to estimate the strength of association between telomere features and the risk of urothelial carcinoma of the bladder. High telomere length variation (TLV) across all chromosomal ends was significantly associated with an increased risk of bladder cancer [adjusted odds ratios (OR) = 2.22, 95% confidence interval (CI) = 1.48-3.35], as was long average telomere length (OR = 3.19, 95% CI = 2.07, 4.91). Further, TLV and average telomere length jointly affected bladder cancer risk: when comparing individuals with long telomere length and high TLV to those with short telomere length and low TLV, the adjusted OR was 14.68 (95% CI: 6.74-31.98). These associations were stronger among individuals who are 60 years of age or younger. In summary, long and heterogeneous telomere length in blood lymphocytes was strongly associated with an increased bladder cancer risk in Egyptian and the association was modulated by age.

The Role of Tobacco Smoke in Bladder and Kidney Carcinogenesis: A Comparison of Exposures and Meta-analysis of Incidence and Mortality Risks

CONTEXT

Tobacco smoke includes a mix of carcinogens implicated in the etiology of bladder cancer (BC) and renal cell cancer (RCC).

OBJECTIVE

We reviewed the impact of tobacco exposure on BCC and RCC incidence and mortality, and whether smoking cessation decreases the risk.

EVIDENCE ACQUISITION

A systematic review of original articles in English was performed in August 2013. Meta-analysis of risks was performed using adjusted risk ratios where available. Publication bias was assessed using Begg and Egger tests.

EVIDENCE SYNTHESIS

We identified 2683 papers, of which 107 fulfilled our inclusion criteria, of which 83 studies investigated BC and 24 investigated RCC. The pooled relative risk (RR) of BC incidence was 2.58 (95% confidence interval [CI] 2.37-2.80) for all smokers, 3.47 (3.07-3.91) for current smokers, and 2.04 (1.85-2.25) for former smokers. The corresponding pooled RR of BC disease-specific mortality (DSM) was 1.47 (1.24-1.75), 1.53 (1.12-2.09) and 1.44 (0.99-2.11). The pooled RR of RCC incidence was 1.31 (1.22-1.40) for all smokers, 1.36 (1.19-1.56) for current smokers, and 1.16 (1.08-1.25) for former smokers. The corresponding RCC DSM risk was 1.23 (1.08-1.40), 1.37 (1.19-1.59), and 1.02 (0.90-1.15).

CONCLUSIONS

We present an up-to-date review of tobacco smoking and BC and RCC incidence and mortality. Tobacco smoking significantly increases the risk of BC and RCC incidence. BC incidence and DSM risk are greatest in current smokers and lowest in former smokers, indicating that smoking cessation confers benefit. We found that secondhand smoke exposure is associated with a significant increase in BC risk.

PATIENT SUMMARY

Tobacco smoking affects the development and progression of bladder cancer and renal cell cancer. Smoking cessation reduces the risks of developing and dying from these common cancers. We quantify these risks using the most up-to-date results published in the literature.

HISTOPATHOLOGIC PATTERN OF BLADDER CANCERS IN IBADAN SOUTHWEST NIGERIA: AN UPDATE

BACKGROUND

A study from the University College Hospital, Ibadan, Southwest, Nigeria on bladder cancers had described an increase in the frequency of urothelial carcinoma compared to the earlier reported preponderance of squamous-cell carcinoma.

AIM

To provide an update on the histopathologic pattern of bladder cancers in our community and to explore its implications for future health system policies.

METHODS

The records of the Ibadan Cancer Registry from January 1997 to December 2014 were reviewed and the data analyzed for the histologic subtypes of bladder cancers diagnosed in the hospital.

