Bladder Cancer Mortality in the United States: A Geographic and Temporal Analysis of Socioeconomic and Environmental Factors

Ambient air pollution and urological cancer risk: A systematic review and meta-analysis of epidemiological evidence

Exposure to ambient air pollution has significant adverse health effects; however, whether air pollution is associated with urological cancer is largely unknown. We conduct a systematic review and meta-analysis with epidemiological studies, showing that a 5 μg/m3 increase in PM2.5 exposure is associated with a 6%, 7%, and 9%, increased risk of overall urological, bladder, and kidney cancer, respectively; and a 10 μg/m3 increase in NO2 is linked to a 3%, 4%, and 4% higher risk of overall urological, bladder, and prostate cancer, respectively. Were these associations to reflect causal relationships, lowering PM2.5 levels to 5.8 μg/m3 could reduce the age-standardized rate of urological cancer by 1.5 ~ 27/100,000 across the 15 countries with the highest PM2.5 level from the top 30 countries with the highest urological cancer burden. Implementing global health policies that can improve air quality could potentially reduce the risk of urologic cancer and alleviate its burden.

GW4064 inhibits migration and invasion through cathepsin B and MMP2 downregulation in human bladder cancer

The ability of bladder cancer to invade and metastasize often leads to poor prognosis in bladder cancer patients. The aim of this study was to evaluate the effect of the farnesoid X receptor (FXR) agonist GW4064 on the migration and invasion of human bladder cancer cells. Long-term exposure to GW4064 decreased the colony formation of RT4 and T24 cells. The wound healing migration assay revealed an inhibitory effect of GW4064 on both of these bladder cancer cell lines. In addition, integrin β3 expression and myosin light chain phosphorylation were decreased after GW4064 treatment. Immunocytochemistry showed an increase in E-cadherin and a decrease in β-catenin in the cell membrane of bladder cancer cells. Total protein expression and membrane fractionation assays also indicated upregulation of E-cadherin and downregulation of β-catenin. Moreover, GW4064 reduced the invasion of muscle-invasive T24 cells. The GW4064-decreased migration and invasion were reversed by the proteasome inhibitor MG132 and the lysosome inhibitor NH4Cl. Furthermore, the GW4064-induced inhibition of matrix metalloproteinase-2 (MMP2) and cathepsin B expression was reversed by NH4Cl. Xenograft animal studies revealed that GW4064 declined MMP2, cathepsin B and lung metastasis of bladder cancer. In conclusion, GW4064 decreases the migration and invasion of human bladder cancer cells, which may provide a new therapeutic strategy for the treatment of human bladder cancer.

Longitudinal Analysis of Bladder Cancer-Specific Mortality Trends in the United States

BACKGROUND

Bladder cancer is the tenth leading cause of cancer death in the United States (US). Advances in diagnosis, imaging, and treatments have led to improvements in bladder cancer management.

OBJECTIVE

To evaluate longitudinal bladder cancer mortality trends from 1999-2020 in the US by gender, race, ethnicity, age, geographic region, and urbanization category.

METHODS

Age-adjusted bladder cancer death and incidence rates of individuals in the US of all ages between 1999-2020 were obtained using the CDC WONDER and NAACCR databases. Trends and average annual percent changes (AAPC) in age-adjusted Bladder Cancer-Specific Mortality (BCSM) and incidence rates were estimated. Data were analyzed from May 2023 to October 2023.

RESULTS

From 1999-2020, overall BCSM decreased by 0.4% annually, with a dramatic decrease in deaths between 2015-2020 (AAPC: -2.0% [95% CI: -2.6,-1.3]). However, BCSM rates and metastatic malignant bladder cancer incidence rates from 1999-2020 increased for individuals≥85 years old (AAPC for BCSM: 0.8% [95% CI:0.5,1.1]; AAPC for metastatic malignant incidence: 2.5% [95% CI: 2.0,2.9]). Increases in BCSM were found for certain years in the South, in rural areas, and for Non-Hispanic White and Asian or Pacific Islander individuals.

CONCLUSIONS

Overall mortality from bladder cancer has been decreasing in the US over two decades. Upon disaggregation, increasing trends were found for BCSM and for metastatic malignant bladder cancer incidence for individuals≥85 years old from 1999-2020. Further evaluation of these trends is essential to understand how to target specific populations to improve patient outcomes.

Insurance Type and Area Deprivation Are Associated With Worse Overall Mortality for Patients With Muscle-invasive Bladder Cancer

OBJECTIVE

To examine the association of area-level socioeconomic status, rural-urban residence, and type of insurance with overall and cancer-specific mortality among patients with muscle-invasive bladder cancer.

METHODS

Using the Pennsylvania Cancer Registry, which collects demographic, insurance, and clinical information on every patient with cancer within the state, we identified all patients diagnosed with non-metastatic muscle-invasive bladder cancer between 2010 and 2016 based on clinical and pathologic staging. We used the Area Deprivation Index (ADI) as a surrogate for socioeconomic status and Rural-Urban Commuting Area codes to classify urban, large town, and rural communities. ADI was reported in quartiles, with 4 representing the lowest socioeconomic status. We fit multivariable logistic regression and Cox models to assess the relationship of these social determinants with overall and cancer-specific survival adjusting for age, sex, race, stage, treatment, rural-urban classification, insurance and ADI.

RESULTS

We identified 2597 patients with non-metastatic muscle-invasive bladder cancer. On multivariable analysis, Medicare (hazards ratio [HR] 1.15), Medicaid (HR 1.38), ADI 3 (HR 1.16) and ADI 4 (HR 1.21) were independent predictors of greater overall mortality (all P < 0.05). Female sex and receipt of non-standard treatment were associated with increased overall mortality and bladder cancer-specific mortality. There was no significant difference in both overall and cancer-specific survival between patients who were non-Hispanic White compared to non-White or between those from urban areas, large towns, or rural locations.

CONCLUSION

Lower socioeconomic status and Medicare and Medicaid insurance were associated with a greater risk of overall mortality while rural residence was not a significant factor. Implementation of public health programs may help reduce the gap in mortality for low SES at-risk populations.

HER2 Expression in Bladder Cancer: A Focused View on Its Diagnostic, Prognostic, and Predictive Role

Bladder cancer (BC) is a heterogeneous disease from a molecular, morphological, and clinical standpoint. HER2 is a known oncogene involved in bladder carcinogenesis. Assessing HER2 overexpression as a result of its molecular changes in a routine pathology practice using immunohistochemistry might be a useful adjunct in several scenarios, namely (1) to correctly identify flat urothelial lesions and inverted urothelial lesions in the diagnostic setting; (2) to provide prognostic hints in both non-muscle invasive (NMI) and muscle invasive (MI) tumors, thus supplementing risk stratification tools, especially when evaluating higher-risk tumors such as those with variant morphology; (3) to improve antibody panels as a surrogate marker of BC molecular subtyping. Furthermore, the potential of HER2 as a therapeutic target has been only partly explored so far, in light of the ongoing development of novel target therapies.

