Epidemiology of Bladder Cancer

Current and Emerging Treatments for Urothelial Carcinoma: A Focus on Enfortumab Vedotin

Urothelial carcinoma is a common malignancy that affects the urinary system, with bladder cancer being the most prevalent form. Although the management of early-stage disease has seen significant improvements, the treatment of locally advanced and metastatic urothelial carcinoma remains challenging. Over the past decade, there has been an explosion in the number of therapies available for the treatment of advanced disease, with immune checkpoint inhibitors and antibody-drug conjugates leading the way. Enfortumab vedotin is an antibody-drug conjugate that targets Nectin-4, a protein that is overexpressed in urothelial carcinoma cells. In clinical trials, it has shown promising outcomes for the treatment of advanced urothelial carcinoma that has progressed after chemotherapy or immunotherapy. The US Food and Drug Administration has granted expedited approval for enfortumab vedotin in the treatment of advanced urothelial carcinoma. This review provides an overview of the current and emerging treatments for urothelial carcinoma, with a particular focus on enfortumab vedotin. We discuss the mechanisms of action, clinical efficacy, safety, and ongoing research of enfortumab vedotin, along with the current landscape of other approved therapies and promising agents in development. The aim of this review is to provide a comprehensive and up-to-date summary of the available treatment options for urothelial carcinoma, including their limitations and future prospects.

Short- and Long-Term Stability of Aromatic Amines in Human Urine

Several aromatic amines (AAs) are established by the International Agency for Research on Cancer as carcinogenic (group 1) or probable/possible carcinogens to humans (group 2A/2B). AAs can be found in mainstream and sidestream smoke from combustible tobacco products, as well as in certain environmental pollution and occupational exposure from several chemical industry sectors. Exposure to AAs can be estimated by measuring their concentrations in urine; however, information about the short-term and long-term stabilities of AAs in urine need to be characterized before conducting large-scale population studies on AA exposure and the potentially harmful effects of AA exposure. In this report, the storage stability of o-toluidine, 2,6-dimethylaniline, o-anisidine, 1-aminonaphthalene, 2-aminonaphthalene, and 4-aminobiphenyl fortified in pooled, filtered, non-smokers' urine is analyzed by isotope dilution gas chromatography-triple quadrupole mass spectrometry (ID GC-MS/MS). The six AAs were measured in urine samples stored at ~20 °C (collection temperature), 4 °C and 10 °C (short-term transit temperatures), and -20 °C and -70 °C (long-term storage temperatures) over a 10-day period. All six analytes were stable for 10 days at transit and long-term storage temperatures but showed reduced recovery at 20 °C. The instability of the target AAs at 20 °C suggests that immediate storage of freshly voided urine at low temperatures is needed to attenuate degradation. A subset of the urine samples was analyzed following a longer storage duration at -70 °C: all AAs were stable for up to 14 months at this temperature. The stability of the six AAs in urine samples can be maintained at the various temperature levels and storage times expected in a typical study set.

A Review of the Etiology and Epidemiology of Bladder Cancer: All You Need To Know

Bladder cancer is any tumor that originates in the urinary bladder. It is the most prevalent tumor of the urinary system, with urothelial carcinoma being the most prevalent histologic subtype. It impacts both men and women. The development of bladder cancer was influenced by several risk factors, including advanced age, male sex, cigarette smoking, and occupational and environmental toxin exposure. Bladder tumors may manifest as gross or microscopic hematuria, which is assessed using cystoscopy, urine analysis, and other specialized tests. Due to the large number of cases related to environmental causes, bladder cancer is an appropriate target for public health preventative interventions. Cessation of smoking, adequate occupational safety procedures, diet, weight loss, and schistosomiasis prevention may mitigate the rising global incidence.

Evaluation of secondary cancers, synchronous and metachronous with bladder cancer

The number of bladder cancer survivors worldwide is increasing due to the advancement of diagnostic methods and bladder cancer treatment. Besides, bladder cancer is the sixth most common cancer in Iran. Nowadays, many secondary cancers have been proven with bladder cancer. This study focused on synchronous and metachronous cancers with bladder cancer. This study was performed retrospectively. A total of 276 patients with a definitive diagnosis of bladder cancer were included in the study. Tumors were diagnosed using ultrasound and cystoscopy. Out of 276 patients with bladder tumor, 240 underwent resection, 25 underwent radical cystectomy, and 31 underwent chemotherapy in addition to resection. The mean age of patients was 65±3.9 years. Among the patients, 184 were male (67%), and 92 were female (33%). Smoking was the most common known risk factor. There were 165 smokers, 135 of whom were male and 30 female. Sixty-nine patients had no known risk factor (P <0.05). Gastric cancer was the most common secondary cancer with bladder cancer in all individuals (5.7%). Prostate cancer (20%) in men and cervical cancer (11.9%) in women was the most common secondary cancer simultaneous with bladder cancer. Given the importance of SPC as a cause of cancer death, early detection and screening of primary cancer survivors will increase patients' life expectancy and quality of life.

Supportive Roles of the Health Care Team Throughout the Illness Trajectory of Bladder Cancer Patients Undergoing Radical Cystectomy: A Qualitative Study Exploring the Patients' Perspectives

OBJECTIVES

To explore patient perspectives of muscle-invasive bladder cancer (MIBC) on how the health care team and their social network can support them during their cancer trajectory.

DATA SOURCES

Sixteen semi-structured interviews were conducted with MIBC survivors who underwent radical cystectomies at Ghent University Hospital. The interviews were audiotaped, transcribed verbatim, and analyzed with an iterative content analysis approach.

CONCLUSION

Information to support people affected by bladder cancer (BC) in several aspects of their disease trajectory (eg, shared decision-making and self-management of their urinary diversion) was most important throughout the interviews (although type and source of required information varied). The clinical nurse specialist was important for informational and emotional support because receiving sufficient information might help patients reduce emotional stress. People affected by BC are still reluctant to consult a psychologist, and several barriers were indicated for this. Also physical needs in the early postoperative phase could be reduced with appropriate information. Communication skills of clinicians in the hospital and knowledge of general practitioners about the important aspects of BC care are also important aspects that should be further optimized. Furthermore, peer support groups and family members can offer important support throughout the BC pathway.

IMPLICATIONS FOR NURSING PRACTICE

This study provides an overview of how people affected by BC want to be supported by their health care team and their social network. This overview can serve as a basis to develop educational interventions for both patients and health care professionals to guide restructuring of BC pathways and can also be used to develop future intervention studies to improve BC outcomes.

Fluid intake and clinicopathological characteristics of bladder cancer: the West Midlands Bladder Cancer Prognosis Programme

OBJECTIVE

Between 10 and 20% of bladder cancer patients who are diagnosed with nonmuscle-invasive bladder cancer will progress to muscle-invasive disease. Risk of progression depends on several factors at diagnosis including age, tumour stage, grade, size and number, and the presence or absence of carcinoma in situ. Fluid intake may be related to these factors.

METHODS

Data of 1123 participants from the West Midlands Bladder Cancer Prognosis Programme were used. Data collection was via a semistructured questionnaire, and case report forms were used to collect clinicopathological data. Fluid intake was measured for six main categories: alcoholic fluids, hot fluids, fruit fluids, milk, fizzy drinks, and water, and converted into quintile variables. Multilevel mixed-effects linear regression was performed for every beverage category per clinicopathological variable and corrected for age, gender, and smoking status.

RESULTS

Age at diagnosis was distributed differently amongst those in different total fluid intake quintiles (predicted means 71.5, 70.9, 71.5, 69.9, and 67.4, respectively) and showed a significant inverse linear trend in alcohol (P < 0.01), hot fluids (P < 0.01), and total fluids intake (P < 0.01), in nonmuscle-invasive bladder cancer patients.

