Tobacco and bladder cancer in males: increased risk for inhalers and smokers of black tobacco

Comet-FISH analysis of urothelial cells. A screening opportunity for bladder cancer?

INTRODUCTION

Bladder cancer (BCa) is the most frequent cancer of the urinary tract, with more than 500,000 reported cases and nearly 200,000 related deaths yearly. Cystoscopy is the standard examination used for the initial diagnosis and follow-up of BCa in the noninvasive stage. However, the American Cancer Society does not include BCa screening in its list of recommended cancer screenings.

AREAS COVERED

Recently, several urine-based bladder tumor markers (UBBTMs) that identify genomic, transcriptomic, epigenetic, or protein alterations have been introduced, some of which have been approved by the Food and Drug Administration (FDA) to improve its diagnosis and surveillance. Several biomarkers have been found in the tissues and blood of individuals with BCa or predisposed to develop the disease, further enriching our information.

EXPERT OPINION

From a prevention perspective, alkaline Comet-FISH could be a valuable tool with broad potential for clinical application. Furthermore, a comet assay could be more beneficial for diagnosing and monitoring bladder cancer and determining individual susceptibility. Thus, we recommend further studies to understand the potential of this combined assay in the general population as a potential screening test and in patients initiated into the diagnostic process.

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.

Pancreatic Cancer Risk in Relation to Lifetime Smoking Patterns, Tobacco Type, and Dose-Response Relationships

BACKGROUND

Despite smoking being a well-established risk factor for pancreatic cancer, there is a need to further characterize pancreatic cancer risk according to lifespan smoking patterns and other smoking features, such as tobacco type. Our aim was to deeply investigate them within a large European case-control study.

METHODS

Tobacco smoking habits and other relevant information were obtained from 2,009 cases and 1,532 controls recruited in the PanGenEU study using standardized tools. Multivariate logistic regression analysis was performed to evaluate pancreatic cancer risk by smoking characteristics and interactions with other pancreatic cancer risk factors. Fractional polynomials and restricted cubic splines were used to test for nonlinearity of the dose-response relationships and to analyze their shape.

RESULTS

Relative to never-smokers, current smokers [OR = 1.72; 95% confidence interval (95% CI), 1.39-2.12], those inhaling into the throat (OR = 1.48; 95% CI, 1.11-1.99) or chest (OR = 1.33; 95% CI, 1.12-1.58), and those using nonfiltered cigarettes (OR = 1.69; 95% CI, 1.10-2.61), were all at an increased pancreatic cancer risk. Pancreatic cancer risk was highest in current black tobacco smokers (OR = 2.09; 95% CI, 1.31-3.41), followed by blond tobacco smokers (OR = 1.43; 95% CI, 1.01-2.04). Childhood exposure to tobacco smoke relative to parental smoking was also associated with increased pancreatic cancer risk (OR = 1.24; 95% CI, 1.03-1.49). Dose-response relationships for smoking duration, intensity, cumulative dose, and smoking cessation were nonlinear and showed different shapes by tobacco type. Effect modification by family history of pancreatic cancer and diabetes was likely.

CONCLUSIONS

This study reveals differences in pancreatic cancer risk by tobacco type and other habit characteristics, as well as nonlinear risk associations.

IMPACT

This characterization of smoking-related pancreatic cancer risk profiles may help in defining pancreatic cancer high-risk populations.

Association of Cyclooxygenase-2 Immunoreactivity with Tumor Recurrence and Disease Progression in Superficial Urothelial Bladder Cancer

Aims and Background

The main characteristic of urothelial bladder cancer is a clear predisposition to recurrence and disease progression. The aim of this study was to assess the possible relationship between cyclooxygenase-2 (COX-2) immunoreactivity in superficial urothelial bladder carcinoma and tumor grade, stage, number of recurrences and clinical disease progression.

Methods

In this prospective study 70 consecutive patients who underwent transurethral resection for superficial urothelial bladder cancer were included. Tumor slides were immuno-histochemically stained for COX-2, and COX-2 immunoreactivity in tumor and inflammatory stromal cells was categorized as negative or mildly, moderately or strongly positive. Patients were followed up for 2 years, and during this period the possible association of COX-2 immunoreactivity with tumor stage and grade, number of recurrences and progression of disease was evaluated.

Results

COX-2 immunoreactivity in tumor cells was found in 57 (81.4%) patients and did not correlate with tumor grade, stage of disease, number of recurrences, and progression of disease. COX-2 immunoreactivity in inflammatory cells was found in 16 of the 57 patients with COX-2 positive tumors, and was significantly related to the number of recurrences, time to appearance of the first recurrence, and disease progression.

Conclusions

COX-2 immunoreactivity in inflammatory stromal cells adjacent to the COX-2-positive tumor might be useful in clinical practice for selection of patients with a high risk of tumor recurrence and disease progression.

Tar, nicotine and carbon monoxide yield of UK cigarettes and the risk of non-muscle-invasive and muscle-invasive bladder cancer

Cigarette smoking is a major risk factor for bladder cancer (BC); however, the impact of cigarette content remains unclear. This study aims to investigate tar, nicotine and carbon monoxide (TNCO) yields of different filtered cigarettes in relation to BC risk. From the Bladder Cancer Prognosis Programme 575 non-muscle-invasive bladder cancer (NMIBC) cases, 139 muscle-invasive bladder cancer (MIBC) cases and 130 BC-free controls with retrospective data on smoking behaviour and cigarette brand were identified. Independently measured TNCO yields of cigarettes sold in the UK were obtained through the UK Department of Health and merged with the Bladder Cancer Prognosis Programme dataset to estimate the daily intake of TNCO. BC risk increased by TNCO intake category for NMIBC cases (P <0.050 in all multivariate models), but only for the daily intake of tar for MIBC cases (P=0.046) in multivariate models. No difference in risk was observed between smokers of low-tar/low-nicotine and high-tar/high-nicotine cigarettes compared with never smokers, either for NMIBC (P=0.544) or MIBC (P=0.449). High daily intake of TNCO additionally increases the risk of both NMIBC and MIBC compared with low daily intake. However, as there is no difference in BC risk between low-tar/low-nicotine and high-tar/high-nicotine cigarette smokers, it remains unclear whether smoking behaviour or TNCO yield of cigarettes explains this association.