Fine particulate matter induces METTL3-mediated m6A modification of BIRC5 mRNA in bladder cancer

Long-term exposure to fine particulate matter (PM_2.5) is reportedly related to a variety of cancers including bladder cancer. However, little is known about the biological mechanism underlying this association. In the present study, PM_2.5 exposure was significantly associated with increased levels of m⁶A modification in bladder cancer patients and bladder cells. METTL3 expression was aberrantly upregulated after PM_2.5 exposure, and METTL3 was involved in PM_2.5-induced m⁶A methylation. Higher METTL3 expression was observed in bladder cancer tissues and METTL3 knockdown dramatically inhibited bladder cancer cell proliferation, colony formation, migration and invasion, inducing apoptosis and disrupting the cell cycle. Mechanistically, PM_2.5 enhanced the expression of METTL3 by inducing the promoter hypomethylation of its promoter and increasing the binding affinity of the transcription factor HIF1A. BIRC5 was identified as the target of METTL3 through m⁶A sequencing (m⁶A-Seq) and KEGG analysis. The methylated BIRC5 transcript was subsequently recognized by IGF2BP3, which increased its mRNA stability. In particular, PM_2.5 exposure promoted the m⁶A modification of BIRC5 and its recognition by IGF2BP3. In addition, BIRC5 was involved in bladder cancer proliferation and metastasis, as well as VEGFA-regulated angiogenesis_. This comprehensive study revealed that PM_2.5 exposure exerts epigenetic regulatory effects on bladder cancer via the HIF1A/METTL3/IGF2BP3/BIRC5/VEGFA network.

Variation in and Factors Associated With US County-Level Cancer Mortality, 2008-2019

IMPORTANCE

The association between cancer mortality and risk factors may vary by geography. However, conventional methodological approaches rarely account for this variation.

OBJECTIVE

To identify geographic variations in the association between risk factors and cancer mortality.

DESIGN, SETTING, AND PARTICIPANTS

This geospatial cross-sectional study used county-level data from the National Center for Health Statistics for individuals who died of cancer from 2008 to 2019. Risk factor data were obtained from County Health Rankings & Roadmaps, Health Resources and Services Administration, and Centers for Disease Control and Prevention. Analyses were conducted from October 2021 to July 2022.

MAIN OUTCOMES AND MEASURES

Conventional random forest models were applied nationwide and by US region, and the geographical random forest model (accounting for local variation of association) was applied to assess associations between a wide range of risk factors and cancer mortality.

RESULTS

The study included 7 179 201 individuals (median age, 70-74 years; 3 409 508 women [47.5%]) who died from cancer in 3108 contiguous US counties during 2008 to 2019. The mean (SD) county-level cancer mortality rate was 177.0 (26.4) deaths per 100 000 people. On the basis of the variable importance measure, the random forest models identified multiple risk factors associated with cancer mortality, including smoking, receipt of Supplemental Nutrition Assistance Program (SNAP) benefits, and obesity. The geographical random forest model further identified risk factors that varied at the county level. For example, receipt of SNAP benefits was a high-importance factor in the Appalachian region, North and South Dakota, and Northern California; smoking was of high importance in Kentucky and Tennessee; and female-headed households were high-importance factors in North and South Dakota. Geographic areas with certain high-importance risk factors did not consistently have a corresponding high prevalence of the same risk factors.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, the associations between cancer mortality and risk factors varied by geography in a way that did not correspond strictly to risk factor prevalence. The degree to which other place-specific characteristics, observed and unobserved, modify risk factor effects should be further explored, and this work suggests that risk factor importance may be a preferable paradigm for selecting cancer control interventions compared with risk factor prevalence.

KRT6A expedites bladder cancer progression, regulated by miR-31-5p

Bladder cancer is one of the most severe life-threatening illnesses worldwide. To contribute to a solution to this public health issue, here, we sought to identify a novel biomarker for the early diagnosis of bladder tumors. We conducted RNA sequence analysis utilizing samples from tumorous tissue and adjacent healthy tissue in bladder cancer patients and found that KRT6A was upregulated in bladder tumor tissues, suggesting that it might be a candidate for involvement in bladder tumorigenesis. Accordingly, we performed a series of experiments to further verify the role of KRT6A in bladder tumor progression. Our results revealed that KRT6A promoted bladder tumor cell viability, proliferation, and adhesion, while diminishing bladder tumor cell apoptosis. We also focused on the role of epigenetics in bladder tumors and verified that KRT6A was a miR-31-5p target gene, and its positive effect on bladder tumor progression was relieved by miR-31-5p. Overall, this study sheds new light regarding a novel oncogenic regulatory axis, KRT6A/miR-31-5p, which is related to bladder tumor growth.

Wnt/β-Catenin Signalling and Its Cofactor BCL9L Have an Oncogenic Effect in Bladder Cancer Cells

Bladder cancer (BC) is characterised by a high recurrence and progression rate. However, the molecular mechanisms of BC progression remain poorly understood. BCL9L, a coactivator of β-catenin was mutated in the 5′ and 3′ untranslated regions (UTRs). We assessed the influence of UTRs mutations on BCL9L, and the role of BCL9L and Wnt/β-catenin signalling in BC cells. UTR mutations were analysed by a luciferase reporter. BCL9L protein was assessed by immunohistochemistry in BC tissues. Cell proliferation was examined by crystal violet staining and by the spheroid model. Moreover, migration and invasion were analysed in real-time using the xCelligence RTCA system. The A > T mutation at 3′ UTR of BCL9L reduces the luciferase reporter mRNA expression and activity. BCL9L is predominantly increased in dysplastic urothelial cells and muscle-invasive BC. Knockdown of BCL9L and inhibition of Wnt/β-catenin signalling significantly repress the proliferation, migration and invasion of Cal29 and T24. In addition, BCL9L knockdown reduces mRNA level of Wnt/β-catenin target genes in Cal29 but not in T24 cells. BCL9L and Wnt/β-catenin signalling play an oncogenic role in bladder cancer cells and seems to be associated with BC progression. Nevertheless, the involvement of BCL9L in Wnt/β-catenin signalling is cell-line specific.

Surgery improves survival in bladder signet-ring cell carcinoma-a population-based study

Objectives:

The purpose of this study is to determine the therapeutic value of surgery in individuals with urinary bladder signet ring cell carcinoma (SRCC). Surgery has not been examined as a prognostic factor for urinary bladder cancer (SRCC).

Materials and Methods:

Using the Surveillance, Epidemiology, and End Results program (SEER), patients with urinary bladder SRCC who presented from 1975 to 2018 were included in a retrospective study. The effect of surgical therapy on cause-specific survival (CSS) and overall survival (OS) was examined using univariate and multivariate Cox regression models. We subdivided 595 patients with SRCC into 2 groups, as follows: 496 who underwent surgery; and 99 who did not undergo surgery.

Results:

Males had high predominance in all cases in both groups ( p = 0.04). Moderate and poor differentiation (III–IV) were observed in the majority of patients who underwent surgery (77.2 vs 58.6, p ⩽ 0.001) and had no insurance ( p ⩽ 0.001). By using KM, the OS and CSS of the surgery group were found to be significantly better than those of the non-surgery group ( p  = 0.001,%) after adjusting for the variables of age, race, sex, primary site, grade, stage, lymph node removal, chemotherapy record, radiotherapy record, insurance, and marital status in the multivariate Cox proportional hazard model (hazard ratio [HR]= 0. 592; 95% confidence interval [CI] = 0.449–0.782; p = 0.0001). In comparison with chemotherapy and radiation, which resulted in poorer survival rates, surgery considerably improved survival outcomes in urinary bladder SRCC. The nomogram prediction model was built with C-index values of 0.70 and 73 for OS and CSS prediction, respectively. AUC in OS values were 0.77, 0.76, and 0.74, whereas AUC in CSS were 0.83, 0.80, and 0.79 for the 1-, 3-, and 5-year survival nomograms, respectively.

