Higher than expected association of clinical prostate and bladder cancers

Triple Synchronous Urogenital Malignancies of the Bladder, Kidney, and Prostate: Management in a Single Operation

Synchronous occurrence of three primary malignancies is a rare occurrence, and treatment options are often a difficult undertaking. We present a case of a 57-year-old Hispanic male with synchronous urothelial cell carcinoma of the bladder, renal cell carcinoma, and prostate adenocarcinoma. We elected to manage this patient with a single operation. To our knowledge, this is only the second time a reported operation has been performed of this nature, which includes 21 case reports of triple primary genitourinary tumors, 15 of which are reported as synchronous.

Clinical characteristics and prostate-cancer-specific mortality of competitive risk nomogram in the second primary prostate cancer

Background

With the development of early diagnosis and treatment, the second primary malignancy (SPM) attracts increasing attention. The second primary prostate cancer (spPCa) is an important class of SPM, but remains poorly understood.

Methods

We retrospectively analyzed 3,322 patients with spPCa diagnosed between 2004 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) database. Chi-square test was applied to compare demographic and clinical variables and analyze causes of death. Multivariate competitive risk regression model was used to identify risk factors associated with prostate-cancer-specific mortality (PCSM), and these factors were enrolled to build a nomogram of competitive risk. The C-index, calibration curve, and decision curve analysis (DCA) were employed to evaluate the discrimination ability of our nomogram.

Results

The median follow-up (interquartile range, IQR) time was 47 (24-75) months, and the median (IQR) diagnosis interval between the first primary cancer (FPC) and spPCa was 32 (16-57) months. We found that the three most common sites of SPM were the urinary system, digestive system, and skin. Through multivariate competitive risk analysis, we enrolled race (p < 0.05), tumor-node-metastasis (TNM) stage (p < 0.001), Gleason score (p < 0.05), surgery (p = 0.002), and radiotherapy (p = 0.032) to construct the model to predict the outcomes of spPCa. The C-index was 0.856 (95% CI, 0.813-0.899) and 0.905 (95% CI, 0.941-0.868) in the training and validation set, respectively. Moreover, both the calibration curve and DCA illustrated that our nomogram performed well in predicting PCSM.

Conclusion

In conclusion, we identified four risk factors associated with the prognosis of spPCa and construct a competing risk nomogram, which performed well in predicting the 3-, 5-, and 10-year PCSM.

Risk of second cancer among young prostate cancer survivors

Purpose

About 40% of men diagnosed with prostate cancer (Pca) are ≤65 years of age. This study evaluates the risk of second cancer among young Pca patients treated with surgery or radiation.

Materials and Methods

This is a retrospective review of 150,915 men aged ≤65 years at Pca diagnosis treated with surgery or radiation registered in the Surveillance, Epidemiology, and End Results (SEER) database between 1973 and 2014. Incidence rates of second rectum/rectosigmoid junction (RJ), bladder, and lung cancer in each treatment group were reported with adjustment for potential confounders. Cumulative incidence functions were used to summarize the risk of second cancer after completing initial treatment.

Results

Men treated with external beam radiation (BEAM), brachytherapy (SEED), or combined radiation all exhibited a statistically significant increased incidence of second bladder cancer compared to men treated with surgery (adjusted incidence rate ratio [IRR]: 2.09, 1.91, and 2.04, respectively). Incidence of rectum/RJ cancer was also significantly increased in men receiving BEAM and combined radiation (adjusted IRR: 1.58 and 1.98, respectively). There were also significant differences in the cumulative incidence of second bladder cancer after receiving any form of radiation compared to surgery.

Conclusion

Pca survivors ≤65 years of age at Pca diagnosis had an increased risk of second bladder and rectum/RJ cancer after BEAM and combined radiation treatment after adjusting for confounding factors. Second bladder cancer incidence after either form of radiation treatment was increased even at 5 years after a Pca diagnosis.

Racial differences in the risk of second primary bladder cancer following radiation therapy among localized prostate cancer patients

OBJECTIVES

To investigate the race-specific second primary bladder cancer (SPBC) risk following prostatic irradiation.

METHODS

Louisiana residents who were diagnosed with localized prostate cancer (PCa) in 1996-2013 and received surgery or radiation were included. Patients were followed until SPBC diagnosis, death, or Dec. 2018. The exposure variable was type of treatment (radiation only vs. surgery only). The outcome was time from PCa diagnosis to SPBC diagnosis, stratified by race. Fine and Gray's competing risk model was applied with death as a competing event and adjustment of sociodemographic and tumor characteristics. We used 5 years and 10 years as lag time in the analyses.