Targeting and Internalization of Liposomes by Bladder Tumor Cells Using a Fibronectin Attachment Protein-Derived Peptide-Lipopolymer Conjugate

A synthetic peptidolipopolymer conjugate, incorporated into liposomes to promote specific binding to the fibronectin (FBN) matrix surrounding bladder tumor cells and promote cellular internalization of FBN-integrin complexes, is reported. The peptide promotes association with MB49 mouse model bladder tumor cells in a sequence-specific and concentration-dependent manner, with the maximum cell association occurring at 2 mol % RWFV-PEG2000-DSPE. Double PEGylation of the liposome membrane (i.e., 4 mol % mPEG1000-DSPE + 2 mol % RWFV-PEG2000-DSPE) enhanced binding by >1.6-fold, by improving ligand presentation on the liposome surface. The sequence specificity of the peptide-lipopolymer construct was confirmed by comparing liposomes containing RWFV-PEG2000-DSPE with scrambled and nonpeptidic lipopolymer liposomal formulations. MB49 tumor-bearing mice showed greater mean radiance values for FAP peptide-targeted liposomes in tumor-associated regions of interest than for nontargeted and scrambled peptide liposome formulations. These findings suggest that peptide-modified liposomes may be an attractive vehicle for targeted delivery to bladder tumors in vivo.

Cancers of the bladder

Bladder cancer is the fifth most common malignancy in Europe and the fourth most common malignancy in the United States.1 It affects one in 4000 people and accounts for 5% of all diagnosed cancers. The peak incidence is in the fifth and seventh decade.

There is a strong association between smoking and bladder cancer. Smokers have a fourfold higher incidence of developing bladder cancer than the general population.2

The disease has a spectrum of clinical severity varying from superficial bladder cancer to muscle invasive or metastatic disease which carries a poor prognosis. Currently the superficial form of the disease is managed by endoscopic resection of the tumour, often followed by the instillation into the bladder of cytotoxic agents. Due to the tendency of bladder cancer to recur repeated cystoscopies and resections are often required. Because of this, one of the main thrusts of research is to find a way of preventing the progression from superficial disease to muscle invasive and metastatic bladder cancer.

Modifiable risk factors for the prevention of bladder cancer: a systematic review of meta-analyses

Each year, 430,000 people are diagnosed with bladder cancer. Due to the high recurrence rate of the disease, primary prevention is paramount. Therefore, we reviewed all meta-analyses on modifiable risk factors of primary bladder cancer. PubMed, Embase and Cochrane database were systematically searched for meta-analyses on modifiable risk factors published between 1995 and 2015. When appropriate, meta-analyses (MA) were combined in meta-meta-analysis (MMA). If not, the most comprehensive MA was selected based on the number of primary studies included. Probability of causation was calculated for individual factors and a subset of lifestyle factors combined. Of 1496 articles identified, 5 were combined in MMA and 21 were most comprehensive on a single risk factor. Statistically significant associations were found for current (RR 3.14) or former (RR 1.83) cigarette smoking, pipe (RR 1.9) or cigar (RR 2.3) smoking, antioxidant supplementation (RR 1.52), obesity (RR 1.10), higher physical activity levels (RR 0.86), higher body levels of selenium (RR 0.61) and vitamin D (RR 0.75), and higher intakes of: processed meat (RR 1.22), vitamin A (RR 0.82), vitamin E (RR 0.82), folate (RR 0.84), fruit (RR 0.77), vegetables (RR 0.83), citrus fruit (RR 0.85), and cruciferous vegetables (RR 0.84). Finally, three occupations with the highest risk were tobacco workers (RR 1.72), dye workers (RR 1.58), and chimney sweeps (RR 1.53). The probability of causation for individual factors ranged from 4 to 68 %. The combined probability of causation was 81.8 %. Modification of lifestyle and occupational exposures can considerably reduce the bladder cancer burden. While smoking remains one of the key risk factors, also several diet-related and occupational factors are very relevant.

Inhibition of Lon blocks cell proliferation, enhances chemosensitivity by promoting apoptosis and decreases cellular bioenergetics of bladder cancer: potential roles of Lon as a prognostic marker and therapeutic target in baldder cancer

ATP-dependent Lon protease within mitochondrial matrix contributes to the degradation of abnormal proteins. The oxidative or hypoxic stress which represents the stress phenotype of cancer leads to up-regulation of Lon. However, the role of Lon in bladder cancer remains undefined. Here, we found that Lon expression in bladder cancer tissues was significantly higher than those in noncancerous tissues; down-regulation of Lon in bladder cancer cells significantly blocked cancer cell proliferation via suppression c-Jun N-terminal kinase (JNK) phosphorylation due to decreased reactive oxygen species (ROS) production and enhanced the sensitivity of bladder cancer cells to chemotherapeutic agents by promoting apoptosis. We further found that Lon down-regulation in bladder cancer cells decreased cellular bioenergetics as determined by measuring aerobic respiration and glycolysis using extracellular flux analyzer. The tissue microarray (TMA) results showed that high expression of Lon was related to the T and TNM stage, as well as histological grade of bladder cancer patients. We also demonstrated that Lon was an independent prognostic factor for overall survival of bladder cancer. Taken together, our data suggest that Lon could serve as a potential diagnostic biomarker and therapeutic target for treatment of bladder cancer, as well as for prediction of the effectiveness of chemotherapy.

ZIP8 expression in human proximal tubule cells, human urothelial cells transformed by Cd+2 and As+3 and in specimens of normal human urothelium and urothelial cancer

Background

ZIP8 functions endogenously as a Zn⁺²/HCO₃^- symporter that can also bring cadmium (Cd⁺²) into the cell. It has also been proposed that ZIP8 participates in Cd-induced testicular necrosis and renal disease. In this study real-time PCR, western analysis, immunostaining and fluorescent localization were used to define the expression of ZIP8 in human kidney, cultured human proximal tubule (HPT) cells, normal and malignant human urothelium and Cd⁺² and arsenite (As⁺³) transformed urothelial cells.

Results

It was shown that in the renal system both the non-glycosylated and glycosylated form of ZIP8 was expressed in the proximal tubule cells with localization of ZIP8 to the cytoplasm and cell membrane; findings in line with previous studies on ZIP8. The studies in the bladder were the first to show that ZIP8 was expressed in normal urothelium and that ZIP8 could be localized to the paranuclear region. Studies in the UROtsa cell line confirmed a paranuclear localization of ZIP8, however addition of growth medium to the cells increased the expression of the protein in the UROtsa cells. In archival human samples of the normal urothelium, the expression of ZIP8 was variable in intensity whereas in urothelial cancers ZIP8 was expressed in 13 of 14 samples, with one high grade invasive urothelial cancer showing no expression. The expression of ZIP8 was similar in the Cd⁺² and As⁺³ transformed UROtsa cell lines and their tumor transplants.