Conclusion:

Surgery was a significant independent predictor of bladder SRCC survival. Patients who underwent surgery had higher CSS and OS than people who did not undergo surgery. Surgery also led to better survival than the combination of the different treatment modalities.

Risk of bladder cancer and lymphoma in dogs is associated with pollution indices by county of residence

Human urothelial cell carcinoma (UCC) and non-Hodgkin lymphoma are considered environmental cancers in people, but less is known about environment risk for UCC and lymphoma in dogs. The objective of this study was to determine whether dogs with these cancers, compared to unaffected control dogs, live in counties with higher tap water contaminants or higher levels of air pollution as measured by the Environmental Protection Agency (EPA) and by National Air Toxics Assessment chemical exposure risk estimates. Dogs with available home addresses from two previously published case-control populations were included: 66 dogs with UCC and 70 unaffected controls; and 56 boxer dogs with lymphoma and 84 unaffected boxer controls. Tap water total trihalomethanes, which are water disinfection by-products, were more than threefold higher in UCC case counties of residence compared to controls (p < .0001), and a higher proportion of dogs with UCC lived in counties exceeding EPA ozone limits (41.8%) compared to controls (13.6% p = .0008). More boxers with lymphoma lived in counties exceeding EPA ozone limits (52.1%) compared to controls (29.0%; p = .018), with higher exposure risk estimates for airborne 1,3-butadiene and formaldehyde (p = .004-.005). These data support the hypothesis that tap water contaminants and airborne environmental pollutants contribute to the risk of both urothelial carcinoma and lymphoma in dogs. If these findings reflect causal relationships, then it is possible that tap water filtration units and more effective air pollution controls could decrease the overall incidence of these cancers in dogs.

The Significance of Squamous Histology on Clinical Outcomes and PD-L1 Expression in Bladder Cancer

Objectives. To compare the clinicopathologic characteristics of urothelial carcinoma (UC), urothelial carcinoma with squamous differentiation (UCSD), and squamous cell carcinoma (SCC) of the bladder, which have been suggested to differ in terms of risk factors, immunophenotype, and prognosis. Methods. We evaluated the clinicopathologic features of radical cystectomy specimens between 1980 and 2015 with a diagnosis of SCC, UCSD, and UC. PD-L1 immunohistochemistry (clinically available clones 22C3, SP142, and SP263) was performed on SCC and UCSD. Multivariate Cox regression was used to identify prognostic factors. Kaplan-Meier curves were plotted to assess cancer-specific survival (CSS). Results. Of the 1478 cases, there were 1126 UC (76%), 217 UCSD (15%), and 135 SCC (9%). Bladder cancer was more common in men than women (80% vs 20%, P < .0001). However, a higher proportion of SCC and UCSD occurred in women (SCC-36%, UCSD-22%, UC-18%). Women were significantly more likely to be never smokers in all 3 cohorts (UC: 45% vs 16%, UCSD: 44% vs 12%, SCC: 40% vs 18%, P < .0001). Patients with SCC and UCSD were at a higher pathologic stage (>pT2) at the time of cystectomy (UCSD-74%, SCC 71%, UC-44%, P < .0001) and had worse CSS compared to patients with UC (P = 0.006). SCC had higher PD-L1 scores (all clones) than UCSD (P < .0001). PD-L1 22C3 (P = .02, HR: 0.36) and SP142 scores (P = .046, HR: 0.27) predicted CSS on Kaplan-Meier analysis for SCC cases. Conclusions. UC, UCSD, and SCC are associated with different risk factors, gender distributions, and clinical outcomes. PD-L1 is expressed in SCC and UCSD, suggesting some patients may benefit from targeted therapy.

Gender-related outcomes in robot-assisted radical cystectomy: A multi-institutional study

Purpose

Robot-assisted radical cystectomy (RARC) optimizes patient recovery and has outcomes comparable with those of open surgery. This study aimed to compare the perioperative and oncologic outcomes of RARC in female and male patients.

Materials and Methods

A retrospective cohort study of the Korean Robot-Assisted Radical Cystectomy Study Group database from 2007 to 2019 identified 749 patients (111 females and 638 males). Female were matched 1:1 to male by propensity score matching using a logistic regression. We compared perioperative outcomes, oncologic outcomes, and complications between the two groups.

Results

The female group had comparable perioperative outcomes to the male group in terms of operation time, lymph node yield, positive surgical margin, blood transfusion rate, and hospitalization days. Complication rate and grade were not significantly different between the two groups. The most common complication was infection in female and gastrointestinal complications in male. We compared the 5-year overall, disease-specific, and recurrence-free survival of female and male: 58.2% vs. 68.0% (p=0.495), 75.7% vs. 79.3% (p=0.645), and 40.8% vs. 53.5% (p=0.913), respectively. On multivariable analysis, T stage (>T2), postoperative complications, and positive surgical margin were prognostic factors of poor outcome. Sex was not an independent predictor of the three survivals.

Conclusions

The current study suggests that RARC in female has comparable perioperative and oncologic outcomes to those in male. The complication rate of RARC in female was comparable to that in male, but the type of complications differed by sex.

Bladder Cancer and Google Trends: Associations Between US Search Patterns and Disease Outcomes May Show Need for Improved Awareness Strategies

Interest in and awareness of bladder cancer may translate to better health-seeking behaviors and earlier detection, given modifiable risk factors such as smoking. We assessed bladder cancer interest in the USA over the past 15 years as reflected by Internet search trends, and correlated these trends with epidemiologic patterns in bladder cancer. Google Trends was used to estimate US bladder cancer interest in the unit search volume index (SVI), which estimates the volume of online search activity for a specified period relative to the highest volume of searches within a specified location. Between January 2004 and June 2019, SVIs were collected for the search term "bladder cancer" and other related search terms. To evaluate the effect of public awareness campaigns, the SVIs for the month of May (US bladder cancer awareness month) were compared with the SVIs of all other months. Correlations between "bladder cancer" SVI and incidence, mortality, and mortality-to-incidence ratio (proxy for survival) by state were evaluated. There was no increase in the relative search volumes for "bladder cancer" during the national bladder cancer awareness month compared with all other months (p = 0.27). By state, there were positive correlations between SVIs of "bladder cancer" and incidence (R = 0.72, p < 0.001) and mortality (R = 0.47, p < 0.001). However, there was no correlation between SVIs and mortality-to-incidence ratio (R = - 0.24, p = 0.08). Interest in bladder cancer is positively associated with disease incidence and mortality but not survival, suggesting interest is driven by new diagnoses or deaths, and not early detection that can improve survival. Our findings may show the need for better public education endeavors.

Cohort studies of long-term exposure to outdoor particulate matter and risks of cancer: A systematic review and meta-analysis

Robust evidence is needed for the hazardous effects of outdoor particulate matter (PM) on mortality and morbidity from all types of cancers. To summarize and meta-analyze the association between PM and cancer, published articles reporting associations between outdoor PM exposure and any type of cancer with individual outcome assessment that provided a risk estimate in cohort studies were identified via systematic searches. Of 3,256 records, 47 studies covering 13 cancer sites (30 for lung cancer, 12 for breast cancer, 11 for other cancers) were included in the quantitative evaluation. The pooled relative risks (RRs) for lung cancer incidence or mortality associated with every 10-μg/m³ PM_2.5 or PM₁₀ were 1.16 (95% confidence interval [CI], 1.10–1.23; I² = 81%) or 1.22 (95% CI, 1.02–1.45; I² = 96%), respectively. Increased but non-significant risks were found for breast cancer. Other cancers were shown to be associated with PM exposure in some studies but not consistently and thus warrant further investigation.