RESULTS

A total of 26,277 PCa patients with a median follow-up of 10.7 years were analyzed, including 18,598 white and 7679 black patients. About 42.9 % of whites and 45.7 % of blacks received radiation. SPBC counted for 1.84 % in the radiation group and 0.90 % in the surgery group among white patients and for 0.91 % and 0.58 %, respectively, among black patients. The adjusted subdistribution hazard ratio of SPBC was 1.80 (95 % CI: 1.30-2.48) for radiation recipients compared to surgery recipients among white patients; 1.93 (95 % CI: 1.36-2.74) if restricted to external beam radiation therapy (EBRT). The SPBC risk was not significantly different between irradiated and surgically treated among blacks.

CONCLUSIONS

The SPBC risk is almost two-fold among white irradiated PCa patients compared to their counterparts treated surgically. Our findings highlight the need for enhanced surveillance for white PCa survivors receiving radiotherapy, especially those received EBRT.

Treatment and prognosis of patients with urinary bladder cancer with other primary cancers: a nationwide population-based study in the Bladder Cancer Data Base Sweden (BladderBaSe)

OBJECTIVE

To study how patients with urinary bladder cancer (UBC) with previous or concomitant other primary cancers (OPCs) were treated, and to investigate their prognosis.

PATIENTS AND METHODS

Using nationwide population-based data in the Bladder Cancer Data Base Sweden (BladderBaSe), we analysed the probability of treatment with curative intent, and UBC-specific and overall survival (OS) in patients with UBC diagnosed in the period 1997-2014 with or without OPC. The analyses considered the patient's characteristics, UBC tumour stage at diagnosis, and site of OPC.

RESULTS

There were 38 689 patients, of which 9804 (25%) had OPCs. Those with synchronous OPCs more often had T2 and T3 tumours and clinically distant disease at diagnosis than those with UBC only. Patients with synchronous prostate cancer, female genital cancer and lower gastro-intestinal cancer were more often treated with curative intent than patients with UBC only. When models of survival were adjusted for age at diagnosis, marital status, education, year of diagnosis, Charlson Comorbidity Index and T-stage, UBC-specific survival was similar to patients with UBC only, but OS was lower for patients with synchronous OPC, explained mainly by deaths in OPC primaries with a bad prognosis.

CONCLUSIONS

OPC is common in patients with UBC. Treatment for UBC, after or in conjunction with an OPC, should not be neglected and carries just as high a probability of success as treatment in patients with UBC only. The needs of patients with UBC and OPC, and optimisation of their treatment considering their complicated disease trajectory are important areas of research.

Assessment of 5-year overall survival in bladder cancer patients with incidental prostate cancer identified at radical cystoprostatectomy

OBJECTIVE

To investigate the oncological impact of incidental prostate cancer (iPCa) found during radical cystoprostatectomy (RCP) on overall survival (OS) prognosis of urothelial carcinoma of the bladder (BCa).

PATIENTS AND METHODS

A total of 122 RCP cases resected between 2002 and 2012 at our center were included for study. Survival of BCa patient was compared using the Kaplan-Meier method and the log-rank test. Cox proportional hazards regression models were used to analyze the impact of iPCa on the 5-year overall mortality of BCa patients after RCP.

RESULTS

Among the 122 BCa cases that underwent RCP, 38 cases (31.1%) had iPCa, in which, 17 cases (44.7%) were identified as clinically significant iPCa (csPCa). BCa patients with iPCa were older (71 vs 64 years, p = 0.004) and had higher preoperative PSA level (3.1 ng/mL vs 1.4 ng/mL, p = 0.017) when compared to those without iPCa. Cases with iPCa showed a more favorable 5-year OS than cases without iPCa, although this difference did not reach statistical significance (p = 0.219). When excluding the higher risk cases with Gleason score (GS) ≥ 4 + 3 and/or preoperative PSA > 10 ng/mL, BCa patients with iPCa showed a significantly longer OS than cases without iPCa on univariate analysis (p = 0.044), but not on multivariate analysis (p = 0.125).

CONCLUSION

Our results demonstrated that the frequent findings of low-risk iPCa in BCa patients could indicate the potential possibility of shared pathogenesis pathways between iPCa and BCa. Future study with a larger cohort is warranted to validate this result.