Conclusion

This is the first study which shows that ZIP8 is expressed in the normal urothelium and in bladder cancer. In addition the normal UROtsa cell line and its transformed counterparts show similar expression of ZIP8 compared to the normal urothelium and the urothelial cancers suggesting that the UROtsa cell line could serve as a model system to study the expression of ZIP8 in bladder disease.

Methylation markers for urine-based detection of bladder cancer: the next generation of urinary markers for diagnosis and surveillance of bladder cancer

Cancer of the urinary bladder is the fifth most common neoplasm in the industrialized countries. Diagnosis and surveillance are dependent on invasive evaluation with cystoscopy and to some degree cytology as an adjunct analysis. Nomuscle invasive bladder cancer is characterized by frequent recurrences after resection, and up to 30% will develop an aggressive phenotype. The journey towards a noninvasive test for diagnosing bladder cancer, in order to replace or extend time between cystoscopy, has been ongoing for more than a decade. However, only a handful of tests that aid in clinical decision making are commercially available. Recent reports of DNA methylation in urine specimens highlight a possible clinical use of this marker type, as high sensitivities and specificities have been shown. This paper will focus on the currently available markers NMP22, ImmunoCyt, and UroVysion as well as novel DNA methylation markers for diagnosis and surveillance of bladder cancer.

Lkb1 and Pten synergise to suppress mTOR-mediated tumorigenesis and epithelial-mesenchymal transition in the mouse bladder

The AKT/PI3K/mTOR pathway is frequently altered in a range of human tumours, including bladder cancer. Here we report the phenotype of mice characterised by deletion of two key players in mTOR regulation, Pten and Lkb1, in a range of tissues including the mouse urothelium. Despite widespread recombination within the range of epithelial tissues, the primary phenotype we observe is the rapid onset of bladder tumorigenesis, with median onset of approximately 100 days. Single deletion of either Pten or Lkb1 had no effect on bladder cell proliferation or tumour formation. However, simultaneous deletion of Lkb1 and Pten led to an upregulation of the mTOR pathway and the hypoxia marker GLUT1, increased bladder epithelial cell proliferation and ultimately tumorigenesis. Bladder tissue also exhibited characteristic features of epithelial-mesenchymal transition, with loss of the epithelial markers E-cadherin and the tight junction protein ZO-1, and increases in the mesenchymal marker vimentin as well as nuclear localization of epithelial-mesenchymal transition (EMT) regulator Snail. We show that these effects were all dependent upon mTOR activity, as rapamycin treatment blocked both EMT and tumorigenesis. Our data therefore establish clear synergy between Lkb1 and Pten in controlling the mTOR pathway within bladder epithelium, and show that loss of this control leads to the disturbance of epithelial structure, EMT and ultimately tumorigenesis.

Urine from current smokers induces centrosome aberrations and spindle defects in vitro in nonmalignant human cell lines

Tobacco smoke containing numerous derived chemical carcinogens is the main risk factor for urothelial carcinoma. These carcinogens can induce DNA damage leading to chromosomal instability, which plays a fundamental role in urothelial carcinogenesis. Possible mechanisms could be centrosomal aberrations, which cause defective spindles and may be responsible for genetic instability. We evaluated the effect of urine from never smokers (NS) and current smokers (CS) in concentrations of 0 to 50% on cell proliferation, chromosomes, centrosomes, and the spindle status of normal human dermal fibroblasts and normal human urothelial cells (UROtsa). After 2 weeks of urine treatment, cell cultures were analyzed by centrosome and spindle immunostaining and conventional cytogenetics. Effects were compared to results of untreated controls. Analysis of normal human dermal fibroblasts and UROtsa cells revealed that urine from CS induced higher values of centrosome aberrations in a dose-dependent and cell line-independent manner when compared to cultures treated with urine from NS and untreated controls. Centrosomal alterations correlated with spindle defects and an increase of sporadic chromosomal aberrations. The observations suggest a causative role of chemical carcinogens in urine from CS in the origin of centrosome and spindle defects in vitro leading to chromosomal instability and may be involved in urothelial carcinogenesis.

Genetic polymorphisms in the DNA repair genes XPD and XRCC1, p53 gene mutations and bladder cancer risk

Previous studies have suggested that certain genetic polymorphisms, specifically the Xeroderma pigmentosum group D (XPD) gene codon 751 and the X-ray repair cross-complementing group 1 (XRCC1) gene codon 399 polymorphisms, were associated with an increased risk of lung cancer, and, in some studies, with a greater risk for mutations in the p53 tumor suppressor gene in lung tumors. To evaluate whether these gene polymorphisms may be associated with an increased risk for bladder cancer or in association with p53 mutation status in bladder tumors, we screened for polymorphisms at XPD codons 751 and XRCC1 codon 399 in DNA isolated from blood of 194 bladder cancer patients and 313 healthy controls and for mutations in exons 4 to 8 of the p53 gene in bladder tumor DNA from 174 bladder cancer patients. There was a significantly higher prevalence of the XPD 751 Gln allele among the bladder cancer group, compared with the control group. No association was found between bladder cancer risk and the XRCC1 399 polymorphism. p53 mutations were found in 20.1% (35/174) patients. There was no difference in p53 mutation status among individuals with different genotypes. These results suggest that individuals who have the XPD 751 Gln allele may be at an increased risk for bladder cancer, although this may not lead to an increased risk for mutations in the p53 gene.

Variation of keratin 7 expression and other phenotypic characteristics of independent isolates of cadmium transformed human urothelial cells (UROtsa)

This laboratory has shown that a human urothelial cell line (UROtsa) transformed by cadmium (Cd(2+)) produced subcutaneous tumor heterotransplants that resemble human transitional cell carcinoma (TCC). In the present study, additional Cd(2+) transformed cell lines were isolated to determine if independent exposures of the cell line to Cd(2+) would result in malignantly transformed cell lines possessing similar phenotypic properties. Seven independent isolates were isolated and assessed for their doubling times, morphology, ability to heterotransplant subcutaneously and in the peritoneal cavity of nude mice, and for the expression of keratin 7. The 7 cell lines all displayed an epithelial morphology with no evidence of squamous differentiation. Doubling times were variable among the isolates, being significantly reduced or similar to those of the parental cells. All 7 isolates were able to form subcutaneous tumor heterotransplants with a TCC morphology, and all heterotransplants displayed areas of squamous differentiation of the transitional cells. The degree of squamous differentiation varied among the isolates. In contrast to subcutaneous tumor formation, only 1 isolate of the Cd(2+) transformed cells (UTCd#1) was able to effectively colonize multiple sites within the peritoneal cavity. An analysis of keratin 7 expression showed no correlation with squamous differentiation for the subcutaneous heterotransplants generated from the 7 cell lines. Keratin 7 was expressed in 6 of the 7 cell lines and their subcutaneous tumor heterotransplants. Keratin 7 was not expressed in the cell line that was able to form tumors within the peritoneal cavity. These results show that individual isolates of Cd(2+) transformed cells have both similarities and differences in their phenotype.