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Updated evidence for the association between PM and lung cancer risk has been provided

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Associations between PM and cancer risks from 13 sites were summarized

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Further studies should be conducted to fill the research gaps

Bladder Cancer: Current Challenges and Future Directions

Bladder cancer (BCa) is the most common malignancy of the urinary tract and one of the most prevalent cancers worldwide. While the clinical approach to BCa has remained largely unchanged for many years, recent discoveries have paved the way to a new era of diagnosis and management of the disease. BCa-specific mortality started to decrease in the regions with a wide range of activities leading to greater social awareness of the risk factors and the decline in carcinogenic exposure. The urologic community refines the role of transurethral surgery towards more rigorous and high-quality techniques. New agents have been approved for patients with BCG failure who faced radical cystectomy so far. Although radical removal of the bladder is the gold standard for muscle invasive cancer management, the extent and clinical value of lymphadenectomy is currently heavily challenged in randomized trials. Furthermore, alternatives to perioperative chemotherapy have arisen to increase the likelihood of complete treatment delivery and successful oncological outcomes. Finally, improvements in molecular biology and our understanding of tumorigenesis open the era of personalized medicine in bladder cancer. In the present review, the status and future directions in bladder cancer epidemiology, diagnosis and management are thoroughly discussed.

Can Aspirin Use Be Associated With the Risk or Prognosis of Bladder Cancer? A Case-Control Study and Meta-analytic Assessment

Aspirin, widely used to prevent cardiovascular disease, had been linked to the incidence of bladder cancer (BCa). Existing studies focusing on Chinese populations are relatively rare, especially for Northeast China. Meanwhile, relevant studies on the effects of aspirin on the occurrence or prognosis of BCa are inconsistent or even controversial. First, in the case control study, logistic regression analysis was used to investigate the association between aspirin intake and risk of BCa including 1121 patients with BCa and the 2242 controls. Subsequently, Kaplan-Meier curve and Cox regression analyses were applied to explore the association between aspirin intake and clinicopathological factors which may predict overall survival (OS) and recurrence-free survival (RFS) of BCa patients. Finally, we quantificationally combined the results with those from the published literature evaluating aspirin intake and its effects on the occurrence, outcome of surgery and prognosis of BCa by meta-analysis up to May 1, 2021.Our case-control study demonstrated that the regular use of aspirin was not associated with a reduced incidence of BCa (P=0.175). Stratified analyses of sex showed that aspirin intake did not lead to a lower risk of BCa in female patients (P=0.063). However, the male population who regularly took aspirin had a lower incidence of BCa (OR=0.748, 95% CI= 0.584-0.958, P=0.021). Subgroup analyses stratified by smoking found a significant reduction in the risk of BCa in current smokers with aspirin intake (OR=0.522, 95% CI=0.342-0.797, P=0.002). In terms of prognosis of BCa, patients with a history of aspirin intake did not had a markedly longer OS or RFS than those with no history of aspirin intake by Kaplan-Meier curves. Stratified analysis by sex showed no correlation between aspirin intake and the recurrence or survival of BCa for either male or female patients. However, in people younger than 68, aspirin intake seemed to have prolonged effects for overall survival (HR=3.876; 95% CI=1.326-11.325, P=0.019). Then, we performed a meta-analysis and the combined results from 19 articles and our study involving more than 39524 BCa cases indicated that aspirin intake was not associated with the occurrence of BCa (P=0.671). Subgroup analysis by whether regular use of aspirin, by the mean duration of use of aspirin, by sex, by smoking exposure, by research region and by study type also supported the above results. In terms of the impact of aspirin intake on the prognosis of patients with BCa, 11 articles and our study involving 8825 BCa cases were eligible. The combined results showed that patients with aspirin intake did not have significantly influence on survival, recurrence, progression and metastasis than those without aspirin intake. On the whole, both our retrospective study and literature meta-analysis suggested a lack of a strong relevant association between the use of aspirin and the incidence or prognosis of BCa. Thus, additional long-term follow-up prospective research is warranted to clarify the association of aspirin with BCa incidence and prognosis.

Bladder Cancer Incidence and Survival in the United States and Texas Non-Latino Whites and Latinos

BACKGROUND: Bladder cancer (BC) poses an enormous burden on health care systems. Latinos in Texas (TX) were underrepresented in previous studies on racial/ethnic disparity of BC in the US. OBJECTIVE: To examine whether BC incidence and survival rates differ among Latinos compared to non-Latino whites (NLW) in South TX, TX, and the US SEER. METHODS: Data was collected from the US SEER Program and the Texas Cancer Registry. Annual age-specific and age-adjusted BC incidence rates and annual 5-year relative survival were calculated. RESULTS: South TX and TX had significantly lower BC incidence rates than SEER for both Latinos and NLW regardless of gender (Ps < 0.05). South TX women had worse BC survival rates than SEER women for both Latinos and NLW (Ps < 0.05). TX NLW had worse BC survival rates than SEER NLW for both genders together and men only (Ps < 0.05). All Latino groups had lower incidence but worse survival rates than NLW groups for both men and women in each geographic area (all Ps < 0.05). Women had significantly lower BC incidence but worse survival rates than men regardless of race/ethnicity in each geographic area (all Ps < 0.05). CONCLUSIONS: South TX women had lower BC incidence but worse survival rates than US SEER women for both Latinos and NLW. Latinos had worse survival but lower incidence rates than NLW. Women had lower BC incidence but worse survival rates than men. The study identifies the BC distribution and high-risk population, racial/ethnic disparities, and geographic differences. It facilitates health care services planning.

Application of GIS Spatial Analysis and Scanning Statistics in the Gynecological Cancer Clustering Pattern and Risk Screening: A Case Study in Northern Jiangxi Province, China

OBJECTIVE

The incidence of gynecological cancer is high in China, and the effects of related treatments and preventive measures need to be improved.

METHODS

This study uses GIS spatial analysis methods and a scanning statistical analysis to study the major gynecological cancers in northern Jiangxi Province from 2016 to 2018.

RESULTS

The incidence and spatial pattern of cervical cancer, ovarian cancer, and uterine cancer had agglomeration characteristics and changes during the study period. The gynecological cancer had a spatial autocorrelation and agglomeration in its spatial pattern. The Moran's Index of the overall gynecological cancer incidence rate was 0.289 (p = 0.005). Ripley's L(d) function showed that the agglomeration radius was between 51.40 and 52.82 km. The results of the kernel density estimation showed that the cases of gynecological cancer were concentrated in the central and northeastern areas of the study area. The overall county-level incidence of gynecological cancer varied from 0.26 to 11.14 per 100,000. The results of the gravity center analysis showed that the spatial distribution of the gravity center point of gynecological cancer had moved toward the east during the past three years. The results of a hotspot analysis showed that there were five hotspot areas that had gynecological cancers. The most likely clusters of gynecological cancer at the county level in northern Jiangxi Province were distributed in the adjacent areas of Jiujiang, Yichun, and Nanchang, with a relative risk of 1.85.