RESULTS

Two hundred and sixteen bladder tumours were recorded during this period with a male to female ratio of 3.2:1. Complete information was available in 195 cases of which 181 (96.8%) were bladder carcinomas whilst 14 were sarcomas. Of the bladder carcinomas, 68.5%, 19.9% and 11.6% were urothelial carcinomas, squamous cell carcinomas, and adenocarcinomas (AC) respectively. Urothelial carcinoma was more common in all age groups and its peak age of occurrence was in the 51-60 year age group. The peak age for squamous cell carcinoma was in the 41-50 year age group. Mean and median age of occurrence was significantly lower in females in the urothelial and squamous cell carcinomas, but lowest in squamous cell carcinoma [P = < 0.0001].

CONCLUSION

This population study has confirmed urothelial carcinoma as the predominant histotype of bladder cancer in Ibadan, Southwest Nigeria currently and that both urothelial and squamous cell carcinomas occur earlier in women.

Health effects associated with waterpipe smoking

OBJECTIVE

It is widely held that waterpipe smoking (WPS) is not associated with health hazards. However, several studies have documented the uptake of several toxicants and carcinogens during WPS that is strongly associated with harmful health effects. This paper reviews the literature on the health effects of WPS.

DATA SOURCES

Three databases-PubMed, MEDLINE and EMBASE-were searched until August 2014 for the acute and long-term health effects of WPS using the terms 'waterpipe' and its synonyms (hookah, shisha, goza, narghileh, arghileh and hubble-bubble) in various spellings.

STUDY SELECTION

We included original clinical studies, case reports and systematic reviews and focused on clinical human studies. ∼10% of the identified studies met the selection criteria.

DATA EXTRACTION

Data were abstracted by all three authors and summarised into tables. Abstracted data included study type, results and methodological limitations and were analysed jointly by all three authors.

DATA SYNTHESIS

WPS acutely leads to increased heart rate, blood pressure, impaired pulmonary function and carbon monoxide intoxication. Chronic bronchitis, emphysema and coronary artery disease are serious complications of long-term use. Lung, gastric and oesophageal cancer are associated with WPS as well as periodontal disease, obstetrical complications, osteoporosis and mental health problems.

CONCLUSIONS

Contrary to the widely held misconception, WPS is associated with a variety of adverse short-term and long-term health effects that should reinforce the need for stronger regulation. In addition, this review highlights the limitations of the published work, which is mostly cross-sectional or retrospective. Prospective studies should be undertaken to assess the full spectrum of health effects of WPS, particularly in view of its growing popularity and attractiveness to youth.

Pesticides, gene polymorphisms, and bladder cancer among Egyptian agricultural workers

This study examined the associations between pesticide exposure, genetic polymorphisms for

NAD(P)H

quinone oxidoreductase I (NQO1) and superoxide dismutase 2 (SOD2), and urinary bladder cancer risk among male agricultural workers in Egypt. Logistic regression was used to analyze data from a multicenter case-control study and estimate adjusted odds ratio (OR) and 95% confidence interval (CI). Exposure to pesticides was associated with increased bladder cancer risk (odds ratio (95% confidence interval): 1.68 (1.23-2.29)) in a dose-dependent manner. The association was slightly stronger for urothelial (1.79 (1.25-2.56)) than for squamous cell (1.55 (1.03-2.31)), and among participants with combined genotypes for low NQO1 and high SOD2 (2.14 (1.19-3.85)) activities as compared with those with high NQO1 and low SOD2 genotypes (1.53 (0.73-3.25)). In conclusion, among male agricultural workers in Egypt, pesticide exposure is associated with bladder cancer risk and possibly modulated by genetic polymorphism.

P53 and cancer-associated sialylated glycans are surrogate markers of cancerization of the bladder associated with Schistosoma haematobium infection

BACKGROUND

Bladder cancer is a significant health problem in rural areas of Africa and the Middle East where Schistosoma haematobium is prevalent, supporting an association between malignant transformation and infection by this blood fluke. Nevertheless, the molecular mechanisms linking these events are poorly understood. Bladder cancers in infected populations are generally diagnosed at a late stage since there is a lack of non-invasive diagnostic tools, hence enforcing the need for early carcinogenesis markers.