Tobacco smoking and risk of bladder cancer

Tobacco smoking is the main known cause of urinary bladder cancer in humans. In most populations, over half of cases in men and a sizeable proportion in women are attributable to this habit. Epidemiological studies conducted in different populations have shown a linear relationship between intensity and duration of smoking and risk. Quitting smoking reduces the risk of bladder cancer. Smoking black (air-cured) cigarettes results in a higher risk than smoking blond (flue-cured) tobacco cigarettes; results on inhalation patterns and use of filter are not consistent. Cigar and pipe smoking also increases the risk of bladder cancer; data on other tobacco products are limited. The evidence for non-transitional bladder carcinoma is limited, but consistent with an increased risk. The available evidence does not point towards a different carcinogenic effect of tobacco smoking in men and women or in whites and blacks. Data on involuntary smoke and use of smokeless tobacco products are limited, but do not suggest an increased risk of bladder cancer.

Imaging of hematuria

Hematuria may have a number of causes, of which the more common are urinary tract calculi, urinary tract infection, urinary tract neoplasms (including renal cell carcinoma and urothelial tumors), trauma to the urinary tract, and renal parenchymal disease. This article discusses the current status of imaging of patients suspected of having urologic causes of hematuria. The role of all modalities, including plain radiography, intravenous urography or excretory urography, retrograde pyelography, ultrasonography, and multidetector computed tomography (MDCT) in evaluation of these patients is discussed. The article highlights the current status of MDCT urography in imaging of patients with hematuria, and discusses various-often controversial-issues, such as optimal protocol design, accuracy of the technique in imaging of the urothelium, and the significant issue of radiation dose associated with MDCT urography.

The influence of polymorphisms of glutathione S-transferases M1 and M3 on the development of human urothelial cancer

Cigarette smoking is the most important risk factor for development of transitional cell carcinoma of the urinary bladder. The effect of polymorphisms of glutathione S-transferases M1 (GSTM1) and M3 (GSTM3) on the influence of cigarette smoking on urinary bladder carcinogenesis was investigated. In total, 293 bladder cancer patients from hospitals in Dortmund and Wittenberg as well as 176 patients without any malignancy from a Department of Surgery from Dortmund were genotyped for GSTM1 and GSTM3 according to standard PCR/RFLP methods. Smoking habits were quantified by a standardized interview. The proportion of GSTM1 negative cases was 63% in the entire bladder cancer cases group compared to 50% in controls. The GSTM3*A/*A genotype was 76% in cancer cases versus 74% in controls. Smokers and ex-smokers were overrepresented in bladder cancer cases. A significant association between smoking status and GSTM1 or GSTM3 genotype was not detected. The elevated proportion of GSTM1 negative bladder cancer cases shows an effect of this polymorphic enzyme on development of bladder cancer. In contrast to other studies, an influence of GSTM1 on the risk due to cigarette smoking was not observed.

Epidemiology of urinary bladder cancer: from tumor development to patient’s death

Urinary bladder cancer (UBC) ranks ninth in worldwide cancer incidence. It is more frequent in men than in women. We review the main established/proposed factors, both environmental and genetic, associated with bladder cancer etiology and prognosis. Data were extracted from previous reviews and original articles identified from PubMed searches, reference lists, and book chapters dealing with the reviewed topics. Evaluation and consensus of both the contribution of each factor in bladder cancer burden and the appropriateness of the available evidences was done during an ad hoc meeting held during the 18th Congress of the European Society for Urological Research. Cigarette smoking and specific occupational exposures are the main known causes of UBC. Phenacetin, chlornaphazine and cyclophosphamide also increase the risk of bladder cancer. Chronic infection by Schistosoma haematobium is a cause of squamous cell carcinoma of the bladder. NAT2 slow acetylator and GSTM1 null genotypes are associated with an increased risk of this cancer. Vegetables and fresh fruits protect against this tumor. Regarding prognosis, there is little knowledge on the predictive role of environmental exposures and genetic polymorphisms on tumor recurrence and progression and patient's death. Although active tobacco smoking is the most commonly studied factor, no definitive conclusion can be drawn from the literature. More research is needed regarding the effect of complex etiological factors in bladder carcinogenesis. Subgroup analysis according to stage, grade, and molecular features may help in identifying specific etiological and prognostic factors involved in different bladder cancer progression pathways.

Lack of Progress in Early Diagnosis of Bladder Cancer

OBJECTIVES

The stage of presentation of prostate cancer has changed dramatically in the past two decades, largely because of prostate-specific antigen screening and increased public awareness regarding the disease. Recently, strides have been made in the validation, development, and approval of bladder cancer (BC) markers. We sought to evaluate whether any stage migration has occurred for patients with BC during the same period.

METHODS

A total of 351 and 1262 patients underwent radical cystectomy and radical retropubic prostatectomy, respectively, between 1992 and 2005 by one surgeon. The patients were divided into two consecutive groups: group 1 (1992 to 1998) and group 2 (1999 to 2005). The baseline and pathologic characteristics of the patients were compared.

RESULTS

No differences were found in the clinical or pathologic staging between the two groups of patients undergoing radical cystectomy. The 5-year overall and disease-specific survival also was not different between the two groups. For patients with prostate cancer, those in group 2 presented at a younger age, with a lower prostate-specific antigen level, and had a lower clinical stage. Group 2 patients had a decrease in the incidence of extracapsular extension, a decreased tumor volume, and a decrease in the incidence of Gleason 8 to 10 tumors.

CONCLUSIONS

During two consecutive periods, our patients with prostate cancer presented with the cancer at an earlier stage and had more favorable pathologic features after radical retropubic prostatectomy. However, our patients with BC did not demonstrate any stage migration. Physicians need to be more aggressive in diagnosing BC, especially in patients at high risk of the disease. Risk factors must be emphasized, urine markers should be used in a screening strategy, and the indications for radical cystectomy should be liberalized.