CONCLUSION

Our results suggest an inverse association for alcohol intake and total fluid intake with age at diagnosis. These results should be confirmed by future studies, alongside a possible (biological) mechanism that could influence tumour growth, and the effect of micturition frequency.

Monitoring human genotoxicity risk associated to urban and industrial Buenos Aires air pollution exposure

The quality of life in large megacities is directly affected by its air quality. In urban environments, suspended particles from anthropogenic origin is one of the main air contaminants identified as highly genotoxic, mutagenic, or carcinogenic. Atmospheric monitoring is therefore imperative, and bioassays to detect the effects of genotoxic agents give usually excellent results. Analysis of micronucleus (MN) in exfoliated oral mucosa cells is a sensitive non-invasive method for monitoring genetic damage in human populations. The first aim of this study was to analyze and characterize levels of volatile organic compounds (VOCs), particulate matter (PM), and polycyclic aromatic hydrocarbons (PAHs) in two areas from Buenos Aires: La Plata city, an urban (U) area and Ensenada, an industrial (I) area. Secondly, we evaluated the possible health risk of its inhabitants through a simple genotoxic assay on exfoliated oral mucosa cells. Whole blood cell count and nuclear abnormalities frequencies were evaluated in the exfoliated oral mucosa cells from urban and industrial inhabitants. Smoking habit represented a significant factor increasing MN percentage while, age did not increase the production of any of the nuclear aberrations assayed (micronuclei, binucleated, karyorrhexis) when the inhabitants from the urban and the industrial areas were compared. In addition, changes in MN and binucleated cell percentages in males and females were found to be area-dependent. We suggest that regardless PM concentration, PM-specific characteristics (size, shape, chemical elements, etc.) and VOCs levels could be responsible for the different harmful genotoxic effects seen in the two areas. Although this is a preliminary study, our results allowed to recognize that individuals living in both the urban and the industrial areas could be considered susceptible groups and should periodically undergo biological monitoring and appropriate care.

A New Automated Method for the Analysis of Aromatic Amines in Human Urine by GC-MS/MS

Cigarette smoking significantly increases the risk of cancer and cardiovascular diseases as well as premature death. Aromatic amines (AAs) such as o-toluidine, 2-aminonaphthalene and 4-aminobiphenyl are found in cigarette smoke and are well-established human bladder carcinogens presumably acting via the formation of DNA adducts. These amines may be metabolized in the liver to acetylated or glucuronidated forms or oxidized to a hydroxylamine which may react with protein and DNA to form adducts. Free, acetylated and glucuronidated AAs are excreted in urine and can be measured as exposure biomarkers. Using isotope dilution GC-MS/MS, our laboratory quantifies six urinary AAs that are known or suspected carcinogens-o-toluidine, 2,6-dimethylaniline, o-anisidine, 1-aminonaphthalene, 2-aminonaphthalene and 4-aminobiphenyl-for large population studies such as the National Health and Nutrition Examination Survey (NHANES). We also monitor two additional corresponding structural isomers-2-aminobiphenyl and 3-aminobiphenyl-to verify isomer separation. A new and improved automated sample preparation method was developed to quantify these AAs, in which, sample cleanup was done via Supported Liquid Extraction (SLE+ ISOLUTE®) on a Hamilton STAR™ workstation. This automated method increased sample throughput by reducing sample cleanup time from 8 to 4 h while maintaining precision (intra and inter-run coefficient of variation <7%) and accuracy (±17%). Recent improvements in our GC/MS method have enhanced our assay sensitivity and specificity, resulting in longer analytical column life and maintaining or reducing the limit of detection for all six analytes. Indigo ASCENTTM software (3.7.1, Indigo BioAutomation, Inc.) is used for peak integration, calibration and quantification. A streamlined sample data flow was created in parallel with the automated method, in which samples can be tracked from receiving to final laboratory information management system output with minimal human intervention, minimizing potential human error. This newly validated, automated method and sample data flow are currently applied in biomonitoring of AAs in the US noninstitutionalized population NHANES 2013-2014 cycle.

Proteomics Analysis of Tangeretin-Induced Apoptosis through Mitochondrial Dysfunction in Bladder Cancer Cells

Tangeretin is one of the most abundant compounds in citrus peel, and studies have shown that it possesses anti-oxidant and anti-cancer properties. However, no study has been conducted on bladder cancer cells. Bladder cancer has the second highest mortality rate among urological cancers and is the fifth most common malignancy in the world. Currently, combination chemotherapy is the most common approach by which to treat patients with bladder cancer, and thus identifying more effective chemotherapeutic agents that can be safely administered to patients is a very important research issue. Therefore, this study investigated whether tangeretin can induce apoptosis and identified the signaling pathways of tangeretin-induced apoptosis in human bladder cancer cells using two-dimensional gel electrophoresis (2DGE). The results of the study demonstrated that 60 μM tangeretin reduced the cell survival of a BFTC-905 bladder carcinoma cell line by 42%, and induced early and late apoptosis in the cells. In this study 2DGE proteomics technology identified 41 proteins that were differentially-expressed in tangeretin-treated cells, and subsequently LC–MS/MS analysis was performed to identify the proteins. Based on the functions of the differentially-expressed proteins, the results suggested that tangeretin caused mitochondrial dysfunction and further induced apoptosis in bladder cancer cells. Moreover, western blotting analysis demonstrated that tangeretin treatment disturbed calcium homeostasis in the mitochondria, triggered cytochrome C release, and activated caspase-3 and caspase-9, which led to apoptosis. In conclusion, our results showed that tangeretin-induced apoptosis in human bladder cancer cells is mediated by mitochondrial inactivation, suggesting that tangeretin has the potential to be developed as a new drug for the treatment of bladder cancer.

Racial differences in Urinary Bladder Cancer in the United States

Urinary bladder cancer (UBC) has a high incidence rates in many southern and eastern European countries, in parts of Africa and the Middle East, and in North America. It exhibits a wide variety of histological types that goes from less aggressive to rapid-growing ones. In order to compare the different presentations, etiologies, and prognoses among racial groups, including NHW (non-Hispanic white), HW (Hispanic white), blacks, and API (Asian and Pacific Islander), we analyzed the UBC patients diagnosed between 1973 and 2014 using SEER (Surveillance, Epidemiology, and End Results) database. Patient characteristics, age-adjusted incidence rates, and survival were compared across races. There are significant racial differences in patients' characteristics, including gender, marital status, age at diagnosis, treatment strategies, grade, stage, survival time, and so on. Overall, non-Hispanic whites have the highest incidence rate, followed by blacks, Hispanic whites, and APIs. In the analysis of survival, significant racial differences exist when stratified by gender, age group, histological type, stage, location and treatment strategies. Racial differences exist among UBC patients in the United States in terms of characteristics, incidence, and survival. Future studies may collect and analyze more data for comprehensive description and interpretation of the racial differences.

Total Fluid Intake and the Risk of Recurrence in Patients With Non-Muscle Invasive Bladder Cancer: A Prospective Cohort Study

Objectives:

To investigate the role of fluid intake from beverages before and after a diagnosis of bladder cancer in relation to the risk of developing bladder cancer recurrence.

Study Design:

Prospective cohort study.

Methods:

716 patients with non-muscle invasive bladder cancer (NMIBC), who received transurethral resection of a primary bladder tumour (TURBT) and completed self-administrated questionnaires on usual fluid intake from beverages at time of diagnosis (over the year before diagnosis) and during follow-up (over the year after diagnosis), were included. Multivariable Cox regression was used to calculate hazard ratios and 95% confidence intervals of developing recurrent bladder cancer in relation to the intake of total fluid, total alcohol, and individual beverages.