CONCLUSION

The research shows that GIS can display the distribution of cancer cases and can use spatial analysis methods and scanning statistical techniques to obtain key areas of cancer incidence. These results can provide data and key areas for the formulation of regional public health policies and provide recommendations for cancer screening and the rational allocation of health resources.

Determinants of neoadjuvant chemotherapy use in muscle-invasive bladder cancer

Purpose

Cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer (MIBC). However, NAC is used in less than 20% of patients with MIBC. Our goal is to investigate factors that contribute to underutilization NAC to facilitate more routine incorporation into clinical practice.

Materials and Methods

We identified 5,915 patients diagnosed with cT2-T3N0M0 MIBC who underwent RC between 2004 and 2014 from the National Cancer Database. Univariate and multivariable models were created to identify variables associated with NAC utilization.

Results

Only 18.8% of patients received NAC during the study period. On univariate analyses, NAC utilization was more likely at academic hospitals, US South and Midwest (p<0.05). Higher Charlson score was associated with decrease use of NAC (p<0.05). On multivariate analysis, treatment in academic hospitals (odds ratio [OR], 1.367; 95% confidence interval [CI], 1.186–1.576), in the Midwest (OR, 1.538; 95% CI, 1.268–1.977) and South (OR, 1.424; 95% CI, 1.139–1.781) were independently associated with NAC utilization. Older age (75 to 84 years old; OR, 0.532; 95% CI, 0.427–0.664) and higher Charlson score (OR, 0.607; 95% CI, 0.439–0.839) were associated with decreased NAC utilization. Sixty-eight percent of patients did not receive NAC because it was not planned and only 2.5% of patients had contraindications for NAC treatment.

Conclusions

Our study demonstrates that NAC is underutilized. Decreased utilization of NAC was associated with older patients and higher Charlson score. This underutilization may be related to practice patterns as very few patients have true contraindications.

Association between Post-Diagnosis Particulate Matter Exposure among 5-Year Cancer Survivors and Cardiovascular Disease Risk in Three Metropolitan Areas from South Korea

Cancer survivors are at an increased risk for cardiovascular disease (CVD). However, the association between particulate matter (PM) and CVD risk among cancer survivors (alive >5 years since diagnosis) is unclear. We investigated the risk of CVD among 40,899 cancer survivors within the Korean National Health Insurance Service database. Exposure to PM was determined by assessing yearly average PM levels obtained from the Air Korea database from 2008 to 2011. PMs with sizes <2.5 (PM2.5), <10 (PM10), or 2.5-10 (PM2.5-10) μm in diameter were compared, with each PM level exposure further divided into quintiles. Patients were followed up from January 2012 to date of CVD event, death, or December 2017, whichever came earliest. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CVD were calculated using Cox proportional hazards regression by PM exposure levels. Compared with cancer survivors in the lowest quintile of PM2.5 exposure, those within the highest quintile had a greater risk for CVD (aHR 1.31, 95% CI 1.07-1.59). Conversely, increasing PM10 and PM2.5-10 levels were not associated with increased CVD risk (p for trend 0.078 and 0.361, respectively). Cancer survivors who reduce PM2.5 exposure may benefit from lower risk of developing CVD.

Identification of the Key Factors Related to Bladder Cancer by lncRNA-miRNA-mRNA Three-Layer Network

Bladder cancer is the most common malignant tumor of the urinary system, and it has high incidence, high degree of malignancy, and easy recurrence after surgery. The etiology and pathogenesis of bladder cancer are not fully understood, but more and more studies have shown that its development may be regulated by some core molecules. To identify key molecules in bladder cancer, we constructed a three-layer network by merging lncRNA-miRNA regulatory network, miRNA-mRNA regulatory network, and lncRNA-mRNA coexpression network, and further analyzed the topology attributes of the network including the degree, betweenness centrality and closeness centrality of nodes. We found that miRNA-93 and miRNA-195 are controllers for a three-layer network and regulators of numerous target genes associated with bladder cancer. Functional enrichment analysis of their target mRNAs revealed that miRNA-93 and miRNA-195 may be closely related to bladder cancer by disturbing the homeostasis of the cell cycle or HTLV-I infection. In addition, since E2F1 and E2F2 are enriched in various KEGG signaling pathways, we conclude that they are important target genes of miRNA-93, and participate in the apoptotic process by forming a complex with a certain protein or transcription factor activity, sequence-specific DNA binding in bladder cancer. Similarly, AKT3 is an important target gene of miRNA-195, its expression is associated with PI3K-Akt-mTOR signaling pathway and AMPK-mTOR signaling pathway. Therefore, we speculate that AKT3 may participate in proliferation and apoptosis of bladder cancer cells through these pathways, and ultimately affect the biological behavior of tumor cells. Furthermore, through survival analysis, we found that miRNA-195 and miRNA-93 are associated with poor prognosis of bladder cancer. And the Kaplan-Meier curve showed that 24 mRNAs and nine lncRNAs are closely related to overall survival of bladder cancer.

Occupational disparities in bladder cancer survival: A population-based cancer registry study in Japan

Background

Little is known about occupational disparities in bladder cancer survival.

Methods

Using data from a population‐based cancer registry (1970‐2016), we identified 3593 patients with incident bladder cancer diagnosed during 1970‐2011 who completed occupational information. The patients were followed for 5 years (median follow‐up time 5.0 years). Their longest‐held occupations at incident bladder cancer diagnosis were classified according to a national standardized classification. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall death were estimated by Cox proportional hazard model, adjusted for age, sex, and year of diagnosis. Clerical workers served as the reference group.

Results

Overall prognosis was fair in this population (5‐year overall survival, 61.9%). Compared with patients in clerical jobs, survival was poorer for those in professional and managerial jobs (mortality HR 1.36; 95% CI 1.09‐1.69), sales and service jobs (HR 1.25, 95% CI 1.01‐1.56), construction jobs (HR 1.83, 95% CI 1.40‐2.38), and manufacturing jobs (HR 1.32, 95% CI 1.05‐1.66), as well as those not actively employed (HR 1.27, 95% CI 1.02‐1.58). A similar pattern was observed in the subgroup analyses restricted to male patients as well as additional analyses adjusted for potential prognostic variables (eg, stage) with multiple imputation.

Conclusion

We documented occupational disparities in bladder cancer survival in Japan. However, the pattern of disparity did not favor highest occupational groups.

Role of androgen receptor expression in non-muscle-invasive bladder cancer: a systematic review and meta-analysis

In order to evaluate the potential prognostic/predictive role of androgen receptor (AR) expression in non-muscle-invasive bladder cancer (NMIBC), and whether it may represent a therapeutic target, we conducted a systematic search of the literature using 'androgen receptor or AR', 'testosterone', 'bladder cancer' and 'non-muscle invasive bladder cancer or NMIBC' as keywords. Eleven studies met the inclusion/exclusion criteria. No significant association was found between AR status and patients' gender (p=0.232), tumor size (p=0.975), tumor stage (p=0.237), tumor grade (p=0.444), tumor multicentricity (p=0.397), concomitant CIS (p=0.316) and progression of disease (p=0.397). On the other hand, relative lack of AR expression was significantly correlated to recurrent disease (p=0.001). Evidence for a direct correlation between AR expression and recurrence-free survival of patients with NMIBC indicate ARs as potential markers of BC behavior; moreover, the finding of a role of androgen blockade therapy in improving survival highlights the potential clinical application of this pathway, which deserves to be further explored.