Smoking and bladder cancer in Spain: effects of tobacco type, timing, environmental tobacco smoke, and gender

We examined the effects of dose, type of tobacco, cessation, inhalation, and environmental tobacco smoke exposure on bladder cancer risk among 1,219 patients with newly diagnosed bladder cancer and 1,271 controls recruited from 18 hospitals in Spain. We used unconditional logistic regression to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for the association between bladder cancer risk and various characteristics of cigarette smoking. Current smokers (men: OR, 7.4; 95% CI, 5.3-10.4; women: OR, 5.1; 95% CI, 1.6-16.4) and former smokers (men: OR, 3.8; 95% CI, 2.8-5.3; women: OR, 1.8; 95% CI, 0.5-7.2) had significantly increased risks of bladder cancer compared with nonsmokers. We observed a significant positive trend in risk with increasing duration and amount smoked. After adjustment for duration, risk was only 40% higher in smokers of black tobacco than that in smokers of blond tobacco (OR, 1.4; 95% CI, 0.98-2.0). Compared with risk in current smokers, a significant inverse trend in risk with increasing time since quitting smoking blond tobacco was observed (> or =20 years cessation: OR, 0.2; 95% CI, 0.1-0.9). No trend in risk with cessation of smoking black tobacco was apparent. Compared with men who inhaled into the mouth, risk increased for men who inhaled into the throat (OR, 1.7; 95% CI, 1.1-2.6) and chest (OR, 1.5; 95% CI, 1.1-2.1). Cumulative occupational exposure to environmental tobacco smoke seemed to confer increased risk among female nonsmokers but not among male nonsmokers. After eliminating the effect of cigarette smoking on bladder cancer risk in our study population, the male-to-female incidence ratio decreased from 8.2 to 1.7, suggesting that nearly the entire male excess of bladder cancer observed in Spain is explained by cigarette smoking rather than occupational/environmental exposures to other bladder carcinogens.

A pooled analysis of bladder cancer case-control studies evaluating smoking in men and women

OBJECTIVE

A recent study suggested that risk of bladder cancer may be higher in women than in men who smoked comparable amounts of cigarettes. We pooled primary data from 14 case-control studies of bladder cancer from Europe and North America and evaluated differences in risk of smoking by gender.

METHODS

The pooled analysis included 8316 cases (21% women) and 17,406 controls (28% women) aged 30-79 years. Odds ratios (ORs) and 95% confidence intervals (95% CI) for smoking were adjusted for age and study. Exposure-response was evaluated in a stratified analysis by gender and by generalized additive models.

RESULTS

The odds ratios for current smokers compared to nonsmokers were 3.9 (95% CI 3.5-4.3) for males and 3.6 (3.1-4.1) for females. In 11 out of 14 studies, ORs were slightly higher in men. ORs for current smoking were similar for men (OR = 3.4) and women (OR = 3.7) in North America, while in Europe men (OR = 5.3) had higher ORs than women (OR = 3.9). ORs increased with duration and intensity in both genders and the exposure-response patterns were remarkably similar between genders.

CONCLUSION

These results do not support the hypothesis that women have a higher relative risk of smoking-related bladder cancer than men.

Metallothionein-1 and -2 expression in cadmium- or arsenic-derived human malignant urothelial cells and tumor heterotransplants and as a prognostic indicator in human bladder cancer

The goal of this study was to determine if the expression of the metallothionein (MT)-1/2 proteins might serve as a biomarker for the development of bladder cancer. A retrospective analysis of MT-1/2 staining was performed on 343 tissue sections from patients referred for the diagnosis of bladder cancer. The specimens were subdivided into six categories: benign, dysplastic, low-grade cancer, high-grade cancer with no evidence of invasion, high-grade cancer with evidence of invasion, and carcinoma in situ. There was no expression of MT-1/2 in benign lesions and low-grade cancers, a low incidence of expression in dysplastic lesions and high-grade cancers with no evidence of muscle invasion, and a significantly increased incidence of MT-1/2 in high-grade cancers that had invaded the underlying matrix. The expression of MT-1/2 varied in intensity from sample to sample and was focal in its expression. It was concluded from these findings that MT-1/2 may be a prognostic marker for cancers that are progressing to invade the underlying stroma of the bladder wall. The expression of MT-1/2 was also determined in a cell culture model of human urothelium that had been malignantly transformed by Cd2+ and As3+ and shown to be capable of tumor formation in nude mice. It was demonstrated that the expression of MT-1/2 in the tumor heterotransplants was similar to the pattern found in archival specimens of high-grade bladder cancers. The MT-1/2 staining in the heterotransplants was focal in pattern, varied in intensity, and highest in the less differentiated cells of the tumor. These findings indicate that the cell culture model may serve to help define the role of MT-1/2 expression in bladder cancer invasion.

Harnblasenkarzinom

Bladder cancer is a malignant disease with exogenous and thus avoidable causative factors. Cigarette smoking is by far the most relevant risk factor and a clear dose-response relationship has been documented. That the bladder cancer risk decreases only a few years after the cessation of smoking is noteworthy. Occupational exposure, particularly to aromatic amines such as benzidine and beta-naphthylamine and to certain azo dyes, represents another important risk factor. At high risk are workers involved in the production of these chemicals and, to a lesser extent, those processing them. The currently known environmental factors seem to play a minor role. Treatment-induced risks causing secondary bladder cancer also have to be considered. Currently, the prevention of bladder cancer mainly involves avoiding exposure to known causative factors and early detection of the disease in high risk populations.

Radiochemotherapy in locally invasive non-metastatic carcinoma of the bladder

We therefore believe that our therapeutic concept is a true alternative to primary cystectomy, with comparable survival rates. We observed a high rate of functional organ preservation in long-term survivors (79% with complete remission (CR) after 5 years). Radiation bladders were rare at doses not exceeding 60 Gy. Age and co-morbidity were not exclusion criteria. Presence of a competent and cooperative radiotherapy department is a precondition to preventing akinetic radiation bladders. Continuous life-long follow-up is necessary. Cystectomy, together with modern urinary diversions, is still necessary; it is performed in non-responders and in patients with muscle-invasive recurrences.

Primary care update on kidney and bladder cancer: a urologic perspective

The past decade has witnessed many substantive changes in the approach to the diagnosis and treatment of both kidney and bladder cancer. In part, this is based on changes in the understanding of their carcinogenesis and pathogenesis, an appreciation of new concepts in their classification, and the incorporation of new technologies that have emerged. This article reviews advances and updates changes that have been made in the understanding of and approaches to these malignancies from the perspective of their urologic assessment and management while in the context of primary care issues.