METHODOLOGY/PRINCIPAL FINDINGS

Forty-three formalin-fixed paraffin-embedded bladder biopsies of S. haematobium-infected patients, consisting of bladder tumours, tumour adjacent mucosa and pre-malignant/malignant urothelial lesions, were screened for bladder cancer biomarkers. These included the oncoprotein p53, the tumour proliferation rate (Ki-67>17%), cell-surface cancer-associated glycan sialyl-Tn (sTn) and sialyl-Lewisa/x (sLea/sLex), involved in immune escape and metastasis. Bladder tumours of non-S. haematobium etiology and normal urothelium were used as controls. S. haematobium-associated benign/pre-malignant lesions present alterations in p53 and sLex that were also found in bladder tumors. Similar results were observed in non-S. haematobium associated tumours, irrespectively of their histological nature, denoting some common molecular pathways. In addition, most benign/pre-malignant lesions also expressed sLea. However, proliferative phenotypes were more prevalent in lesions adjacent to bladder tumors while sLea was characteristic of sole benign/pre-malignant lesions, suggesting it may be a biomarker of early carcionogenesis associated with the parasite. A correlation was observed between the frequency of the biomarkers in the tumor and adjacent mucosa, with the exception of Ki-67. Most S. haematobium eggs embedded in the urothelium were also positive for sLea and sLex. Reinforcing the pathologic nature of the studied biomarkers, none was observed in the healthy urothelium.

CONCLUSION/SIGNIFICANCE

This preliminary study suggests that p53 and sialylated glycans are surrogate biomarkers of bladder cancerization associated with S. haematobium, highlighting a missing link between infection and cancer development. Eggs of S. haematobium express sLea and sLex antigens in mimicry of human leukocytes glycosylation, which may play a role in the colonization and disease dissemination. These observations may help the early identification of infected patients at a higher risk of developing bladder cancer and guide the future development of non-invasive diagnostic tests.

Urinary bladder cancer risk factors: a Lebanese case- control study

BACKGROUND

Bladder cancer is the second most incident malignancy among Lebanese men. The purpose of this study was to investigate potential risk factors associated with this observed high incidence.

METHODS

A case-control study (54 cases and 105 hospital-based controls) was conducted in two major hospitals in Beirut. Cases were randomly selected from patients diagnosed in the period of 2002-2008. Controls were conveniently selected from the same settings. Data were collected using interview questionnaire and blood analysis. Exposure data were collected using a structured face-to-face interview questionnaire. Blood samples were collected to determine N-acetyltransferase1 (NAT1) genotype by PCR-RFLP. Analyses revolved around univariate, bivariate and multivariate logistic regression, along with checks for effect modification.

RESULTS

The odds of having bladder cancer among smokers was 1.02 times significantly higher in cases vs. controls. The odds of exposure to occupational diesel or fuel combustion fumes were 4.1 times significantly higher in cases vs controls. The odds of prostate-related morbidity were 5.6 times significantly higher in cases vs controls. Cases and controls showed different clustering patterns of NAT1 alleles. No significant differences between cases and controls were found for consumption of alcohol, coffee, tea, or artificial sweeteners.

CONCLUSIONS

This is the first case-control study investigating bladder cancer risk factors in the Lebanese context. Results confirmed established risk factors in the literature, particularly smoking and occupational exposure to diesel. The herein observed associations should be used to develop appropriate prevention policies and intervention strategies, in order to control this alarming disease in Lebanon.