Outcomes of upper tract urothelial carcinoma with isolated lymph node involvement following surgical resection: implications for multi-modal management

BACKGROUND

There are limited data on the oncologic outcomes of upper tract urothelial carcinoma with isolated lymph node (LN) involvement (pN+ M0) following surgical resection. We examined pN+ M0 UTUC in a large, nationwide oncology dataset to characterize its natural history, describe trends in utilization of perioperative chemotherapy, and identify clinicopathologic features associated with survival.

METHODS

We identified 794 patients aged 18-89 years who underwent radical nephroureterectomy with lymph node dissection for pN+ M0 UTUC from 2006 to 2013 in the National Cancer Database. The associations of clinicopathologic features with overall survival (OS) were evaluated using Cox regression models, and a simplified risk score was created.

RESULTS

Median follow-up among survivors was 39.5 months, during which time 555 (70%) patients died. Over the study period, neoadjuvant chemotherapy utilization increased from 6.7 to 14.2% (p = 0.002), while adjuvant chemotherapy utilization remained stable (42.7 to 44.3%; p = 0.86). One-, 5-, and 8-year OS rates were 63.7%, 24.2%, and 18.7%, respectively. On multivariable analysis, older age, larger tumor size, higher pT stage, positive surgical margins, number of positive LNs, and non-receipt of adjuvant chemotherapy were independently associated with worse OS. A simplified risk score consisting of age, tumor size, pT stage, number of positive LNs, and margin status was created with predicted 5-year OS ranging from 12 to 44%.

CONCLUSIONS

In this large, contemporary cohort, pN+ M0 UTUC was associated with a 5-year OS of only 24%. Clinicopathologic predictors of survival after surgical resection may improve risk-stratification, counseling, and selection of patients for multimodal management.

SOX4 regulates invasion of bladder cancer cells via repression of WNT5a

Sry-Related HMG-BOX-4 (SOX4) is a developmental transcription factor that is overexpressed in as many as 23% of bladder cancer patients; however, the role of SOX4 in bladder cancer tumorigenesis is not yet well understood. Given the many roles of SOX4 in embryonic development and the context-dependent regulation of gene expression, in this study, we sought to determine the role of SOX4 in bladder cancer and to identify SOX4-regulated genes that may contribute to tumorigenesis. For this purpose, we employed a CRISPR interference (CRISPRi) method to transcriptionally repress SOX4 expression in T24 bladder cancer cell lines, 'rescued' these cell lines with the lentiviral-mediated expression of SOX4, and performed whole genome expression profiling. The cells in which SOX4 was knocked down (T24-SOX4-KD) exhibited decreased invasive capabilities, but no changes in migration or proliferation, whereas rescue experiments with SOX4 lentiviral vector restored the invasive phenotype. Gene expression profiling revealed 173 high confidence SOX4-regulated genes, including WNT5a as a potential target of repression by SOX4. Treatment of the T24-SOX4-KD cells with a WNT5a antagonist restored the invasive phenotype observed in the T24-scramble control cells and the SOX4 lentiviral-rescued cells. High WNT5a expression was associated with a decreased invasion and WNT5a expression inversely correlated with SOX4 expression, suggesting that SOX4 can negatively regulate WNT5a levels either directly or indirectly and that WNT5a likely plays a protective role against invasion in bladder cancer cells.

A spatial study of bladder cancer mortality and incidence in the contiguous US: 2000-2014

Bladder cancer is a significant health issue across the United States of America (USA). Evidence of unequal distribution of a disease or condition's incidence and mortality would suggest that important geographically-defined variables may play a role. In this study, a spatial cluster analysis of bladder cancer mortality identified significant hot spots in some parts of the USA. Regression analysis modelling estimated the effects of selected covariates or risk factors for bladder cancer mortality and also incidence. Spatial heat maps and cluster identification were done for mortality and incidence. The main result was the significant association between bladder cancer mortality and arsenic intake from well water. A similar result was also obtained for cancer incidence and arsenic. Additionally, there are certain geographic areas that appear to have bladder cancer mortality rates beyond the simple association with the studied covariates. These geographic areas warrant further investigation to better understand why cancer mortality is unusually high in such geographic areas and to potentially identify additional local concerns or needs to further address bladder cancer mortality in those specific sites.

lncRNA CASC11 promotes cancer cell proliferation in bladder cancer through miRNA-150

Long noncoding RNAs (lncRNAs) CASC11 is an oncogenic lncRNA in gastric cancer and colorectal cancer. Our study aimed to investigate the role of lncRNA CASC11 in bladder cancer. In this study we showed that plasma lncRNA CASC11 was upregulated, while plasma miRNA-150 was downregulated in patients with early-stage bladder cancer than in healthy controls. Altered expression of plasma lncRNA CASC11 and miRNA-150 separated patients with bladder cancer from healthy controls. lncRNA CASC11 expression was inversely correlated with miRNA-150 expression in patients with bladder cance but not in healthy controls. Overexpression of lncRNA CASC11 mediated the inhibition of miRNA-150 expression in cancer cells, while miRNA-150 overexpression did not significantly alter lncRNA CASC11 expression. lncRNA CASC11 overexpression promoted, while miRNA-150 overexpression inhibited cancer cell proliferation. miRNA-150 also attenuated the enhancing effects of lncRNA CASC11 overexpression on cancer cell proliferation. However, overexpression of lncRNA CASC11 showed no significant effects on cancer cell migration and invasion. Therefore, lncRNA CASC11 may promote cancer cell proliferation in bladder cancer, and the actions of lncRNA CASC11 are likely through miRNA-150.

Revisiting Histone Deacetylases in Human Tumorigenesis: The Paradigm of Urothelial Bladder Cancer

Urinary bladder cancer is a common malignancy, being characterized by substantial patient mortality and management cost. Its high somatic-mutation frequency and molecular heterogeneity usually renders tumors refractory to the applied regimens. Hitherto, methotrexate-vinblastine-adriamycin-cisplatin and gemcitabine-cisplatin represent the backbone of systemic chemotherapy. However, despite the initial chemosensitivity, the majority of treated patients will eventually develop chemoresistance, which severely reduces their survival expectancy. Since chromatin regulation genes are more frequently mutated in muscle-invasive bladder cancer, as compared to other epithelial tumors, targeted therapies against chromatin aberrations in chemoresistant clones may prove beneficial for the disease. “Acetyl-chromatin” homeostasis is regulated by the opposing functions of histone acetyltransferases (HATs) and histone deacetylases (HDACs). The HDAC/SIRT (super-)family contains 18 members, which are divided in five classes, with each family member being differentially expressed in normal urinary bladder tissues. Since a strong association between irregular HDAC expression/activity and tumorigenesis has been previously demonstrated, we herein attempt to review the accumulated published evidences that implicate HDACs/SIRTs as critical regulators in urothelial bladder cancer. Moreover, the most extensively investigated HDAC inhibitors (HDACis) are also analyzed, and the respective clinical trials are also described. Interestingly, it seems that HDACis should be preferably used in drug-combination therapeutic schemes, including radiation.