Enhancement of urinary bladder carcinogenesis by combined treatment with benzyl isothiocyanate and N-butyl-N-(4-hydroxybutyl)nitrosamine in rats after initiation

Previously we reported that benzyl isothiocyanate (BITC) strongly enhanced rat urinary bladder carcinogenesis after initiation with N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN), while potently inhibiting BBN-induction of lesions when given simultaneously with the carcinogen. In the present experiment, the effects of simultaneous treatment with BITC and low-dose BBN on the post-initiation period of rat urinary bladder carcinogenesis were examined. After treatment with 500 ppm BBN for 4 weeks for initiation, groups of 20, 6-week-old, F344 male rats were given 25 ppm BBN alone, basal diet alone, or 100 or 1000 ppm BITC in the diet together with or without 25 ppm BBN in their drinking water for 36 weeks and then killed for autopsy. Further groups consisting of 10 rats each were similarly given BITC or the basal diet together with or without 25 ppm BBN, without initiation treatment. In the initiated groups receiving subsequent BBN exposure, papillary and nodular hyperplasia, dysplasia and carcinoma incidences were significantly increased, and they were further increased by the combined treatment with 100 and 1000 ppm BITC in a dose-dependent manner. In the non-initiation groups, carcinomas were only observed in a single rat in each of the BBN-treated control and BBN/BITC 100 ppm treatment groups. The results indicate that simultaneous treatment with BITC and a low dose of BBN does not inhibit, but rather enhances rat urinary bladder carcinogenesis after appropriate initiation, and further suggest that BITC may be a human risk factor, at least in high-risk populations.

Smoking and Aging Clinical Implications Part I: Health and Consequence

Smoking is the number one preventable cause of disability and mortality in older adults. In the past few decades there has been an enhanced focus on smoking behaviors and smoking cessation, however, the older smoker has been excluded. Even though nonsmoking status can provide older smokers with a chance for increased quality as well as quantity of life, they are asked less often to quit, given fewer resources, and provided less guidance than younger smokers. There is limited knowledge about how to design and deliver interventions for smoking cessation among older adults. The explanation for the absence of an empirical and clinical focus on smoking cessation for the older adult is in part because of the belief in myths rather than reality. These beliefs about the health consequences of smoking behaviors and the benefits of smoking cessation for older smokers are held by older adults and their health care providers. However, the truth is that older adults can stop smoking, and the benefits are vast.

Diabetes mellitus and bladder cancer--an epidemiological relationship?

An epidemiological association between diabetes mellitus and transitional cell carcinoma of the bladder has been proposed. This study looked retrospectively at 125 patients with transitional cell carcinoma of the bladder as a study group and 80 other hospital patients with conditions not specifically associated with diabetes mellitus as a control group. Diabetic patients had an increased, significant odds ratio for bladder cancer compared with non diabetics even after adjustment for smoking and age [OR: 2.69 p=0.049 (95% CI 1.006-7.194)] A history of smoking OR 2.16 p=0.013 (95% C.I. 1.175-3.964) is a significant independent association with transitional cell carcinoma of the bladder as is age: p=0.001 OR 1.07. We propose potential pathogenic pathways for transitional cell carcinoma of the bladder in diabetic patients based on altered integrin and cadherin distribution in urothelial cells in diabetic patients. A larger study is planned to confirm an association between diabetes mellitus and transitional cell carcinoma of the bladder.

Risk factors for urinary bladder carcinoma in postmenopausal women. The Iowa Women's Health Study

BACKGROUND

We evaluated prospectively the association of smoking and other potential risk factors with bladder carcinoma incidence in postmenopausal women.

METHODS

A total of 37,459 women participating in the Iowa Women's Health Study completed baseline questionnaires in 1986 and were followed 13 years for bladder carcinoma incidence (n = 112).

RESULTS

Adjusted for potential confounders, the relative risk (RR) of bladder carcinoma in women who were current smokers compared with those who had never smoked was 3.58 (95% confidence interval [CI] = 1.86-6.88). The RR declined as years since quitting increased. Currently, married women, compared with unmarried women, had a RR of 0.66 (95% CI = 0.44-0.99). A 2.46-fold (95% CI = 1.32-4.59) increase in bladder carcinoma risk was identified for women who reported, versus did not report, diabetes. Regular versus no physical activity (RR = 0.66, 95% CI 0.43-1.01) and body mass index were inversely associated (P = 0.06) with bladder carcinoma incidence.

CONCLUSIONS

We confirmed that cigarette smoking is an important risk factor for bladder carcinoma in women; women who had quit smoking had a reduction of risk. We also identified diabetes as a potential risk factor, which may invite more research on its role in the development of urinary bladder carcinoma.

Molecular detection approaches for smoking associated tumors

Smoking is directly responsible for approximately 90% of lung cancers and is also strongly associated with cancers of the head and neck, esophagus and urinary bladder. Our growing understanding of the molecular changes that underlie cancer progression has contributed to the development of novel molecular approaches for the detection of cancer. In this study, we review a number of recent studies that have used molecular techniques to detect neoplastic DNA from lung, head and neck, esophagus and bladder cancer. The majority of these approaches are based on polymerase chain reaction (PCR) based assays. These PCR-based techniques can detect a few clonal cancer cells containing a specific DNA mutation, microsatellite alteration, or CpG island methylation among an excess background of normal cells. The ability to accurately detect a small number of malignant cells in a wide range of clinical specimens including sputum, saliva, bronchoalveolar lavage fluid, urine, serum, plasma, or tissue has significant implications for screening high-risk individuals (such as cigarette smokers) for cancer.

Fluid consumption and the risk of bladder cancer: results of a multicenter case-control study

A number of studies suggest a relation between fluid consumption and the risk of bladder cancer but results are contradictory. Different theories involving the quantity or the type of fluid consumed have been put forward to explain these relations but mechanisms remain unclear. We conducted a multicenter case-control study in several hospitals in France including 765 cases and 765 matched controls. Information collected by face-to-face interview included quantity and type of beverages consumed from the age of 18 until age at diagnosis, as well as smoking habits. Among men, we observed a slight non-significant increased risk of bladder cancer associated with total fluid intake, irrespectively of tobacco use. This was essentially due to intake of non-alcoholic drinks, coffee and bottled juice or water. Relative risks greater than 1 were observed in relation with coffee consumption. On the other hand, alcohol consumption, especially wine, was associated with relative risks less than unity. No relation could be identified between bladder cancer risk and fluid consumption among women. Our results do not support an association between total fluid consumption and bladder cancer risk. The role of the different types of fluid consumed, confounding factors and bias in the present analysis are discussed.