Results:

During 2,025 person-years of follow-up, 238 (33%) of the included 716 NMIBC patients developed one or more recurrences of bladder cancer. Total fluid intake before diagnosis was not associated with a first recurrence of bladder cancer when comparing the highest and lowest intake group (HR = 0.98, 95% C.I. 0.70–1.38, p = 0.91). Comparable results were obtained for total fluid intake pre-diagnosis and the risk of developing multiple recurrences of bladder cancer (HR = 1.01, 95% C.I. 0.87–1.19, p = 0.85). A total of 379 of the 716 patients reported on usual fluid intake within 1 year of diagnosis. No significant associations between total fluid intake 1 year after diagnosis and a first recurrence of bladder cancer were found when comparing the highest and lowest intake group (HR = 0.91; 95% C.I. 0.60–1.37, p = 0.65) or with multiple recurrences of bladder cancer (HR = 1.06; 95% C.I. 0.89–1.26, p = 0.54). In addition, total alcohol intake and individual beverages were not associated with bladder cancer recurrence.

Conclusions:

The results indicate that an individual’s fluid intake from beverages is unlikely to have an important role in bladder cancer recurrence.

Preliminary study of prevalence for bladder cancer in Isfahan Province, Iran

OBJECTIVES

To clarify period prevalence (PP), incidence rate (Ir), and reported mortality for patients with bladder cancer (BC) in Isfahan Province/Iran, as BC is the most common cancer of the urinary tract in Iran and other parts of the world.

PATIENTS AND METHODS

Data from 21 March 2011 to 3 March 2015 was obtained from the Isfahan Cancer Registry. BC was distinguished by the related established topography code (C67). Ir and PP were calculated and expressed per 100 000 persons.

RESULTS

In all, 279 females and 1376 males were identified. For the total population the PP was calculated as 33.2. This value corresponded to a PP of 54.4 for males and 11.4 for females (P < 0.001). Histologically, 63% of patients had invasive BC. Irs versus mortality rates were calculated for each year, i.e. 2011-2012, 2012-2013, 2013-2014, and 2014-2015, as 7.7 vs 0.56, 8.1 vs 0.74, 7.4 vs 0.98, and 9.9 vs 0.84, respectively. The mean (SD, range) age of the patients was 65.2 (13.9, 3-100) years. In relation to the age of the study population, BC occurred in 12% of patients aged <50 years and in 15% of those aged ≥80 years.

CONCLUSION

The PP for BC in the male population was 4.8-times higher than females. There was a 28.6% increase in the Ir over the study period. Further study concerning environmental exposure, genetic factors, job-related exposure to various chemical carcinogens, and geographical distribution in Isfahan and its' rural provinces would seem to be valuable.

Lung, Bladder, and Kidney Cancer Mortality 40 Years After Arsenic Exposure Reduction

Background

Region II in northern Chile (population 442 570) experienced a sudden major increase in arsenic water concentrations in 1958 in the main city of Antofagasta, followed by a major reduction in exposure when an arsenic removal plant was installed in 1970. It provides a unique opportunity to study latency effects of exposure to arsenic, and this is the first study with mortality data up to 40 years after exposure reduction.

Methods

We previously identified high mortality rates in Region II up to the year 2000. Here we present rate ratios (RRs) for Region II compared with all the rest of Chile from 2001 to 2010, and with unexposed Region V (population 1 539 852) for all years from 1950 to 2010. All statistical tests were one-sided.

Results

From 2001 to 2010, comparing Region II with the rest of Chile, lung and bladder mortality were still greatly elevated (RR = 3.38, 95% confidence interval [CI] = 3.19 to 3.58, P < .001 for lung cancer in men; RR = 2.41, 95% CI = 2.20 to 2.64, P < .001 for lung cancer in women; RR = 4.79, 95% CI = 4.20 to 5.46, P < .001 for bladder cancer in men; RR = 6.43, 95% CI = 5.49 to 7.54, P < .001 for bladder cancer in women). Kidney cancer mortality was also elevated (RR = 1.75, 95% CI = 1.49 to 2.05, P < .001 for men; RR = 2.09, 95% CI = 1.69 to 2.57, P < .001 for women). Earlier short latency acute myocardial infarction mortality increases had subsided.

Conclusions

Lung, bladder, and kidney cancer mortality due to arsenic exposure have very long latencies, with increased risks manifesting 40 years after exposure reduction. Our findings suggest that arsenic in drinking water may involve one of the longest cancer latencies for a human carcinogen.

Role of Non-Coding RNAs in the Etiology of Bladder Cancer

According to data of the International Agency for Research on Cancer and the World Health Organization (Cancer Incidence in Five Continents, GLOBOCAN, and the World Health Organization Mortality), bladder is among the top ten body locations of cancer globally, with the highest incidence rates reported in Southern and Western Europe, North America, Northern Africa and Western Asia. Males (M) are more vulnerable to this disease than females (F), despite ample frequency variations in different countries, with a M:F ratio of 4.1:1 for incidence and 3.6:1 for mortality, worldwide. For a long time, bladder cancer was genetically classified through mutations of two genes, fibroblast growth factor receptor 3 (FGFR3, for low-grade, non-invasive papillary tumors) and tumor protein P53 (TP53, for high-grade, muscle-invasive tumors). However, more recently scientists have shown that this disease is far more complex, since genes directly involved are more than 150; so far, it has been described that altered gene expression (up- or down-regulation) may be present for up to 500 coding sequences in low-grade and up to 2300 in high-grade tumors. Non-coding RNAs are essential to explain, at least partially, this ample dysregulation. In this review, we summarize the present knowledge about long and short non-coding RNAs that have been linked to bladder cancer etiology.

Lymphotoxin β receptor activation promotes mRNA expression of RelA and pro-inflammatory cytokines TNFα and IL-1β in bladder cancer cells

The role of inflammation in tumorigenesis and development is currently well established. Lymphotoxin β receptor (LTβR) activation induces canonical and noncanonical nuclear factor (NF)‑κB signaling pathways, which are linked to inflammation‑induced carcinogenesis. In the present study, 5,637 bladder cancer cells were cultured and the activation of LTβR was induced by functional ligand, lymphotoxin (LT) α1β2, and silencing with shRNA. Reverse transcription‑quantitative polymerase chain reaction was utilized to detect the mRNA expression levels of NF‑κB family members RelA and RelB, cytokines including LTα, LTβ, tumor necrosis factor (TNF)α, TNF superfamily member 14, interleukin (IL)‑6 and IL‑1β, and proliferation‑related genes including CyclinD1 and Survivin. The expression of phospho‑p65 was determined by western blotting. Activation of LTβR on bladder cancer 5,637 cells was demonstrated to upregulate the mRNA expression levels of the RELA proto‑oncogene, RelA, by 2.5‑fold compared with unstimulated cells, while no significant change was observed in the RELB proto‑oncogene NF‑κB member mRNA levels. Expression of pro‑inflammatory cytokines tumor necrosis factor (TNF)α and interleukin (IL)‑1β mRNA levels were significantly increased nearly 5‑fold and 1.5‑fold, respectively, following LTβR activation compared with unstimulated cells. The LTβR‑induced upregulation of RelA, TNFα and IL‑1β was decreased by ~33, 27, and 26% respectively when LTβR was silenced via short hairpin RNA. Activation of LTβR had no effect on 5,637 cell growth, despite CyclinD1 and Survivin mRNA levels increasing by ~2.7 and 1.3‑fold, respectively, compared with unstimulated cells. In conclusion, activation of LTβR induced the expression of RelA mRNA levels. LTβR activation might be an important mediator in promoting an inflammatory microenvironment in bladder cancer, via the upregulation of TNFα and IL‑1β mRNA levels. LTβR may be a potential therapeutic target for bladder cancer.