Analysis of the association between bladder carcinoma and arsenic concentration in soil and water in southeast Brazil

In approximately 50% of cases of bladder carcinoma, an associated predisposing factor can be established. The main factors are exposure to tobacco, arsenic (As) ore and aromatic compounds. Arsenic is a metalloid with a low average concentration in the earth's crust, and one of the most dangerous substances for human health. The present study aims to evaluate the incidence of hospitalization and mortality from bladder neoplasia and its possible association with As concentration in water and soil in two of the most critical regions of Brazil: the states of São Paulo and Minas Gerais. We have investigated bladder cancer hospitalization and mortality in the states of São Paulo and Minas Gerais during 2010-2014. Water and soil samples were analyzed and As concentrations were established. Data were obtained through the Department of Informatics of the Brazilian Unified Health System. Correlation was made with water samples from São Paulo and with data on soil analysis from Minas Gerais. The results revealed no direct association in the distinctive municipalities. Areas with high environmental As concentration had a low bladder cancer rate, while areas with normal as levels had similar cancer rates. The quantitative variables did not present a normal distribution (p < 0.05). In conclusion, we did not observe a correlation between as concentration in water or soil and bladder cancer's hospitalization and mortality rates in the states of São Paulo and Minas Gerais.

Application of sandwich spatial estimation method in cancer mapping: A case study for breast cancer mortality in the Chinese mainland, 2005

High-accuracy spatial distribution estimation is crucial for cancer prevention and control. Due to their complicated pathogenic factors, the distributions of many cancers' mortalities appear blocky, and spatial heterogeneity is common. However, most of the commonly used cancer mapping methods are based on spatial autocorrelation theory. Sandwich estimation is a new method based on spatial heterogeneity theory. A modified sandwich estimation method suitable for the estimation of cancer mortality distribution is proposed in this study. The variances of cancer mortality data are used to fuse sandwich estimation results from various auxiliary variables, the feasibility of which in estimating cancer mortality distributions is explained theoretically. The breast cancer (BC) mortality of the Chinese mainland in 2005 was taken as a case, and the accuracy of the modified sandwich estimation method was compared with that of the Hierarchical Bayesian (HB), the Co-Kriging (CK) and the Ordinary Kriging (OK) methods. The accuracy of the modified sandwich estimation method was better than the HB, the CK and the OK methods, and the estimation result from the modified sandwich estimation method was more likely to be acceptable. Therefore, this study represents an attempt to apply the sandwich estimation method to the estimation of cancer mortality distributions with strong spatial heterogeneity, which holds great potential for further application.

Factors Associated With Cancer Disparities Among Low-, Medium-, and High-Income US Counties

BACKGROUND

There are concerns about the degree to which county income level might underlie the stark disparities in cancer death rates among US counties; at the same time, there is uncertainty about the factors that may mediate the disparities.

OBJECTIVES

To assess county-level cancer death rates and to identify possible mediators of the association between county-level median incomes and cancer death rates.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study using death records from the National Center for Health Statistics in 2014, with data collected and analyzed between October 1, 2016, and July 31, 2017. All US counties and county equivalents were included.

EXPOSURES

County-level median household income.

MAIN OUTCOMES AND MEASURES

County-level age-standardized cancer death rate.

RESULTS

In 3135 counties, median incomes ranged from $22 126 to $121 250 per year. Low-income counties (median income, $33 445) vs high-income counties (median income, $55 780) had higher proportions of residents who were non-Hispanic black, lived in rural areas, or reported poor or fair health. The mean (SD) cancer death rate was 185.9 (24.4) per 100 000 person-years in high-income counties, compared with 204.9 (26.3) and 229.7 (32.9) per 100 000 person-years in medium- and low-income counties, respectively. In mediation models, health risk behaviors (smoking, obesity, and physical inactivity); clinical care factors (unaffordable care and low-quality care); health environments (food insecurity); and health policies (state smoke-free laws and Medicaid payment rates) in aggregate accounted for more than 80% of the income-related disparity. The strongest possible mediators were food insecurity (explaining 19.1% [95% CI, 12.5%-26.5%] of the association between county incomes and cancer deaths), low-quality care (17.9%; 95% CI, 14.0%-21.8%), smoking (12.7%; 95% CI, 9.4%-15.6%), and physical inactivity (12.2%; 95% CI, 9.4%-15.6%).

CONCLUSIONS AND RELEVANCE

There are wide gaps in cancer death rates between low-, medium-, and high-income counties. Future studies are needed to assess whether targeting the possible mediators might ameliorate the substantial socioeconomic cancer disparities.

Increased expression of immediate early response gene 3 protein promotes aggressive progression and predicts poor prognosis in human bladder cancer

Background

Immediate early response gene 3 (IER3) is a stress-inducible gene, which exerts diverse effects in regulating cell apoptosis and cell cycle. Growing evidence shows that IER3 functions either as an oncogene or a tumor suppressor in various human cancers with a cancer type-dependent manner. However, the involvement of IER3 in human bladder cancer (BCa) has not been elucidated. In the current study, we aimed to investigate the expression pattern and the clinical significance of IER3 in BCa.

Methods

We performed immunohistochemistry analysis to examine the subcellular localization and the expression levels of IER3 protein in 88 BCa specimens obtained from Department of Pathology in Massachusetts General Hospital. The associations of IER3 protein expression with various clinicopathological features and patients’ overall survival were statistically evaluated.

Results

IER3 protein was mainly expressed in the cytoplasm in bladder cancer cell. Of 88 BCa tissue specimens, 39 (44.3%) showed high expression of IER3 protein and 49 (55.7%) showed low expression. High IER3 protein expression was significantly associated with high pathologic nodal stage (p = 0.018). Kaplan-Meier analysis revealed that the overall survival of BCa patients with overexpression of IER3 protein was shorter than that with low expression (p < 0.01). Multivariate analysis by Cox regression further identified IER3 as an independent prognostic factor of BCa patients (p = 0.010).

Conclusions

Our findings suggest for the first time that the increased expression of IER3 protein may promote the aggressive progression of BCa. Importantly, IER3 may be a potential prognostic marker for BCa patients.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0388-6) contains supplementary material, which is available to authorized users.

Genomic case report of a low grade bladder tumor metastasis to lung

BACKGROUND

We present a rare case where distant metastasis of a low grade bladder tumor was observed. We carried out detailed genomic analysis and cell based experiments on patient tumor samples to study tumor evolution, possible cause of disease and provide personalized treatment strategies.

CASE PRESENTATION

A man with a smoking history was diagnosed with a low-grade urothelial carcinoma of the bladder and a concurrent high-grade upper urinary tract tumor. Seven years later he had a lung metastasis. We carried out exome sequencing on all the patient's tumors and peripheral blood (germline) to identify somatic variants. We constructed a phylogenetic tree to capture how the tumors are related and to identify somatic changes important for metastasis. Although distant metastasis of low-grade bladder tumor is rare, the somatic variants in the tumors and the phylogenetic tree showed that the metastasized tumor had a mutational profile most similar to the low grade urothelial carcinoma. The primary and the metastatic tumors shared several important mutations, including in the KMT2D and the RXRA genes. The metastatic tumor also had an activating MTOR mutation, which may be important for tumor metastasis. We developed a mutational signature to understand the biologic processes responsible for tumor development. The mutational signature suggests that the tumor mutations are associated with tobacco carcinogen exposure, which is concordant with the patient's smoking history. We cultured cells from the lung metastasis to examine proliferation and signaling mechanisms in response to treatment. The mTOR inhibitor Everolimus inhibited downstream mTOR signaling and induced cytotoxicity in the metastatic tumor cells.