Diagnosis and management of superficial bladder cancer

Bladder cancer is the fourth leading cause of cancer in American men, accounting for more than 12,000 deaths annually. It was one of the first malignancies in which carcinogens were recognized as an important factor in its cause. Currently, cigarette smoking is by far the most common cause of bladder cancer, although occupational exposure to arylamines has been implicated in the past. Gross or microscopic hematuria is the most common sign at presentation. Initial radiologic evaluation usually includes the excretory urography (intravenous pyelography), although further evaluation of the renal parenchyma with ultrasound or computed tomography scanning has been advocated by some. These radiologic studies are unable to provide adequate bladder imaging, and thus cystoscopy is required for the diagnosis of bladder cancer. Most bladder cancers present as "superficial" disease, confined to the bladder mucosa or submucosal layer, without muscle invasion. Superficial tumors consist of papillary tumors that are mucosally confined (Ta), papillary or sessile tumors extending into the lamina propria (T1), and carcinoma in situ, which occurs as "flat" mucosal dysplasia, which can be focal, diffuse, or associated with a papillary or sessile tumor. The natural history of these pathologic subtypes differ significantly. Most superficial tumors (60% to 70%) have a propensity for recurrence after transurethral resection. Some (15% to 25%) are at high risk for progression to muscle invasion. Most superficial tumors can be stratified into high- or low-risk groups depending on tumor stage, grade, size, number, and recurrence pattern. It is important to identify those tumors at risk for recurrence or progression so that adjuvant intravesical therapies can be instituted. Many intravesical chemotherapeutic agents have been shown to reduce tumor recurrence when used in conjunction with transurethral tumor resection. Unfortunately, however, none of these agents have proved to be of benefit in preventing disease progression. Most are given intravesically on a weekly basis, although many studies suggest that a single instillation immediately after transurethral resection may be as good as a longer course of therapy. Although all of these drugs have toxicity, they usually are well tolerated. Intravesical bacille Calmette-Guérin (BCG) is an immunotherapeutic agent that when given intravesically is very effective in the treatment of superficial transitional cell carcinoma. Compared with controls, BCG has a 43% advantage in preventing tumor recurrence, a significantly better rate than the 16% to 21% advantage of intravesical chemotherapy. In addition, BCG is particularly effective in the treatment of carcinoma in situ, eradicating it in more than 80% of cases. In contrast to intravesical chemotherapy, BCG has also been shown to decrease the risk of tumor progression. The optimal course of BCG appears to be a 6-week course of weekly instillations, followed by a 3-week course at 3 months in those tumors that do not respond. In high-risk cancers, maintenance BCG administered for 3 weeks every 6 months may be optimal in limiting recurrence and preventing progression. Unfortunately, adverse effects associated with this prolonged therapy may limit its widespread applicability. In those patients at high risk in whom BCG therapy fails, intravesical interferon-alpha with or without BCG may be beneficial in some. Photodynamic therapy has also been used but is limited by its toxicity. In patients who progress or do not respond to intravesical therapies, cystectomy should be considered. With the development of orthotopic lower urinary tract reconstruction to the native urethra, the quality of life impact of radical cystectomy has been lessened.

Gender- and smoking-related bladder cancer risk

BACKGROUND

There is growing evidence that, when smoking habits are comparable, women incur a higher risk of lung cancer than men. Because smokers are also at risk for bladder cancer, we investigated possible sex differences in the susceptibility to bladder cancer among smokers.

METHODS

A population-based, case--control study was conducted in Los Angeles, CA, involving 1514 case patients with bladder cancer and 1514 individually matched population control subjects. Information on tobacco use was collected through in-person interviews. Peripheral blood was collected from study participants to measure 3- and 4-aminobiphenyl (ABP)-hemoglobin adducts, a marker of arylamine exposure. Data were analyzed to determine whether the risk of bladder cancer differs between male and female smokers and whether female smokers exhibit higher levels of ABP-hemoglobin adducts than male smokers with comparable smoking habits. All statistical tests were two-sided.

RESULTS

Cigarette smokers had a statistically significant 2.5-fold higher risk (95% confidence interval = 2.1 to 3.0) of bladder cancer than never smokers. Use of filtered versus nonfiltered cigarettes, low-tar versus higher tar cigarettes, or the pattern of inhalation did not modify the risk. The risk of bladder cancer in women who smoked was statistically significantly higher than that in men who smoked comparable numbers of cigarettes (P =.016 for sex-lifetime smoking interaction). Consistent with the sex difference in smoking-related bladder cancer risk, the slopes of the linear regression lines of the 3- and 4-ABP--hemoglobin adducts by cigarettes per day were statistically significantly steeper in women than in men (P values for sex differences <.001 and.006, respectively).

CONCLUSION

The risk of bladder cancer may be higher in women than in men who smoked comparable amounts of cigarettes.

Are tobacco use and urine pH indicated as risk factors for bladder carcinoma?

BACKGROUND

Many case-control and cohort studies have shown a positive relationship between bladder carcinoma and tobacco use. Recently, urine pH has been reported to influence aromatic amine carcinogenesis, which have been implicated as potent carcinogens in bladder carcinoma patients. Herein the correlation between bladder carcinoma, tobacco use and urine pH is reported.

METHOD

One hundred and forty-one patients with bladder carcinoma and 128 patients with benign prostatic hyperplasia or urolithiasis as controls were selected. All patients were admitted to Osaka City University Hospital for the purpose of surgical treatment. Urine pH was checked by a test tape.

RESULTS

Of the patients with bladder carcinoma, 106 were smokers and 35 were non-smokers. In contrast, the number of smokers in the control group was 76 and that of non-smokers was 52. The odds ratio in the bladder carcinoma group calculated for the smoker patients was 2.07, showing a significant correlation between bladder carcinoma and tobacco use. Regarding urine pH, acidic urine was found in 126 patients in the bladder carcinoma group and in 116 patients in the control group. The odds ratio in the bladder carcinoma group for acidic urine was 0.87, showing no significant relationship between bladder carcinoma and urine pH.

CONCLUSION

The study found a positive relationship between bladder carcinoma and tobacco use; however, it could not establish a clear relationship between bladder carcinoma and urine pH, even in the smoker group.