Diagnostic evaluation of urinary angiogenin (ANG) and clusterin (CLU) as biomarker for bladder cancer

Bladder carcinoma is an important worldwide health problem. Both cystoscopy and urine cytology used in detecting bladder cancer suffer from drawbacks where cystoscopy is an invasive method and urine cytology shows low sensitivity in low grade tumors. This study validates easier and less time-consuming techniques to evaluate the value of combined use of angiogenin and clusterin in comparison and combination with voided urine cytology in the detection of bladder cancer patients. This study includes malignant (bladder cancer patients, n = 50), benign (n = 20) and healthy (n = 20) groups. The studied groups were subjected to cystoscopic examination, detection of bilharzial antibodies, urine cytology, and estimation of urinary angiogenin and clusterin by ELISA. The overall sensitivity and specificity were 66 and 75 % for angiogenin, 70 and 82.5 % for clusterin and 46 and 80 % for voided urine cytology. Combined sensitivity of voided urine cytology with the two studied biomarkers was 88 % which is higher than the combined sensitivity of both markers alone (82 %) and that of the cytology with each marker (76 and 80 %) for angiogenin and clusterin respectively. In conclusion, combined use of the cytology with the studied biomarkers can improve the sensitivity for detecting bladder cancer, and may be very useful in monitoring the effectiveness of antiangiogenic and apoptotic therapies in bladder cancer.

Genome-wide association study identifies multiple loci associated with bladder cancer risk

Candidate gene and genome-wide association studies (GWAS) have identified 11 independent susceptibility loci associated with bladder cancer risk. To discover additional risk variants, we conducted a new GWAS of 2422 bladder cancer cases and 5751 controls, followed by a meta-analysis with two independently published bladder cancer GWAS, resulting in a combined analysis of 6911 cases and 11 814 controls of European descent. TaqMan genotyping of 13 promising single nucleotide polymorphisms with P < 1 × 10(-5) was pursued in a follow-up set of 801 cases and 1307 controls. Two new loci achieved genome-wide statistical significance: rs10936599 on 3q26.2 (P = 4.53 × 10(-9)) and rs907611 on 11p15.5 (P = 4.11 × 10(-8)). Two notable loci were also identified that approached genome-wide statistical significance: rs6104690 on 20p12.2 (P = 7.13 × 10(-7)) and rs4510656 on 6p22.3 (P = 6.98 × 10(-7)); these require further studies for confirmation. In conclusion, our study has identified new susceptibility alleles for bladder cancer risk that require fine-mapping and laboratory investigation, which could further understanding into the biological underpinnings of bladder carcinogenesis.

Agricultural workers and urinary bladder cancer risk in Egypt

The authors examined the associations between farming and the risk for squamous cell (SCC) or urothelial cell (UC) carcinoma of the urinary bladder among Egyptians. The authors used data from a multicenter case-control study (1,525 male and 315 female cases, and 2,069 male and 547 female age- and residence-matched, population-based controls) to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs). Men in farming and who never smoked had increased risk for either SCC or UC (AOR [95% CI]: 4.65 [2.59-8.36] and 6.22 [3.82-10.15], respectively). If they ever smoked, their risks were 2.27 (1.75-2.95) and 1.93 (1.58-2.35), respectively. Women in farmer households were at increased risk for SCC (1.40 [0.93-2.09] and UC [1.25 (0.82-1.89]), although not statistically significant. Occupational and environmental exposures to farming increased the risk for bladder cancer among Egyptians.

Toxicogenetic profile and cancer risk in Lebanese

An increasing number of genetic polymorphisms in drug-metabolizing enzymes (DME) were identified among different ethnic groups. Some of these polymorphisms are associated with an increased cancer risk, while others remain equivocal. However, there is sufficient evidence that these associations become significant in populations overexposed to environmental carcinogens. Hence, genetic differences in expression activity of both Phase I and Phase II enzymes may affect cancer risk in exposed populations. In Lebanon, there has been a marked rise in reported cancer incidence since the 1990s. There are also indicators of exposure to unusually high levels of environmental pollutants and carcinogens in the country. This review considers this high cancer incidence by exploring a potential gene-environment model based on available DME polymorphism prevalence, and their impact on bladder, colorectal, prostate, breast, and lung cancer in the Lebanese population. The examined DME include glutathione S-transferases (GST), N-acetyltransferases (NAT), and cytochromes P-450 (CYP). Data suggest that these DME influence bladder cancer risk in the Lebanese population. Evidence indicates that identification of a gene-environment interaction model may help in defining future research priorities and preventive cancer control strategies in this country, particularly for breast and lung cancer.