MMP23B expression and protein levels in blood and urine are associated with bladder cancer

Urothelial bladder cancer (UBC) represents a public health problem because of its high incidence/relapse rates. At present, there are no suitable biomarkers for early diagnosis or relapse/progression prognosis. To improve diagnostic accuracy and overcome the disadvantages of current diagnostic strategies, the detection of UBC biomarkers in easily accessible biofluids, such as urine, represents a promising approach compared with painful biopsies. We investigated the levels of MMP23 genes (microarray and qPCR) and protein (western blot and enzyme-linked immunosorbent assay) in a set of samples (blood, plasma and urine) from patients with UBC and controls as biomarkers for this cancer. MMP23B and its pseudogene MMP23A resulted downregulated in blood cells from UBC compared with controls (66 cases, 70 controls; adjusted P-value = 0.02 and 0.03, respectively). In contrast, MMP23B protein levels in plasma (53 UBC, 49 controls) and urine (59 UBC, 57 controls) increased in cases, being statistically significant in urine. MMP23B dosage observed in urine samples was related to both tumor risk classification and grading. As the lack of correlation between mRNA and protein levels could be due to a posttranscriptional regulation mediated by microRNAs (miRNAs), we investigated the expression of urinary miRNAs targeting MMP23B. Five miRNAs resulted differentially expressed between cases and controls. We reported the first evidence of MMP23B secretion in plasma and urine, suggesting a role of this poorly characterized metalloproteinase in UBC as a potential non-invasive biomarker for this cancer. Further analyses are needed to elucidate the mechanism of regulation of MMP23B expression by miRNAs.

Second malignancies after radiotherapy for prostate cancer: systematic review and meta-analysis

OBJECTIVE

To determine the association between exposure to radiotherapy for the treatment of prostate cancer and subsequent second malignancies (second primary cancers).

DESIGN

Systematic review and meta-analysis of observational studies.

DATA SOURCES

Medline and Embase up to 6 April 2015 with no restrictions on year or language.

STUDY SELECTION

Comparative studies assessing the risk of second malignancies in patients exposed or unexposed to radiotherapy in the course of treatment for prostate cancer were selected by two reviewers independently with any disagreement resolved by consensus.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted study characteristics and outcomes. Risk of bias was assessed with the Newcastle-Ottawa scale. Outcomes were synthesized with random effects models and Mantel-Haenszel weighting. Unadjusted odds ratios and multivariable adjusted hazard ratios, when available, were pooled.

MAIN OUTCOME MEASURES

Second cancers of the bladder, colorectal tract, rectum, lung, and hematologic system.

RESULTS

Of 3056 references retrieved, 21 studies were selected for analysis. Most included studies were large multi-institutional reports but had moderate risk of bias. The most common type of radiotherapy was external beam; 13 studies used patients treated with surgery as controls and eight used patients who did not undergo radiotherapy as controls. The length of follow-up among studies varied. There was increased risk of cancers of the bladder (four studies; adjusted hazard ratio 1.67, 95% confidence interval 1.55 to 1.80), colorectum (three studies; 1.79, 1.34 to 2.38), and rectum (three studies; 1.79, 1.34 to 2.38), but not cancers of the hematologic system (one study; 1.64, 0.90 to 2.99) or lung (two studies; 1.45, 0.70 to 3.01), after radiotherapy compared with the risk in those unexposed to radiotherapy. The odds of a second cancer varied depending on type of radiotherapy: treatment with external beam radiotherapy was consistently associated with increased odds while brachytherapy was not. Among the patients who underwent radiotherapy, from individual studies, the highest absolute rates reported for bladder, colorectal, and rectal cancers were 3.8%, 4.2%, and 1.2%, respectively, while the lowest reported rates were 0.1%, 0.3%, and 0.3%.

CONCLUSION

Radiotherapy for prostate cancer was associated with higher risks of developing second malignancies of the bladder, colon, and rectum compared with patients unexposed to radiotherapy, but the reported absolute rates were low. Further studies with longer follow-up are required to confirm these findings.

Quantifying the risk of malignancy in patients with visible haematuria presenting to the emergency department

Introduction:

Visible haematuria (VH) is a very common presentation to the emergency department (ED). In an outpatient setting, 18%−24% of such patients have been shown to have an underlying malignancy. The aim of this study is to determine the malignancy rates of patients presenting acutely to ED and whether the degree of bleeding or presence of clots is a higher risk factor for cancer.

Method:

We retrospectively collected data from adult patients (>18 years) presenting to ED with VH for a six-month period. Diagnostic outcomes after one year were assessed.

Results:

Our study population has 96 patients (male = 77, female = 19) with a mean age of 68 years (SD = 20.2). Twenty-eight patients (29%) had haematuria with clots. Twenty-five patients (26%) had a new diagnosis of malignancy, and 10 had a known diagnosis of malignant disease. Bladder cancer was the most commonly found malignancy, in 17 patients (15 new diagnoses), while prostate cancer was second with 14 cases (six new). Renal cancer two, testicular one and colorectal one accounted for the other new malignancies diagnosed following presentation. All but one patient with cancer were male. Although most malignancies were found in patients over 70 years old, the two youngest patients were in their 30s. The incidence of malignancy appears to increase in patients who have urinary blood clots (58%), p = 0.08.