Total fluid consumption and risk of bladder cancer: a meta-analysis with updated data

With meta-analysis we tented to reveal the potential relationship between daily fluid consumption and bladder cancer risk, and to find out a recommendation on daily fluid intake. Databases of the Web of Science, PubMed and EMBASE were searched then 21 case-control and 5 cohort studies were included. Stratified analyses on gender, region, time of subjects recruiting and fluid quantity were performed as well as dose-response meta-analysis. Comparing the highest exposure category with the lowest in each study, no association appeared when all data pooled together (p=0.50), but a significant OR of 1.46 (1.02-2.08, p=0.04) was found in male subgroup. For different regions, the summarized OR was 1.44 (1.10-1.89) in American case-control studies, 1.87 (1.20-2.90) in European male subgroup and 0.24 (0.10-0.60) in Asia. There was a significant relationship that each increment 1000ml daily consumption would increase the risk by 28.6% in European male (p=0.007). Similarly every additional 1000ml consumption may increase the OR by 14.9% in American people but the association wasn't that strong (p=0.057). Stratified analyses showed fluid consumption over 3000ml/day in American residents and 2000ml/day in European male resulted in OR>1 with statistical significance. In conclusion, a relationship between higher fluid intake and higher bladder cancer risk was observed in European male and American residents and a limitation to <2000ml and <3000ml per day are recommended respectively.

Bladder cancer in individuals with spinal cord injuries: a meta-analysis

OBJECTIVES

To conduct a scoping review of all the literature related to bladder cancer in individuals with spinal cord injuries (SCIs).

METHODS

We searched for trials in MEDLINE, EMBASE, CINAHL and the Cochrane Register. Meta-analysis methods were used to evaluate these studies.

RESULTS

A total of 18 articles were identified and included as the evidence base for analysis. The incidence of bladder cancer in individuals with SCI is 6‰ (95% confidence interval (CI), 5-6‰, I²=49.2%). Mean patient age at bladder cancer diagnosis was 50 years (95% CI, 45-55 years, I²=92.7%). Length of indwelling catheterization of the patient population ranged from 6 to 29 years, with an average of 16 years (95% CI, 12-20 years, I²=94.4%). The interval between SCI and the first diagnosis of bladder cancer was 24 years (95% CI, 21-27 years, I²=85.3%). In the SCI population the estimated percent of squamous cell carcinoma is 36.8% (95% CI, 31.6-42.5%, I²=32.3%). In addition, 46.3% (95% CI, 33.7-59.4%, I²=40.5%) of the bladder cancer histology was traditional transitional cell carcinoma. Other pathological subtypes account for 17.1% (95% CI, 12.8-22.6%, I²=21.5%). The 1-year overall survival rate after treatment of bladder cancer was 62.1% (95% CI, 56.2-66.7%, I²=21.3%). Cystoscopy demonstrated a sensitivity of 64% (95% CI, 49.3-76.5%, I²=37.7%) for detecting bladder cancer. Cytology demonstrated a sensitivity of 36.3% (95% CI, 21.5-54.3%, I²=40.2%) for detecting bladder cancer.

CONCLUSION

Bladder cancer is a rare and potentially lethal occurrence in SCI patients. Physicians need to have a high index of suspicion for bladder cancer, particularly among SCI patients managed with long-term indwelling catheters.

Mutational signatures associated with tobacco smoking in human cancer

Tobacco smoking increases the risk of at least 17 classes of human cancer. We analyzed somatic mutations and DNA methylation in 5243 cancers of types for which tobacco smoking confers an elevated risk. Smoking is associated with increased mutation burdens of multiple distinct mutational signatures, which contribute to different extents in different cancers. One of these signatures, mainly found in cancers derived from tissues directly exposed to tobacco smoke, is attributable to misreplication of DNA damage caused by tobacco carcinogens. Others likely reflect indirect activation of DNA editing by APOBEC cytidine deaminases and of an endogenous clocklike mutational process. Smoking is associated with limited differences in methylation. The results are consistent with the proposition that smoking increases cancer risk by increasing the somatic mutation load, although direct evidence for this mechanism is lacking in some smoking-related cancer types.

Identification of microRNAome in rat bladder reveals miR-1949 as a potential inducer of bladder cancer following spinal cord injury

The costs of spinal cord injury and its complications are high in personal, social and financial terms. Complications include bladder cancer, for which the risk is 16-28 times higher than that of the general population, There is currently little consensus regarding the cause of this discrepancy. As microRNAs are stable biomarkers and potential therapeutic targets of cancer, the present study aimed to explore the underlying mechanisms of this phenomenon by examining changes in the microRNAome. Rats were used to produce models of spinal cord injury. Microarrays and bioinformatics were used to investigate the cancer-associated microRNAs that are upregulated in rat bladders following spinal cord injury. In order to validate the results, quantitative reverse transcription-polymerase chain reaction (qRT-PCR), western blotting and immunohistochemistry were performed. The expression of miR-1949 was found to be deregulated and abundant in the rat bladder following spinal cord injury. Bioinformatics demonstrated that retinoblastoma 1, which is involved in tumorigenesis, is a target gene of miR-1949. qRT-PCR, western blotting and immunohistochemistry confirmed the results of the microarray analysis. In addition, it was shown that miR-1949 expression was not influenced by aging. Furthermore, the expression of miR-1949 was stable until the third month following spinal cord injury, after which it significantly increased. If this increase was prolonged, the expression of retinoblastoma 1 may decline to a carcinogenic level. The present study suggests a role for miR-1949 in the translational regulation of retinoblastoma 1 and in subsequent bladder tumorigenesis following spinal cord injury.

Histopathological evaluation of urothelial carcinomas in transurethral resection urinary bladder tumor specimens: eight years of single center experience

BACKGROUND

Urothelial carcinoma (UC) is a malignant neoplasm that most commonly occurs in the urinary bladder. The primary aim of this study was to evaluate the clinicopathologic features, recurrence and progression in patients with bladder urothelial cancer.

MATERIALS AND METHODS

The medical records of patients diagnosed with UC in the state pathology laboratory between January 2006 and July 2014 were retrospectively included. Carcinomas were categorized according to age, gender, histologic grade, tumor configuration, pathologic staging, recurrence status, and progression.

RESULTS

A total of 125 (113 men, 12 women) patients were examined. The mean age was 65.9 years and the male-to-female urothelial cancer incidence ratio was 9.4:1. Low-grade UCs were observed in 85 (68%) and high-grade in 40 (32%). A papillary tumor pattern was observed in 67.2% of the UCs. Cases were classified with the following pathological grades: 34 (27.2%) cases of pTa, 70 (56%) of pT1, and 21 (16.8%) of pT2. Recurrence occurred in 27 (21.6%) patients. Ten progressed to a higher stage (pT1 to pT2), and three cases to higher grade (low to high). We also analyzed the results separately for 70 (56%) patients 65 years of age and older.

CONCLUSIONS

With early detection and diagnosis of precursor lesions in older patients, by methods such as standard urologic evaluation, urinary cytology, ultrasound scanning and contrast urography, and cystoscopy, in addition to coordinated efforts between pathologists and urologists, early diagnosis may reduce the morbidity and mortality of patients with urothelial carcinoma.

Investigation of two week wait referred haematuria patients in the UK: A national survey

Aim:

To analyse current UK practice for investigation of patients with visible haematuria (VH) or non-visible haematuria (NVH) who meet referral criteria according to National Institute of Clinical Excellence referral guidelines for suspected cancer.

Patients and methods:

Questionnaires were sent to 131 trusts. Data collected included demographics, conformity with NICE improving outcomes in urological cancer guidelines, standard first line investigations into VH and NVH and criteria for second line investigations.