CONCLUSION

We used genomic analysis to examine a rare case of low grade bladder tumor metastasis to distant organ (lung). Our analysis also revealed exposure to carcinogens found is tobacco as a possible cause in tumor development. We further validated that the patient might benefit from mTOR inhibition as a potential salvage therapy in an adjuvant or recurrent disease setting.

The global epidemiology of bladder cancer: a joinpoint regression analysis of its incidence and mortality trends and projection

We tested the hypotheses that the global incidence of bladder cancer was increasing but its mortality was reducing and its incidence was positively correlated with country-specific socioeconomic development. We retrieved data on age-standardized incidence and mortality rates/100,000 from the GLOBOCAN database in 2012. Temporal patterns were examined for 39 countries from the Cancer Incidence in Five Continents volumes I-X and other national registries. We evaluated the correlation between the incidence/mortality rates and Human Development Index (HDI)/ logarithmic values of Gross Domestic Product per capita (GDP). The average annual percent change of the incidence and mortality rates in the most recent 10 years was examined by joinpoint regression analysis. The highest incidence rates were observed in Southern Europe, Western Europe and North America. The mortality rates were the highest in Western Asia and Northern Africa. The incidence was positively correlated with HDI (r = 0.66 [men]; r = 0.50 [women]) and to a lesser extent logarithmic values of GDP per capita (r = 0.60 [men]; r = 0.50 [women], all p < 0.01). Many European countries experienced incidence rise. A substantial mortality reduction was observed in most countries, yet increases in mortality rates were observed in the Philippines and Iceland. These findings identified countries where more preventive actions are required.

A DNA hypermethylation profile reveals new potential biomarkers for the evaluation of prognosis in urothelial bladder cancer

DNA hypermethylation has emerged as a molecular biomarker for the evaluation of cancer diagnosis and prognosis. We define a methylation signature of bladder cancer and evaluate whether this profile assesses prognosis of patients. Genome-wide methylation analysis was performed on 70 tumor and 10 normal bladder samples. Hypermethylation status of 1505 CpGs present in the promoter region of 807 genes was studied. Thirty-three genes were significantly hypermethylated in ≥10% of the tumors. Three clusters of patients were characterized by their DNA methylation profile, one at higher risk of dead of disease (p = 0.0012). Association between cluster distribution and stage (p = 0.02) or grade (p = 0.02) was demonstrated. Hypermethylation of JAK3 and absence of hypermethylation of EYA4, GAT6, and SOX1 were associated with low-grade non-invasive disease. On the other hand, in high-grade invasive disease hypermethylation of CSPG2, HOXA11, HOXA9, HS3ST2, SOX1, and TWIST1 was associated with muscle invasiveness. A panel of hypermethylated genes including APC, CSPG2, EPHA5, EYA4, HOXA9, IPF1, ISL1, JAK3, PITX2, SOX1, and TWIST1 predicted cancer-specific survival and SOX1 (HR = 3.46), PITX2 (HR = 4.17), CSPG2 (HR = 5.35), and JAK3 hypermethylation (HR = 0.19) did so independently. Silencing of genes by hypermethylation is a common event in bladder cancer and could be used to develop diagnostic and prognostic markers. Combined hypermethylation of SOX1, PITX2, or CSPG2 signals patients at higher risk of death from bladder cancer.

Particulate Matter (Fine Particle) and Urologic Diseases

Particulate matter (PM) has been found to damage vital body organs, including the lungs and heart, through vascular damage and oxidative stress. Recently, renal function and chronic urologic diseases have also been found to be related to PM. To investigate this, we reviewed the characteristics of PM related to renal toxicity, including recent studies on the associations of urologic diseases with PM. PM can include constituents that cause renal toxicity, such as lead, cadmium, arsenic, and crystalline silica, which result in renal tubular or interstitial damage. Since 2008, 7 studies have evaluated the renal effects of PM. Two prospective cohort studies and a quantitative study of consecutive patients showed that PM may be related to decreased renal function, as shown by the estimated glomerular filtration rate of diseased or aged participants. Two cross-sectional studies found an association between PM and chronic kidney disease. One of those studies identified the specific renal diseases of immunoglobulin A nephropathy and membranous nephropathy. Two studies that analyzed renal cancer and PM showed no evidence that renal cancer is related to PM. Nine studies were evaluated regarding the relationship of bladder and prostate cancer with PM. The evidence for an association of PM with bladder and prostate cancer is still inconclusive. Although some recently published studies have shown a significant relationship, the causal relationship is not clear. Further well-designed studies on specific renal diseases are required.

Spatial Analysis of Ambient PM2.5 Exposure and Bladder Cancer Mortality in Taiwan

Fine particulate matter (PM_2.5) is an air pollutant that is receiving intense regulatory attention in Taiwan. In previous studies, the effect of air pollution on bladder cancer has been explored. This study was conducted to elucidate the effect of atmospheric PM_2.5 and other local risk factors on bladder cancer mortality based on available 13-year mortality data. Geographically weighted regression (GWR) was applied to estimate and interpret the spatial variability of the relationships between bladder cancer mortality and ambient PM_2.5 concentrations, and other variables were covariates used to adjust for the effect of PM_2.5. After applying a GWR model, the concentration of ambient PM_2.5 showed a positive correlation with bladder cancer mortality in males in northern Taiwan and females in most of the townships in Taiwan. This is the first time PM_2.5 has been identified as a risk factor for bladder cancer based on the statistical evidence provided by GWR analysis.

Bladder cancer

Bladder cancer is a highly prevalent disease and is associated with substantial morbidity, mortality and cost. Environmental or occupational exposures to carcinogens, especially tobacco, are the main risk factors for bladder cancer. Most bladder cancers are diagnosed after patients present with macroscopic haematuria, and cases are confirmed after transurethral resection of bladder tumour (TURBT), which also serves as the first stage of treatment. Bladder cancer develops via two distinct pathways, giving rise to non-muscle-invasive papillary tumours and non-papillary (solid) muscle-invasive tumours. The two subtypes have unique pathological features and different molecular characteristics. Indeed, The Cancer Genome Atlas project identified genetic drivers of muscle-invasive bladder cancer (MIBC) as well as subtypes of MIBC with distinct characteristics and therapeutic responses. For non-muscle-invasive bladder cancer (NMIBC), intravesical therapies (primarily Bacillus Calmette-Guérin (BCG)) with maintenance are the main treatments to prevent recurrence and progression after initial TURBT; additional therapies are needed for those who do not respond to BCG. For localized MIBC, optimizing care and reducing morbidity following cystectomy are important goals. In metastatic disease, advances in our genetic understanding of bladder cancer and in immunotherapy are being translated into new therapies.

Androgen Receptor Signaling in Bladder Cancer

Emerging preclinical findings have indicated that steroid hormone receptor signaling plays an important role in bladder cancer outgrowth. In particular, androgen-mediated androgen receptor signals have been shown to correlate with the promotion of tumor development and progression, which may clearly explain some sex-specific differences in bladder cancer. This review summarizes and discusses the available data, suggesting the involvement of androgens and/or the androgen receptor pathways in urothelial carcinogenesis as well as tumor growth. While the precise mechanisms of the functions of the androgen receptor in urothelial cells remain far from being fully understood, current evidence may offer chemopreventive or therapeutic options, using androgen deprivation therapy, in patients with bladder cancer.