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Primary Prevention and Early Detection of Bladder Cancer: Two Main Goals for Urologists
EUROPEAN UROLOGY 63 (2013) 242–243
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 234–241 of this issue
Primary Prevention and Early Detection of Bladder Cancer: Two Main Goals for Urologists Maurizio A. Brausi * Department of Urology, Ausl Modena, Nuovo Ospedale Civile - S. Agostino Estense, Via Giardini 1355, Modena, Italy
Bladder cancer is one of the most frequently occurring tumors worldwide [1]. About 75% of newly diagnosed tumors are non–muscle invasive bladder cancer (NMIBC) and have a good survival rate but a high risk of recurrence. A significant proportion of patients have high-grade tumors and are at risk for progression [2]. These tumors need early and accurate diagnosis with cytology, imaging, and cystoscopy. Treatment consists of transurethral resection followed in the majority of the cases by intravesical instillations of chemotherapeutic agents or immunotherapy. These treatments should be continued for 1–3 yr, and patients should be closely followed in specialized centers for many years. The remaining 25% of newly diagnosed bladder cancers are muscle invasive and need aggressive radical surgery or radiotherapy with or without chemotherapy. The mortality rate for these patients is high, and diagnosis at an early stage could improve survival. The need for accurate diagnosis, continuous surveillance, and possible repeat treatments for NMIBC, together with the aggressive treatment of invasive disease makes bladder cancer one of the most expensive tumors in terms of total medical care expenditures [3]. Moreover, as mentioned in the article by Burger et al., transitional cell carcinoma (TCC) of the bladder was the eighth most common cause of cancer-specific mortality in Europe in 2008 [4]. High recurrence and mortality rates are the main characteristics of a disease that has a profound medical and economic impact on our society. A program for reducing incidence, morbidity, and mortality of TCC of the bladder should be part of future plans for urologists and European and international urologic societies as well as for governments. Incidence of a disease can be reduced with prevention. To achieve this reduction, information about factors that cause the disease is absolutely necessary.
Burger et al. focused very well on the epidemiologic aspects of this disease and evaluated the most important risk factors [4]. Smoking was the most common risk factor and accounted for approximately half of all TCCs of the bladder. Because about 20% of adults in Europe are cigarette smokers, the number of patients who will develop TCC of the bladder is huge. Cigarette smokers have a two- to fourfold increased risk of bladder cancer compared with nonsmokers [5], and the risk increases with increasing intensity and duration of smoking [6]. On cessation of smoking, the risk of bladder cancer falls >30% after 1–4 yr and by >60% after 25 yr but never returns to the risk level of nonsmokers [1]. Occupational exposure to aromatic amines is another important risk factor, whereas the impact of diet and environmental pollution is less evident. Finally, there is increased evidence that genetic predisposition may influence the incidence of TCC of the bladder [4]. In light of these observations, urologists can play a crucial role in prevention and early diagnosis. 1.
Primary prevention programs
Urologists should display information on bladder cancer incidence, morbidity, and mortality in their own offices and departments. Leaflets with information on the causative factors of the disease should be designed and given to all incoming patients. Cigarette-smoking patients, even if affected by benign diseases, should be strongly counseled to stop smoking. This advice should be part of a checklist that includes family history (genetic changes), habits (tobacco), type of work (environmental factors), and information on previous diseases and surgical operations. In addition, urologists
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2012.07.033. * Tel. +39 338 2923270. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2012.10.038
EUROPEAN UROLOGY 63 (2013) 242–243
must involve general practitioners in this process to continue the educational process. Our communities must be informed about the consequences of these diseases for mortality and cost. Avoiding tobacco and protecting workers have to become necessities to which everyone should attend. Media coverage is the best way to release this information. Television, radio, newspapers, and magazines should be all utilized. Special Web sites dedicated to bladder cancer and containing detailed information are already present in some countries and should be disseminated more broadly. Primary prevention programs can start in the schools. Students have to be clearly informed about the real risks of cigarette smoking and the consequences of TCC of the urothelium. The risks and consequences of prolonged exposure to aromatic amines, chemicals, and rubber also should be illustrated in detail. Dye industries must be obliged to test workers periodically with at least cytology and urine examination annually and to protect workers with the use of masks during their daily work. Finally, urologic societies should be strongly involved in supporting this policy and should discuss control programs with public policymakers. Urologists should be much closer to politics, and urologic societies should be able to influence the decision process of politicians. Investing money in prevention will result in lives saved and reduced costs for society.