Results:

Seventy-two trusts (55%) responded from 15 deaneries including 48 cancer centres. Almost two-thirds (63.9%) provide a one-stop service. First line investigations into VH varied considerably: 82% of trusts undertake urine tests (cytology 43.0%); three-quarters perform blood tests (prostate-specific antigen 54.2%); all conduct varying radiological imaging of the upper tracts; 95.8% of patients had flexible cystoscopy. Forty per cent of trusts’ first line investigations differ for NVH. Triple phase computed tomography-urogram is not routinely undertaken. Of the trusts, 55.5% perform second line investigations for VH and 55.5% for recurrent VH including computed tomography-urogram or retrograde studies; 20.5% perform non-contrast helical computed tomography scan of the kidneys, ureters and bladder or urine cytology for NVH if the history is indicative.

Conclusion:

Across trusts, there are wide variations in the regimes for investigation of haematuria. Development of an evidence based guideline to standardise practice across the National Health Service for haematuria referrals is required to abolish the postcode lottery system.

Dysfunction of lower urinary tract in patients with spinal cord injury

Over the past 50 years, the mortality for urorenal cause in patients with spinal cord injuries (SCI) has decreased from over 75% to 2.3%, as a result of dramatic improvements in the diagnosis and management of lower urinary tract dysfunction (LUTD). The aims of this chapter are to assess the physiopathology of upper and lower motor neuron lesion on bladder and sphincter function after SCI, to give an overview of required clinical and instrumental examination and to discuss treatment modalities. Videourodynamic examination plays a key role in the assessment and follow-up of LUTD in SCI patients, in conjunction with neurophysiological and radiological examinations. The cornerstone of bladder management in SCI is clean intermittent self-catheterization, but often other treatments are needed to achieve full continence, to reduce infections and stone formation, to protect the upper urinary tract from excessive bladder pressure, and to prevent chronic renal failure. Treatments may be pharmacologic (i.e., anticholinergic drugs and botulinum toxin) or surgical (by enterocystoplasty or urinary diversion). In selected cases, neuromodulation and sacral root stimulation can be used to reduce detrusor overactivity and empty the bladder. Management of LUTD in SCI patients requires a deep knowledge of spinal cord medicine and functioning of patients with neurologic disability.

Detection of human papillomavirus infection and p16 immunohistochemistry expression in bladder cancer with squamous differentiation

OBJECTIVES

To determine the potential association between HPV infection and the squamous cell component of urothelial carcinoma (UC) of the bladder and to validate p16 overexpression as a surrogate marker for HPV infection in these cancers among Koreans.

METHODS

We analyzed the presence of HPV infection using an HPV-DNA chip and the expression of p16 using immunohistochemistry in 47 subjects between July 2001 and March 2011. The study group (n = 35) included patients with squamous differentiation of UC of the bladder. The control group (n = 12) included patients with squamous metaplasia of the bladder.

RESULTS

Baseline characteristics of control and study groups were similar. HPV DNA detection rates were approximately 2-fold higher in the study than the control group (17.1% [6/35] versus 8.3% [1/12], respectively), but the difference was not statistically significant. P16 overexpression was detected in 16/35 (45.7%) study group and 1/12 (8.3%) control group samples (p = 0.034). Both HPV-positivity and p16 overexpression were present in 3/35 (8.8%) study group samples, but none of the control group (p = 0.295). In the study group, the percentage of HPV-positive cases who were non-smokers was 2-fold higher than the percentage of HPV-negative cases who were non-smokers (66.7% [4/6] versus 31.0% [9/29], respectively); however, statistical significance was not achieved due to the small sample size.

CONCLUSIONS

HPV infection may be associated with UC of the bladder with squamous differentiation, especially in non-smokers. However, p16 expression does not appear to be a strong surrogate marker for evidence of HPV infection in this type of cancer.

Fluid intake and risk of bladder cancer in the Nurses' Health Studies

Increase in fluid intake may reduce bladder cancer risk by decreasing the contact time between carcinogens in urine and bladder epithelium. However, this association has not been examined in a large cohort of women. The association between total fluid intake and bladder cancer risk in two large prospective women's cohorts with 427 incident bladder cancer cases was examined. Detailed information on total fluid intake was collected by repeated food frequency questionnaires over time. Multivariable relative risks (RRs) and 95% confidence intervals (95% CIs) were estimated by using Cox proportional hazards regression models. Results from the two cohorts were pooled together using the random-effects model. Using the average values from the earliest two dietary assessments and lowest quartile as reference, a suggestive inverse association was observed between total fluid intake and overall bladder cancer risk (RR: 0.83, 95% CI: 0.61-1.12, p-value for trend: 0.08), and invasive bladder cancer risk (RR: 0.47, 95% CI: 0.23-0.97, p-value for trend: 0.04). Among heavy cigarette smokers, women with the highest quartile of total fluid intake had a 38% decrease in bladder cancer risk (RR: 0.62, 95% CI: 0.41-0.93, p-value for trend: 0.02). The findings suggested that total fluid intake may reduce bladder cancer risk for female smokers, as well as reduce the risk of invasive bladder cancer.

Egg consumption and risk of bladder cancer: a meta-analysis

The findings of epidemiologic studies on the association between egg consumption and bladder cancer risk remain conflicting. We conducted a meta-analysis to clarify the potential association between egg consumption and bladder cancer risk. Four cohort studies and 9 case-control studies in the PubMed database through February 2012 were identified on egg consumption and risk of bladder cancer involving 2715 cases and 184,727 participants. Random-effects models were used to calculate the summary relative risk estimates (SRRE) based on the highest compared with the lowest category of egg consumption. In addition, we performed stratified analyses and sensitivity and dose-response analyses to examine the association. Overall, no significant association was observed between egg consumption and bladder cancer (SRRE = 1.11 95% CI: 0.90-1.35). However, increased risk of bladder cancer was detected in North/South America (SRRE = 1.40 95% CI: 1.05-1.86) and, moreover, fried egg intake positively associated with bladder cancer as well (SRRE = 2.04, 95% CI: 1.41-2.95). In conclusion, our findings suggest no significant association between egg consumption and bladder cancer risk, except for a possible positive relationship with the intake of fried eggs based on the limited number of studies. Additional studies, especially large prospective cohort studies, are warranted to confirm these findings.

Impact of fluid intake in the prevention of urinary system diseases: a brief review

We are often told that we should be drinking more water, but the rationale for this remains unclear and no recommendations currently exist for a healthy fluid intake supported by rigorous scientific evidence. Crucially, the same lack of evidence precludes the claim that a high fluid intake has no clinical benefit. The aim of this study is to describe the mechanisms by which chronic low fluid intake may play a crucial role in the pathologies of four key diseases of the urinary system: urolithiasis, urinary tract infection, chronic kidney disease and bladder cancer. Although primary and secondary intervention studies evaluating the impact of fluid intake are lacking, published data from observational studies appears to suggest that chronic low fluid intake may be an important factor in the pathogenesis of these diseases.

Evaluation of acute toxicity and symptoms palliation in a hypofractionated weekly schedule of external radiotherapy for elderly patients with muscular invasive bladder cancer

AIM

To evaluate acute toxicity and symptoms palliation of a weekly hypofractionated 3DCRT schedule as radical treatment in elderly patients with organ confined bladder cancer cT1-2N0.

MATERIALS AND METHODS

Between February 2005 and June 2011, 58 prospectively selected patients diagnosed with organ confined bladder cancer were treated with external 3DCRT (4-field arrangement). All candidates were medically inoperable, with poor performance status, and with age ranged from 75 to 88 years (median 78). A dose of 36 Gy in 6 weekly fractions was prescribed. The primary study endpoints were the evaluation of haematuria, dysuria, frequency and pain palliation as well as the acute toxicity according to the RTOG/EORTC scale: an assessment was performed at baseline, during and 3 months after radiotherapy, while the maximum reported score was taken into account.