Genetic polymorphisms in NQO1 and SOD2: interactions with smoking, schistosoma infection, and bladder cancer risk in Egypt

BACKGROUND

Bladder cancer is the most prevalent form of cancer in men among Egyptians, for whom tobacco smoke exposure and Schistosoma haematobium (SH) infection are the major risk factors. We hypothesized that functional polymorphisms in

NAD(P)H

quinone oxidoreductase 1 (NQO1) and superoxide dismutase 2 (SOD2), modulators of the effects of reactive oxidative species, can influence an individual's susceptibility to these carcinogenic exposures and hence the risk of bladder cancer.

METHODS

We assessed the effects of potential interactions between functional polymorphisms in the NQO1 and SOD2 genes and exposure to smoking and SH infection on bladder cancer risk among 902 cases and 804 population-based controls in Egypt. We used unconditional logistic regression to estimate the odds ratios (OR) and confidence intervals (CI) 95%.

RESULTS

Water pipe and cigarette smoking were more strongly associated with cancer risk among individuals with the TT genotype for SOD2 (OR [CI 95%] = 4.41 [1.86-10.42]) as compared with those with the CC genotype (OR [CI 95%] = 2.26 [0.97-6.74]). Conversely, the risk associated with SH infection was higher among the latter (OR [CI 95%] = 3.59 [2.21-5.84]) than among the former (OR [CI 95%] = 1.86 [1.33-2.60]). Polymorphisms in NQO1 genotype showed a similar pattern, but to a much lesser extent. The highest odds for having bladder cancer following SH infection were observed among individuals with the CC genotypes for both NQO1 and SOD2 (OR [CI 95%] = 4.41 [2.32-8.38]).

CONCLUSION

Our findings suggest that genetic polymorphisms in NQO1 and SOD2 play important roles in the etiology of bladder cancer by modulating the effects of known contributing factors such as smoking and SH infection.

Evaluation of urinary HURP mRNA as a marker for detection of bladder cancer: relation to bilharziasis

This study was carried out to assess the efficacy of urinary hepatoma up-regulated protein (HURP) RNA in bladder cancer diagnosis and its relation to bilharziasis. Voided urine samples and blood were collected from 344 consecutive participants: 211 patients diagnosed with bladder cancer, 71 patients with benign urological disorders and 62 healthy volunteers. Serologic assessment of schistosomiasis antibody in sera, urine cytology and estimation of HURP RNA by reverse transcription polymerase chain reaction in urothelial cells was carried out in all samples. HURP RNA expression showed a significant difference among the three investigated groups. The best cutoff point for HURP RNA was determined as 0.0132 at 78.67 % sensitivity and 94 % specificity. The sensitivity of urine cytology was improved when combined with HURP RNA in detection of early stage (77.3 %), low grade (85.3 %) and bilharzial bladder cancer (78.1 %). Detection of urinary HURP RNA is a useful non-invasive test for early detection of bladder cancer and bilharzial bladder cancer and it improves sensitivity of urine cytology up to 91 %.

CEA, SCC and NSE levels in exhaled breath condensate--possible markers for early detection of lung cancer