243
tumors and thus avoid too many unnecessary evaluations. Finally, costs have to be considered. Different reports show that screening should not be addressed to the whole population but only to individuals at risk [7,8]. In addition, the recommendations of the US Preventive Services Task Force (USPSTF) are that the current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults and that screening programs should not be adopted [9]. Even if criticized by different urologists, this statement has been reconfirmed by the USPSTF [9]. Thus screening can be directed to those individuals at risk: patients with family history of bladder cancer, cigarette smokers, and workers exposed to carcinogens. Urologists should circulate details of the initial symptoms of bladder cancer to their patients and communities in the attempt to detect tumors as early as possible. Early detection with the subsequent proper treatment and follow-up could have an important and beneficial effect on the mortality rate and can reduce the costs of cancer. Conflicts of interest: The author has nothing to disclose.
References [1] Colombel M, Soloway M, Akaza H, et al. Epidemiology, staging, grading, and risk stratification of bladder cancer. Eur Urol Suppl 2008;7:618–26. [2] Brausi M, Witjes JA, Lamm D, et al. A review of current guidelines and
2.
Early diagnosis
best practice recommendations for the management of nonmuscle invasive bladder cancer by the International Bladder Cancer Group.
The second important goal in bladder cancer is early diagnosis. Detection of bladder cancer at an early stage, prior to muscle invasion or metastasis, could determine a significant improvement in patient morbidity and outcome. Consequently, survival can be positively affected, and there is evidence of this. Data from the US National Cancer Data Base, including >70 000 patients, shows that the overall 5-yr survival for patients with stage 0 and stage I is 72% and 65%, respectively. This drops to 38.5% for stage II and to 12% for patients with metastatic disease [7]. Screening is a possible tool to achieve these results; however, screening programs in bladder cancer have been discussed and criticized. It is not sufficient to show that cancers detected earlier will improve survival. A test that can identify these tumors in the early stages is needed. This test should have reasonable sensitivity and specificity and a high positive predictive value to identify the majority of
J Urol 2011;186:2158–67. [3] Botteman MF, Pashos CL, Redaelli A, et al. The health economics of bladder cancer: a comprehensive review of the published literature. Pharmacoeconomics 2003;21:1315–20. [4] Burger M, Catto JWF, Dalbagni G, et al. Epidemiology and risk factors of urothelial bladder cancer. Eur Urol 2013;63:234–41. [5] Kirkali Z, Chan T, Manoharan M, et al. Bladder cancer epidemiology, staging and grading and diagnosis. Urology 2005;66(Suppl 1):4–34. [6] Silverman DT, Devesa SS, Moore LE, et al. Bladder cancer. In: Schottenfeld D, Fraumeni J, editors. Cancer epidemiology and prevention, ed. 3. New York, NY: Oxford University Press; 2006. [7] National Cancer Data Base. American College of Surgeons Web site. http://www.facs.org/cancer/ncdb/. Updated March 28, 2011. [8] Vikers AJ, Bennette C, Kibel AS, et al. Who should be included in a clinical trial of screening for bladder cancer? Cancer. In press. http:// dx.doi.org/10.1002/cncr.27692. [9] Moyer VA, US Preventive Services Task Force. Screening for bladder cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med 2011;155:246–53.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 234–241 of this issue
Primary Prevention and Early Detection of Bladder Cancer: Two Main Goals for Urologists Maurizio A. Brausi * Department of Urology, Ausl Modena, Nuovo Ospedale Civile - S. Agostino Estense, Via Giardini 1355, Modena, Italy
Bladder cancer is one of the most frequently occurring tumors worldwide [1]. About 75% of newly diagnosed tumors are non–muscle invasive bladder cancer (NMIBC) and have a good survival rate but a high risk of recurrence. A significant proportion of patients have high-grade tumors and are at risk for progression [2]. These tumors need early and accurate diagnosis with cytology, imaging, and cystoscopy. Treatment consists of transurethral resection followed in the majority of the cases by intravesical instillations of chemotherapeutic agents or immunotherapy. These treatments should be continued for 1–3 yr, and patients should be closely followed in specialized centers for many years. The remaining 25% of newly diagnosed bladder cancers are muscle invasive and need aggressive radical surgery or radiotherapy with or without chemotherapy. The mortality rate for these patients is high, and diagnosis at an early stage could improve survival. The need for accurate diagnosis, continuous surveillance, and possible repeat treatments for NMIBC, together with the aggressive treatment of invasive disease makes bladder cancer one of the most expensive tumors in terms of total medical care expenditures [3]. Moreover, as mentioned in the article by Burger et al., transitional cell carcinoma (TCC) of the bladder was the eighth most common cause of cancer-specific mortality in Europe in 2008 [4]. High recurrence and mortality rates are the main characteristics of a disease that has a profound medical and economic impact on our society. A program for reducing incidence, morbidity, and mortality of TCC of the bladder should be part of future plans for urologists and European and international urologic societies as well as for governments. Incidence of a disease can be reduced with prevention. To achieve this reduction, information about factors that cause the disease is absolutely necessary.