Bladder cancer: race differences in extent of disease at diagnosis

BACKGROUND

Blacks are less likely than whites to develop bladder cancer; although once diagnosed, blacks experience poorer survival. This study sought to examine multiple biological and behavioral factors and their influence on extent of disease.

METHODS

A population-based cohort of black bladder cancer patients and a random sample of frequency-matched white bladder cancer patients, stratified by age, gender, and race were identified through cancer registry systems in metropolitan Atlanta, New Orleans, and the San Francisco/Oakland area. Patients were ages 20-79 years at bladder cancer diagnosis from 1985-1987, and had no previous cancer history. Medical records were reviewed at initial diagnosis. Of the patients selected for study, a total of 77% of patients was interviewed. Grade, stage, and other variables (including age, socioeconomic status, symptom duration, and smoking history) were recorded. Extent of disease was modeled in 497 patients with urothelial carcinoma using logistic regression.

RESULTS

Extent of disease at diagnosis was significantly greater in Blacks than in Whites. Older age group, higher tumor grade, larger tumors, and presence of carcinoma in situ were related to greater extent of disease in blacks and in whites. Large disparities between blacks and whites were found for socioeconomic status and source of care. Blacks had greater symptom duration and higher grade. Black women were more likely to have invasive disease than white women; this difference was not seen among men. Blacks in unskilled occupational categories, perhaps reflecting socioeconomic factors, were at much higher risk for muscle invasion than whites.

CONCLUSIONS

While specific relationships between variables were noted, an overall pattern defining black and white differences in stage did not emerge. Future studies should examine the basis upon which occupation and life style factors operate by using biochemical and molecular methods to study the genetic factors involved.

Current concepts in assessment and treatment of bladder cancer

Transitional cell carcinoma of the bladder is comprised of a variety of cancer diatheses that manifest a spectrum of distinct biologic potentials. The challenge is to control superficial disease recurrence and progression and to identify invasive carcinoma at an earlier stage, when it may be more amenable to cure.

Cigarette smoking and bladder cancer in men: a pooled analysis of 11 case-control studies

The primary risk factor for bladder cancer is cigarette smoking. Using a combined analysis of 11 case-control studies, we have accurately measured the relationship between cigarette smoking and bladder cancer in men. Available smoking information on 2,600 male bladder cancer cases and 5,524 male controls included duration of smoking habit, number of cigarettes smoked per day and time since cessation of smoking habit for ex-smokers. There was a linear increasing risk of bladder cancer with increasing duration of smoking, ranging from an odds ratio (OR) of 1.96 after 20 years of smoking (95% confidence interval [CI] 1.48-2.61) to 5.57 after 60 years (CI 4.18-7.44). A dose relationship was observed between number of cigarettes smoked per day and bladder cancer up to a threshold limit of 15-20 cigarettes per day, OR = 4.50 (CI 3.81-5. 33), after which no increased risk was observed. An immediate decrease in risk of bladder cancer was observed for those who gave up smoking. This decrease was over 30% after 1-4 years, OR = 0.65 (0. 53-0.79), and was over 60% after 25 years of cessation, OR = 0.37 (0. 30-0.45). However, even after 25 years, the decrease in risk did not reach the level of the never-smokers, OR = 0.20. (0.17-0.24). The proportion of bladder cancer cases attributable to ever-smoking was 0.66 (0.61-0.70) for all men and 0.73 (0.66-0.79) for men younger than 60. These estimates are higher than previously calculated.

Aetiological factors of bladder cancer in the Aegean region of Turkey between the years 1985-1996

A great majority of urological cases are bladder tumours. The purpose of this study is to bring out the aetiological factors related to bladder tumours. The parameters such as age, sex, profession, age at tumour occurrence, smoking, drinking habits, such as the level of consumption of tea and coffee, and accompanying urological diseases were evaluated. Three hundred and forty-seven patients with bladder tumours were included in this study. Of them 332 (95.6%) were males and 15 (4.4%) females. The average age was 62.1 (22-87) years. Of the patients 326 (93.9%) smoked, 175 (50.4%) lived in cities and the other 49.6% lived in the countryside. Of the tumours 89.9% were transitional cell carcinomas. In conclusion, bladder tumours are closely related to consumption of tobacco factors and profession. The risk of tumour development increases progressively in people who are exposed to industrial agents and agricultural chemicals.

Role of chronic catheterization in the development of bladder cancer in patients with spinal cord injury

OBJECTIVES

Patients with spinal cord injury (SCI) and chronic indwelling catheters are known to be at increased risk of bladder malignancy. "Decatheterization" by clean intermittent catheterization, external condom catheterization, or spontaneous voiding is thought to reduce the risk by decreasing the chronic mucosal irritation and rate of infection. We examined two Department of Veterans Affairs (DVA) data bases to test this theory.

METHODS

A population-based retrospective analysis of invasive treatments for carcinoma of the bladder in all DVA hospitals was conducted using computerized inpatient files from fiscal years 1988 to 1992.

RESULTS

One hundred thirty patients with bladder malignancy were identified from a pool of 33,565 patients with SCI (0.39%). All 130 patients underwent either radical cystectomy (n = 63, 48%) or transurethral resection of bladder tumor (n = 67, 52%). The 30-day perioperative mortality and overall 5-year survival rates were 2 (1.5%) and 49 (38%) of 130, respectively. Of the 130 patients analyzed, 42 (32%) had adequate data available regarding tumor pathologic findings and method of bladder management for analysis. The average age at diagnosis was 57.3 years. The histologic finding was transitional cell carcinoma in 23 (55%), squamous cell carcinoma in 14 (33%), and adenocarcinoma in 4 (10%) of 42. Bladder management was an indwelling urethral catheter in 18 (43%), suprapubic catheter in 8 (19%), clean intermittent catheterization in 8 (19%), and condom catheter in 6 (14%) of 42 patients. Squamous cell carcinoma was more common in patients with indwelling urethral catheters and suprapubic tubes (11 of 26, 42%) than in those using clean intermittent catheterization, condom catheterization, or spontaneous voiding (3 of 16, 19%).

CONCLUSIONS

Bladder cancer was diagnosed in approximately 0.39% of this large SCI population during a 5-year period. Most cancers (55%) were transitional cell carcinomas. Squamous cell carcinoma was more common in patients with SCI and indwelling catheters than those without chronic catheterization. These data continue to suggest that avoidance of indwelling catheters, when feasible, is the preferred method of bladder management in patients with SCI.