Lung cancer (LC) is the leading cause of cancer-related death. The sensitive and non-invasive diagnostic tools in the early stage are still poor. We present a pilot study on the early diagnosis of LC by detecting markers in exhaled breath condensate (EBC). EBC samples were collected from 105 patients with LC and 56 healthy controls. We applied chemiluminescence immunoassay to detect CEA (carcinoembryonic antigen), SCC (squamous cell carcinoma) antigen and NSE (neuron specific enolase) in EBC and serum. Concentrations of markers were compared between independent groups and subgroups. A significantly higher concentration level of each marker was found in patients with LC than healthy controls. The areas under curve of receiver operating characteristic (ROC) curves were 0.800, 0.771, 0.659, 0.679, 0.636 and 0.626 for EBC-CEA, serum-CEA, EBC-SCC, serum-SCC, EBC-NSE and serum-NSE, respectively. Markers in EBC had a higher positive rate (PR) and were more specific to histologic types than markers in serum. In addition, multivariate analysis was performed to evaluate the association of presenting markers with the stages of non-small cell lung cancer (NSCLC). EBC-CEA showed the best predictive characteristic (p < 0.006) of early-NSCLC. Our study suggested that tumor markers in EBC may have a better diagnostic performance for LC than those in serum. With further investigation on the combination of markers in EBC, detection of EBC could probably be a novel and non-invasive method to detect NSCLC earlier.

Smoking water-pipe, chewing nass and prevalence of heart disease: a cross-sectional analysis of baseline data from the Golestan Cohort Study, Iran

OBJECTIVE

Water-pipe and smokeless tobacco use have been associated with several adverse health outcomes. However, little information is available on the association between water-pipe use and heart disease (HD). Therefore, we investigated the association of smoking water-pipe and chewing nass (a mixture of tobacco, lime and ash) with prevalent HD.

DESIGN

Cross-sectional study.

SETTING

Baseline data (collected in 2004-2008) from a prospective population-based study in Golestan Province, Iran.

PARTICIPANTS

50 045 residents of Golestan (40-75 years old; 42.4% men).

MAIN OUTCOME MEASURES

ORs and 95% CIs from multivariate logistic regression models for the association of water-pipe and nass use with HD prevalence.

RESULTS

A total of 3051 (6.1%) participants reported a history of HD, and 525 (1.1%) and 3726 (7.5%) reported ever water-pipe or nass use, respectively. Heavy water-pipe smoking was significantly associated with HD prevalence (highest level of cumulative use vs never use, OR=3.75; 95% CI 1.52 to 9.22; p for trend=0.04). This association persisted when using different cut-off points, when restricting HD to those taking nitrate compound medications, and among never cigarette smokers. There was no significant association between nass use and HD prevalence (highest category of use vs never use, OR=0.91; 95% CI 0.69 to 1.20).

CONCLUSIONS

Our study suggests a significant association between HD and heavy water-pipe smoking. Although the existing evidence suggesting similar biological consequences of water-pipe and cigarette smoking make this association plausible, results of our study were based on a modest number of water-pipe users and need to be replicated in further studies.

N-Acetyltransferase 1 (NAT1) Genotype: A Risk Factor for Urinary Bladder Cancer in a Lebanese Population

In Lebanon, bladder cancer is the second most incident cancer among men. This study investigates a possible association between N-acetyltransferase 1 (NAT1) genotype, a drug-metabolizing enzyme coding gene, and bladder cancer in Lebanese men. A case-control study (54 cases and 105 hospital-based controls) was conducted in two major hospitals in Beirut. Cases were randomly selected from patients diagnosed in the period of 2002–2008. Controls were conveniently identified and selected from the same settings. Data was collected using interview questionnaire and blood analysis. NAT1 genotypes were determined by PCR-RFLP. Statistical analysis revolved around univariate, bivariate, and multivariate logistic regression models, along with checks for effect modification. Results showed NAT1^∗14A allele, smoking, occupational exposure to combustion fumes, and prostate-related symptoms, to be risk factors for bladder cancer. The odds of carrying at least one NAT1^∗14A allele are 7 times higher in cases compared to controls (OR = 7.86, 95% CI: 1.53–40.39). A gene-environment interaction was identified for NAT1^∗14A allele with occupational exposure to combustion fumes. Among carriers of NAT1^∗14A allele, the odds of bladder cancer dropped to 2.03 from 3.72. Our study suggests NAT1^∗14A allele as a possible biomarker for bladder cancer. Further research is recommended to confirm this association.