RESULTS

The gastrointestinal acute toxicities were 13/58 (22.4%) and 5/58 (5.6%), for grade I and II respectively. The genitourinary acute toxicities were 19/58 (32.7%) and 10/58 (17.2%), for grade I and II respectively. In terms of clinical outcome, 55/58 patients (94.8%) reported palliation of haematuria, while 19 out of 58 reported no change in frequency and dysuria. All patients reported significant improvement (P < 0.01) for pain, concerning the visual analogue score before and after radiotherapy. The median progression free survival was 14 months.

CONCLUSIONS

The incidence of patient-reported acute toxicity following weekly hypofractionated external 3DCRT is low while the symptom palliation compares very favorably with other reported outcomes.

Bladder cancer in individuals with spinal cord injuries

STUDY DESIGN

Prospective scoping review.

OBJECTIVES

To conduct a scoping review of all the literature related to bladder cancer in individuals with spinal cord injuries (SCI).

METHODS

Literature search of the databases Pubmed, CINAHL, ProQuest, PsychINFO and Scopus up to and including August 2012. Articles related to bladder cancer among SCI patients were identified, and data pertaining to epidemiology, risk factors, screening, prevention and management was reviewed and summarized.

RESULTS

An association between bladder cancer and SCI was first reported in the 1960s, with some case reports suggesting an alarmingly high rate among SCI patients. More recent epidemiological studies have reported this risk to be substantially lower. However, bladder cancer in SCI patients tends to present at an earlier age and at a more advanced pathological stage than bladder cancer in the general population. Presenting symptoms may be atypical, and early recognition is important to improve prognosis with surgical resection. Several risk factors have been identified, including indwelling catheters, urinary tract infections and bladder calculi. Screening of SCI patients for bladder cancer is routinely recommended in many SCI management guidelines and by expert consensus; however, evidence for screening tools and protocols is lacking.

CONCLUSION

Bladder cancer is a rare, and potentially lethal occurrence in SCI patients. Physicians need to have a high index of suspicion for bladder cancer, particularly among SCI patients managed with long-term indwelling catheters.

A case-control study on the association between bladder cancer and prior bladder calculus

Background

Bladder calculus is associated with chronic irritation and inflammation. As there is substantial documentation that inflammation can play a direct role in carcinogenesis, to date the relationship between stone formation and bladder cancer (BC) remains unclear. This study aimed to examine the association between BC and prior bladder calculus using a population-based dataset.

Methods

This case–control study included 2,086 cases who had received their first-time diagnosis of BC between 2001 and 2009 and 10,430 randomly selected controls without BC. Conditional logistic regressions were employed to explore the association between BC and having been previously diagnosed with bladder calculus.

Results

Of the sampled subjects, bladder calculus was found in 71 (3.4%) cases and 105 (1.1%) controls. Conditional logistic regression analysis revealed that the odds ratio (OR) of having been diagnosed with bladder calculus before the index date for cases was 3.42 (95% CI = 2.48-4.72) when compared with controls after adjusting for monthly income, geographic region, hypertension, diabetes, coronary heart disease, and renal disease, tobacco use disorder, obesity, alcohol abuse, and schistosomiasis, bladder outlet obstruction, and urinary tract infection. We further analyzed according to sex and found that among males, the OR of having been previously diagnosed with bladder calculus for cases was 3.45 (95% CI = 2.39-4.99) that of controls. Among females, the OR was 3.05 (95% CI = 1.53-6.08) that of controls.

Conclusions

These results add to the evidence surrounding the conflicting reports regarding the association between BC and prior bladder calculus and highlight a potential target population for bladder cancer screening.

Environmental procarcinogen hypothesis of bladder cancer in humans: Dapsone hydroxylation as a susceptibility risk factor for aggressive bladder cancer

The dapsone recovery ratio (DPRR), which is determined after single oral dose administration of dapsone by measuring the parent drug and hydroxylated metabolite, provides an in vivo measure of the efficiency of the drug metabolizing enzymes responsible for this metabolic route, putatively CYP3A4. This affords the potential to evaluate the hypothesis that this drug metabolizing enzyme system is involved in the pathogenesis of human bladder cancer. The present study is a matched case-control comparison of DPRR in patients with nonaggressive bladder cancer (grades I and II or Ta, T1 and T2, n = 43), patients with aggressive bladder cancer without invasion (grade III or Ta, T1 and T2, n = 32), patients with aggressive bladder cancer and invasion (grade III or T3 and T4, n = 32), and age- and gender-matched subjects with no urologic tumor on cystoscopy from an urban U.K. community (n = 85). Demographic variables associated with aggressive bladder cancer (Gill or T3, T4, Tis) included pack-years of smoking, alcohol intake, and occupational exposure; for nonaggressive bladder cancer variables included smoking and occupational exposure. DPRR exhibited an unimodal distribution in all subjects: activity was significantly reduced in both noninvasive and invasive aggressive bladder cancer, and was a significant risk factor for cancer after adjustment for other significant risk factors. Combining the two aggressive groups, the lowest tertile of DPRR activity was associated with a sixfold increase in risk (p < 0.02) compared with the upper tertile. We conclude that a low dapsone recovery ratio is an independent risk factor for aggressive bladder cancer irrespective of its stage of invasion and suggest that the enzymes involved in its metabolism are detoxifying enzymes for unknown environmental factors to which an urban community is exposed.

Cell-cycle control in urothelial carcinoma: large-scale tissue array analysis of tumor tissue from Maine and Vermont

BACKGROUND

Cell-cycle proteins are important predictive markers in urothelial carcinoma but may also exhibit exposure-specific heterogeneity.

METHODS

Tumor tissue from 491 bladder cancer cases enrolled in the Maine and Vermont component of the New England Bladder Cancer Study was assembled as tissue microarrays and examined for aberrant expression of p53, p63, p16, cyclin D1, Rb, and Ki-67. The association between expression and histopathology, demographics, and cigarette smoking was examined using χ(2) tests, multivariable Poisson, and multinomial regression models.

RESULTS

We found that overexpression of p53 and Ki-67 was associated with high-stage/grade tumors [relative risk (RR), 1.26; P(trend) = 0.003; and RR, 3.21; P(trend) < 0.0001, respectively], whereas expression of p63 and p16 was decreased in high-stage/grade tumors (RR, 0.52; P(trend) < 0.0001; and RR, 0.88; P(trend) = 0.04, respectively). No significant aberrations of cell-cycle proteins were identified using various smoking variables and multiple statistical models.

CONCLUSION

The results of this population-based study of histologically confirmed urothelial carcinomas show significant aberration of cell-cycle proteins p53, p63, p16, and Ki-67, but not Rb or cyclin D1. p53 showed the most significant heterogeneity with respect to tumor stage and grade, especially when stratified for different staining intensities using novel digital image analysis techniques. Our findings do not support that smoking modifies expression of cell-cycle proteins.

IMPACT

Our study shows significant heterogeneity in the expression of key cell-cycle proteins that are associated with disease progression in bladder cancer. Further studies may lead to the identification of biomarkers and their multiplexed interactions as useful prognostic and therapeutic targets.

Evaluation of vitamin E and selenium supplementation for the prevention of bladder cancer in SWOG coordinated SELECT

PURPOSE

Epidemiological and biological evidence suggests a preventive effect of selenium and vitamin E on bladder cancer. We assessed the effect of selenium and/or vitamin E on bladder cancer development.

MATERIALS AND METHODS

This was a secondary analysis of the randomized, placebo controlled SELECT (Selenium and Vitamin E Cancer Prevention Trial), which included 34,887 men randomly assigned to 4 groups (selenium, vitamin E, selenium plus vitamin E and placebo) in double-blind fashion between August 22, 2001 and June 24, 2004. The primary end point was bladder cancer incidence, as determined by routine clinical management.