Conclusion:

A third of patients presenting to ED with VH will have a urological cancer. Patients with VH and clots have a significantly higher incidence of malignancy. We recommend expedited referral of all such patients to a urologist.

A population-based comparison of second primary cancers in Germany and Sweden between 1997 and 2006: clinical implications and etiologic aspects

Second primary cancer (SPC) has become an increasing concern in cancer survivorship. Patterns of SPCs in different populations may offer clinical implications and research priorities into SPCs. This study is devoted to compare the occurrences and rank correlations of SPCs between Germany and Sweden. Patients diagnosed with 10 common first primaries between 1997 and 2006 from the Swedish Family-Cancer Database and 10 German cancer registries were included in this population-based study. Spearman's rank correlation coefficients were used to evaluate the strength of the relationship of SPCs between the German and Swedish datasets. Spearman's rank correlation coefficients suggested a strong positive correlation between the German and Swedish datasets based on the ranks of thirty possible SPCs after all selected first cancers. This was also true when we compared the rankings and proportions of the five most common SPCs after site-specific first primaries between the two populations. For kidney cancer, non-Hodgkin's lymphoma, and leukemia the components of the five most common SPCs was exactly the same. Also, the ranking and the proportions for the three most common SPCs (i.e., colorectal, bladder, and lung cancers) after prostate cancer were identical in the two populations, as were those after most other primary cancers. The strikingly consistent patterns of SPCs in the two populations provide excellent opportunities for joint studies and they also suggest that many underlying reasons for SPC may have universal and tangible causes that await mechanistic dissection.

Synchronous and metachronous malignancies: analysis of the Minneapolis Veterans Affairs (VA) tumor registry

PURPOSE

Multiple primary malignancies (MPMs) are increasing as cancer survivorship improves. A large analysis of the SEER database estimates that approximately 16 % of new cancers reported to their registry represent a second or higher order malignancy. The purpose of this study is to estimate the number of MPM diagnoses and to define differences in synchronous and metachronous cancers in the Veterans Affairs (VA) population.

METHODS

The primary objective of this study was to determine the proportion of second or higher order cancers diagnosed at the Minneapolis VA Medical Center from 1 January 2005 to 31 December 2009. The secondary objectives were to analyze and compare correlative demographic, exposure, clinical, and tumor data among those with synchronous and metachronous malignancies. We included any patient with a diagnosis of a malignant cancer during the study period.

RESULT

A total of 4,449 patients were diagnosed with malignancies during the study period. Of these, 506 patients (11.4 % of cancer diagnoses) had a diagnosis of a second or higher order malignancy. Of the 506 patients, 124 (24.3 %) had synchronous malignancies and 383 (75.5 %) had metachronous malignancies. The most common malignancy pairing was prostate cancer with bladder/ureter cancer (12 %) of MPM diagnoses. Differences between patients with synchronous and metachronous second occurrences were identified.

CONCLUSION

Multiple primary malignancies are a growing area of interest in cancer survivorship. At our institution, approximately 1 in 9 new cancer diagnoses during the 5-year study period represented second-order malignancies. Our data suggest that the VA population is at risk of developing second primary cancers. Further analysis of this population to identify unique risk factors is warranted.

Risk of prostate cancer among cancer survivors in the Netherlands

BACKGROUND

In parallel with increasing numbers of cancer patients and improving cancer survival, the occurrence of second primary cancers becomes a relevant issue. The aim of our study was to evaluate risk of prostate cancer as second primary cancer in a population-based setting.

METHODS

Data from the Netherlands Cancer Registry were used to estimate standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for prostate cancer as second primary cancer. The effect of time since first cancer diagnosis, specific first cancer sites, age, and pelvic radiotherapy was taken into account.

RESULTS

Out of 551,553 male patients diagnosed with a first primary cancer between 1989 and 2008, 9243 patients were subsequently diagnosed with prostate cancer. Overall, cancer survivors showed an increased risk (SIR 1.3, 95% CI 1.2-1.3) of prostate cancer. The increased prostate cancer risk was limited to the first year of follow-up for the majority of the specific first cancer sites. More than 10 years after the first cancer diagnosis, only melanoma patients were at increased risk (SIR 1.5, 95% CI 1.2-1.9), while patients with head or neck cancers were at decreased risk (SIR 0.7, 95% CI 0.5-0.9) of being diagnosed with prostate cancer. Patients who underwent primary pelvic radiotherapy for their first cancer had a decreased risk of prostate cancer in the long term (SIR 0.5, 95% CI 0.4-0.6).