RESULTS

During a median followup of 7.1 years (IQR 6.4-8.0) 224 bladder cancer cases were recorded. Patients with bladder cancer were older, and more likely to be white and have a smoking history than those without bladder cancer. Most cancers were urothelial and nonmuscle invasive. There was no significant difference in the bladder cancer incidence between the 53 men in the placebo group and the 56 in the vitamin E group (HR 1.05, IQR 0.64-1.73, p=0.79), the 60 in the selenium group (HR 1.13, 0.70-1.84, p=0.52) or the 55 in the vitamin E plus selenium group (HR 1.05, 0.63-1.70, p=0.86).

CONCLUSIONS

This secondary analysis showed no preventive effect of selenium or vitamin E alone or combined on bladder cancer in this population of men. Further studies are needed to assess the effect in women, and at different doses and formulations.

Reexamination of total fluid intake and bladder cancer in the Health Professionals Follow-up Study Cohort

It has been hypothesized that high fluid intake may reduce contact time between carcinogens and bladder epithelium and consequently reduce carcinogenesis. Epidemiologic studies examining fluid intake and bladder cancer have been extremely inconsistent, ranging from strong inverse to strong positive associations. The authors reevaluated the association between fluid intake and bladder cancer among 47,909 participants in the prospective Health Professionals Follow-up Study over a period of 22 years. During follow-up (1986-2008), 823 incident bladder cancer cases were diagnosed. Information on fluid intake was collected by using the food frequency questionnaire at baseline and every 4 years thereafter. Cox proportional hazard regression analysis was used to adjust for risk factors for bladder cancer. Total fluid intake was inversely associated with bladder cancer when the analysis was based on the baseline diet (relative risk = 0.76, 95% confidence interval: 0.60, 0.97), comparing the highest total daily fluid intake quintile (>2,531 mL/day) with the lowest quintile (<1,290 mL/day) (P(trend) = 0.01). However, no association was detected when the analysis was based on recent diet or cumulative updated diet. The updated analysis for total fluid intake and bladder cancer was attenuated compared with the original findings from the first 10-year follow-up period.

A phase 2 cancer chemoprevention biomarker trial of isoflavone G-2535 (genistein) in presurgical bladder cancer patients

The soy compound genistein has been observed preclinically to inhibit bladder cancer growth with one potential mechanism being the inhibition of epidermal growth factor receptor phosphorylation (p-EGFR). A phase 2 randomized, placebo-controlled trial investigated whether daily, oral genistein (300 or 600 mg/d as the purified soy extract G-2535) for 14 to 21 days before surgery alters molecular pathways in bladder epithelial tissue in 59 subjects diagnosed with urothelial bladder cancer (median age, 71 years). G-2535 treatment was well tolerated; observed toxicities were primarily mild to moderate gastrointestinal or metabolic and usually not attributed to study drug. Genistein was detected in plasma and urine of subjects receiving G-2535 at concentrations greater than placebo subjects' but were not dose-dependent. Reduction in bladder cancer tissue p-EGFR staining between the placebo arm and the combined genistein arms was significant at the protocol-specified significance level of 0.10 (P = 0.07). This difference was most prominent when comparing the 300-mg group with placebo (P = 0.015), but there was no significant reduction in p-EGFR staining between the 600-mg group and placebo. No difference in normal bladder epithelium p-EGFR staining was observed between treatment groups. No significant differences in tumor tissue staining between treatment groups were observed for COX-2, Ki-67, activated caspase-3, Akt, p-Akt, mitogen-activated protein kinase (MAPK), or p-MAPK. No significant differences in urinary survivin or BLCA-4 levels between treatment groups were observed. Genistein displayed a possible bimodal effect (more effective at the lower dose) on bladder cancer tissue EGFR phosphorylation that should be evaluated further, possibly in combination with other agents.

Large-scale pathway-based analysis of bladder cancer genome-wide association data from five studies of European background

Pathway analysis of genome-wide association studies (GWAS) offer a unique opportunity to collectively evaluate genetic variants with effects that are too small to be detected individually. We applied a pathway analysis to a bladder cancer GWAS containing data from 3,532 cases and 5,120 controls of European background (n = 5 studies). Thirteen hundred and ninety-nine pathways were drawn from five publicly available resources (Biocarta, Kegg, NCI-PID, HumanCyc, and Reactome), and we constructed 22 additional candidate pathways previously hypothesized to be related to bladder cancer. In total, 1421 pathways, 5647 genes and ∼90,000 SNPs were included in our study. Logistic regression model adjusting for age, sex, study, DNA source, and smoking status was used to assess the marginal trend effect of SNPs on bladder cancer risk. Two complementary pathway-based methods (gene-set enrichment analysis [GSEA], and adapted rank-truncated product [ARTP]) were used to assess the enrichment of association signals within each pathway. Eighteen pathways were detected by either GSEA or ARTP at P≤0.01. To minimize false positives, we used the I(2) statistic to identify SNPs displaying heterogeneous effects across the five studies. After removing these SNPs, seven pathways ('Aromatic amine metabolism' [P(GSEA) = 0.0100, P(ARTP) = 0.0020], 'NAD biosynthesis' [P(GSEA) = 0.0018, P(ARTP) = 0.0086], 'NAD salvage' [P(ARTP) = 0.0068], 'Clathrin derived vesicle budding' [P(ARTP) = 0.0018], 'Lysosome vesicle biogenesis' [P(GSEA) = 0.0023, P(ARTP)<0.00012], 'Retrograde neurotrophin signaling' [P(GSEA) = 0.00840], and 'Mitotic metaphase/anaphase transition' [P(GSEA) = 0.0040]) remained. These pathways seem to belong to three fundamental cellular processes (metabolic detoxification, mitosis, and clathrin-mediated vesicles). Identification of the aromatic amine metabolism pathway provides support for the ability of this approach to identify pathways with established relevance to bladder carcinogenesis.

Interleukin-8 (IL-8) over-production and autocrine cell activation are key factors in monomethylarsonous acid [MMA(III)]-induced malignant transformation of urothelial cells

The association between chronic human exposure to arsenicals and bladder cancer development is well recognized; however, the underlying molecular mechanisms have not been fully determined. We propose that inflammatory responses can play a pathogenic role in arsenic-related bladder carcinogenesis. In previous studies, it was demonstrated that chronic exposure to 50 nM monomethylarsenous acid [MMA(III)] leads to malignant transformation of an immortalized model of urothelial cells (UROtsa), with only 3 mo of exposure necessary to trigger the transformation-related changes. In the three-month window of exposure, the cells over-expressed pro-inflammatory cytokines (IL-1β, IL-6 and IL-8), consistent with the sustained activation of NFKβ and AP1/c-jun, ERK2, and STAT3. IL-8 was over-expressed within hours after exposure to MMA(III), and sustained over-expression was observed during chronic exposure. In this study, we profiled IL-8 expression in UROtsa cells exposed to 50 nM MMA(III) for 1 to 5 mo. IL-8 expression was increased mainly in cells after 3 mo MMA(III) exposure, and its production was also found increased in tumors derived from these cells after heterotransplantation in SCID mice. UROtsa cells do express both receptors, CXCR1 and CXCR2, suggesting that autocrine cell activation could be important in cell transformation. Supporting this observation and consistent with IL-8 over-expression, CXCR1 internalization was significantly increased after three months of exposure to MMA(III). The expression of MMP-9, cyclin D1, bcl-2, and VGEF was significantly increased in cells exposed to MMA(III) for 3 mo, but these mitogen-activated kinases were significantly decreased after IL-8 gene silencing, together with a decrease in cell proliferation rate and in anchorage-independent colony formation. These results suggest a relevant role of IL-8 in MMA(III)-induced UROtsa cell transformation.

Analysis of the Distribution and Temporal Trends of Grade and Stage in Urothelial Bladder Cancer in Northern New England from 1994 to 2004

We investigate the distribution of bladder tumor category and stage in Northern New England by geographic region, smoking status and over time. 1091 incident bladder cancer cases from the New England Bladder Cancer Study (NEBCS), a large population-based case-control study carried out in Maine, New Hampshire and Vermont (2001-2004), and 680 bladder cancer cases from previous case-control studies in New Hampshire (1994-2000) were used in the analysis. Of 1091 incident bladder cancer cases from the NEBCS, 26.7% of tumors were papillary urothelial neoplasms of low malignant potential (PUNLMP), 26.8% low-grade papillary urothelial carcinomas (PUC-LG), 31.3% high-grade papillary urothelial carcinomas (PUC-HG), 9.1% non-papillary urothelial carcinomas (non-PUC), and 4.3% carcinoma in situ (CIS). Approximately 70% of cases were non-invasive (Tis/Ta), and all PUNLMP cases were of the Ta category. By contrast, half of all PUC-HG carcinomas were invasive. Short-term time trend analysis within the NEBCS (2001-2004) indicated an increase in the percentage of PUNLMP (p-trend<0.0001) paralleled by a decrease in PUC-LG (p-trend=0.02), and for PUC-LG an increase in the percentage of non-invasive tumors (p-trend 0.04). Our findings suggest possible short-term trends with an increase in the percentage of PUNLMP and a change in the percentage of PUC-LG towards non-invasive disease.

Pathobiology and chemoprevention of bladder cancer

Our understanding of the pathogenesis of bladder cancer has improved considerably over the past decade. Translating these novel pathobiological discoveries into therapies, prevention, or strategies to manage patients who are suspected to have or who have been diagnosed with bladder cancer is the ultimate goal. In particular, the chemoprevention of bladder cancer development is important, since urothelial cancer frequently recurs, even if the primary cancer is completely removed. The numerous alterations of both oncogenes and tumor suppressor genes that have been implicated in bladder carcinogenesis represent novel targets for therapy and prevention. In addition, knowledge about these genetic alterations will help provide a better understanding of the biological significance of preneoplastic lesions of bladder cancer. Animal models for investigating bladder cancer development and prevention can also be developed based on these alterations. This paper summarizes the results of recent preclinical and clinical chemoprevention studies and discusses screening for bladder cancer.

The Role of Early Re-Resection in pTaG3 Transitional Cell Carcinoma of the Urinary Bladder

Aim:

The clinical outcome and optimal treatment methodology for pTaG3 transitional cell carcinoma (TCC) of the urinary bladder remains controversial. We retrospectively evaluate the clinical behaviour and final outcome of 64 patients diagnosed with primary pTaG3 TCC bladder and evaluate the role of early re-resection following initial diagnosis.

Patients and methods:

Between January 2000 and December 2008, 64 patients were diagnosed with primary pTaG3 TCC of the urinary bladder at our institution. Following a careful retrospective review of their medical records, clinical parameters including patient age, gender, tumour morphology, operating surgeon's experience and adjuvant therapies were entered into a database. The outcome of re-resection, recurrence rate, progression and overall survival were recorded. All patients had their upper tracts screened with an ultrasound and intravenous urogram (IVU).

Results:

The mean age at time of diagnosis was 78 years (range 59–98). Seventy seven percent (49) of patients underwent an early re-resection (group 1). Residual tumour was identified in 49% (24) patients and the incidence of tumour upstaging was 10% (7). At re-resection 3% (2) of patients were found to have muscle-invasive disease. Twenty three percent (15) of patients did not have an early re-resection (group 2). There was a significant reduction in the incidence of recurrent TCC in group 1 in comparison to group 2 (5% vs. 62%) [ p < 0.05]. At a mean follow up of 48.9 months (range 12–124), 48 patients (75%) were alive; 25% (16) of patients had died of causes unrelated to bladder cancer. Disease-specific survival in both groups was 100%.

Conclusion:

pTaG3 TCC of the urinary bladder shows a variable clinical course and early re-resection significantly reduces the risk of recurrence. We strongly recommend treatment with early re-resection and subsequent treatment as per histology at re-resection. All patients with primary pTaG3 TCC of the urinary bladder should be followed up with further close surveillance using a strict follow up as these patients have a potential for disease progression.

High-risk patients with hematuria are not evaluated according to guideline recommendations

BACKGROUND

To determine whether high-risk patients with hematuria receive evaluation according to guideline recommendations.

METHODS

We recently performed a screening study for bladder cancer using a urine-based tumor marker in 1502 subjects at high risk based on aged > or = 50 years, > or = 10-year smoking history, and/or a 15-year or more environmental exposure. We evaluated use of urinalysis (UA) within 3 years preceding the screening study. Chart review was performed to determine if this subset with microhematuria received any additional evaluation.

RESULTS

Of 1502 study participants, routine urinalysis was performed in 73.2% and 164 (14.9%) subjects had documented hematuria (>3 red blood cells / high-power field) before inclusion. Of these, 42.1% had no further evaluation. Additional testing included repeat urinalysis (36%), urine culture (15.2%), cytology (10.4%), imaging (22.6% overall: 15.9% computed tomography, 4.3% intravenous pyelography; 2.4% magnetic resonance imaging), and cystoscopy (12.8%). Three subjects with microscopic hematuria (2%) were subsequently found to have bladder cancer during the screening study but were not referred for evaluation based on their hematuria. The source of hematuria was unknown in 65%, infection in 22%, benign prostatic enlargement in 10%, and renal stone disease in 4%, but these results are based on incomplete evaluation since only 12.8% underwent cystoscopy.

CONCLUSIONS

Subjects at high risk for bladder cancer based on > or = 10 years of smoking or environmental exposure with microscopic hematuria are rarely evaluated thoroughly and only 12.8% were referred for urologic evaluation. Further studies are needed to evaluate both the utilization and effectiveness of guidelines for hematuria.

Genetic variants of XRCC1, APE1, and ADPRT genes and risk of bladder cancer

DNA damaged by exposure to exogenous and endogenous carcinogens could be removed effectively by the base excision repair pathway, in which the XRCC1, APE1, and ADPRT genes play a key role. Genetic variations in these important genes may alter repair function and contribute to cancer risk. We hypothesized that XRCC1, APE1, and ADPRT polymorphisms are associated with risk of bladder cancer. In a hospital-based case-control study of 234 patients with bladder cancer and 253 cancer-free controls, we genotyped the XRCC1-77T>C, Arg194Trp, Arg280His, Arg399Gln, APE1-656T>G, Asp148Glu, ADPRT-442G>A, and Val762Ala polymorphisms using polymerase chain reaction-restriction fragment length polymorphism method. We found an increased risk of bladder cancer associated with the XRCC1 194Trp/Trp and 280Arg/His genotypes (adjusted odds ratio = 3.90, 95% confidence interval = 1.69-8.98 for 194Trp/Trp and 2.53, 1.67-3.83 for 280Arg/His) compared with the 194Arg/Arg and 280Arg/Arg genotypes, respectively. In contrast, the APE1-656GG genotype was associated with a decreased risk of bladder cancer (0.57, 0.33-0.98) compared with the TT genotype. When we evaluated these eight polymorphisms together, we found that the combined genotypes with 9-13 variant (risk) alleles were associated with an increased risk of bladder cancer (2.25, 1.48-3.40) compared with those with 3-8 variants. These findings suggest that the XRCC1 and APE1 polymorphisms may contribute to susceptibility to bladder cancer. Larger studies are warranted to verify these findings.