CONCLUSIONS

Our data showed that cancer survivors have an increased prostate cancer risk in the first year following a first cancer diagnosis, which is most likely the result of active screening or incidental detection.

Increasing age and treatment modality are predictors for subsequent diagnosis of bladder cancer following prostate cancer diagnosis

PURPOSE

To determine the effect of prostate cancer therapy (surgery or external beam irradiation, or both or none) on the actuarial incidence of subsequent bladder cancer.

METHODS AND MATERIALS

The Surveillance, Epidemiology, and End Results registry from 1973 to 2005 was analyzed. Treatment was stratified as radiotherapy, surgery, both surgery and adjuvant radiation, and neither modality. Brachytherapy was excluded.

RESULTS

In all, 555,337 prostate carcinoma patients were identified; 124,141 patients were irradiated; 235,341 patients were treated surgically; 32,744 patients had both surgery and radiation; and 163,111 patients received neither modality. Bladder cancers were diagnosed in: 1,836 (1.48%) men who were irradiated (mean age, 69.4 years), 2,753 (1.09%) men who were treated surgically (mean age, 66.9 years); 683 (2.09%) men who received both modalities (mean age, 67.4 years), and 1,603 (0.98%) men who were treated with neither modality (mean age, 71.8 years). In each treatment cohort, Kaplan-Meier analyses showed that increasing age (by decade) was a significant predictor of developing bladder cancer (p < 0.0001). Incidence of bladder cancer was significantly different for either radiation or surgery alone versus no treatment, radiation versus surgery alone, and both surgery and radiation versus either modality alone (p < 0.0001). On multivariate analysis, age and irradiation were highly significant predictors of being diagnosed with bladder cancer.

CONCLUSIONS

Following prostate cancer, increasing age and irradiation were highly significant predictors of being diagnosed with bladder cancer. While use of radiation increased the risk of bladder cancer compared to surgery alone or no treatment, the overall incidence of subsequent bladder cancer remained low. Routine bladder cancer surveillance is not warranted.

Bladder cancer in cancer patients: population-based estimates from a large Swedish study

Background:

This study quantified the risk of urinary bladder neoplasms in cancer patients taking into account the age at first diagnosis, the gender of the patients and the lead time between diagnoses.

Methods:

We used standardised incidence ratios (SIRs) to compare the incidence of bladder tumours in 967 767 cancer patients with the incidence rate in the general Swedish population. A total of 3324 male and 1560 female patients developed bladder tumours at least 1 year after first cancer diagnosis.

Results:

After bladder and renal pelvis cancers, the SIRs of bladder neoplasms were higher in female than in male patients. Men affected by lung, stomach and larynx tumours belonged to the population at high risk for bladder cancer. Treatment of breast, ovarian and cervical cancers seems to contribute to the subsequent development of bladder neoplasms. Long latencies (16–25 years) were observed after testicular, cervical and endometrial cancers. Detection bias had an important role after prostate cancer. Chemotherapy with cyclophosphamide and cisplatin, and also radiotherapy, seem to increase the risk of subsequent neoplasms in the bladder.

Conclusions:

These population-based results may help urologists to assess the risk of bladder neoplasms in cancer survivors. Our data should guide ongoing studies that investigate the effectiveness of bladder cancer screening in cancer patients.

Prostate cancer as a first and second cancer: effect of family history

BACKGROUND

Diagnosis with prostate cancer has been reported to increase the risk of subsequent tumours. However, specific data on individuals with a parental history are not available so far.

METHODS

On the basis of the nationwide Swedish Family-Cancer Database including 18,207 primary invasive prostate cancers, standardised incidence ratios (SIRs) were used to estimate the relative risks of subsequent tumours after prostate cancer in the general population and among individuals with a parental history of cancer.

RESULTS

A significantly increased SIR of colorectal cancer was found among prostate cancer patients with a parental history of colorectal cancer (2.26, 11 cases). The SIRs of parental concordant (same site) tumours after prostate cancer were also increased for urinary bladder cancer (4.42, 4 cases) and chronic lymphoid leukaemia (38.0, 2 cases).

CONCLUSION

A higher than additive and multiplicative interaction was observed between the individual history of prostate cancer and parental history of colorectal and urinary bladder cancers, although the number of cases did not permit the rejection of any interaction model. The results suggest that the occurrence of second tumours, for example bladder after prostate or prostate after bladder tumours, is mostly related to shared genetic and non-genetic risk factors rather than treatment of first cancer.