Burger et al. focused very well on the epidemiologic aspects of this disease and evaluated the most important risk factors [4]. Smoking was the most common risk factor and accounted for approximately half of all TCCs of the bladder. Because about 20% of adults in Europe are cigarette smokers, the number of patients who will develop TCC of the bladder is huge. Cigarette smokers have a two- to fourfold increased risk of bladder cancer compared with nonsmokers [5], and the risk increases with increasing intensity and duration of smoking [6]. On cessation of smoking, the risk of bladder cancer falls >30% after 1–4 yr and by >60% after 25 yr but never returns to the risk level of nonsmokers [1]. Occupational exposure to aromatic amines is another important risk factor, whereas the impact of diet and environmental pollution is less evident. Finally, there is increased evidence that genetic predisposition may influence the incidence of TCC of the bladder [4]. In light of these observations, urologists can play a crucial role in prevention and early diagnosis. 1.
Primary prevention programs
Urologists should display information on bladder cancer incidence, morbidity, and mortality in their own offices and departments. Leaflets with information on the causative factors of the disease should be designed and given to all incoming patients. Cigarette-smoking patients, even if affected by benign diseases, should be strongly counseled to stop smoking. This advice should be part of a checklist that includes family history (genetic changes), habits (tobacco), type of work (environmental factors), and information on previous diseases and surgical operations. In addition, urologists
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2012.07.033. * Tel. +39 338 2923270. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2012.10.038
EUROPEAN UROLOGY 63 (2013) 242–243
must involve general practitioners in this process to continue the educational process. Our communities must be informed about the consequences of these diseases for mortality and cost. Avoiding tobacco and protecting workers have to become necessities to which everyone should attend. Media coverage is the best way to release this information. Television, radio, newspapers, and magazines should be all utilized. Special Web sites dedicated to bladder cancer and containing detailed information are already present in some countries and should be disseminated more broadly. Primary prevention programs can start in the schools. Students have to be clearly informed about the real risks of cigarette smoking and the consequences of TCC of the urothelium. The risks and consequences of prolonged exposure to aromatic amines, chemicals, and rubber also should be illustrated in detail. Dye industries must be obliged to test workers periodically with at least cytology and urine examination annually and to protect workers with the use of masks during their daily work. Finally, urologic societies should be strongly involved in supporting this policy and should discuss control programs with public policymakers. Urologists should be much closer to politics, and urologic societies should be able to influence the decision process of politicians. Investing money in prevention will result in lives saved and reduced costs for society.
243
tumors and thus avoid too many unnecessary evaluations. Finally, costs have to be considered. Different reports show that screening should not be addressed to the whole population but only to individuals at risk [7,8]. In addition, the recommendations of the US Preventive Services Task Force (USPSTF) are that the current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults and that screening programs should not be adopted [9]. Even if criticized by different urologists, this statement has been reconfirmed by the USPSTF [9]. Thus screening can be directed to those individuals at risk: patients with family history of bladder cancer, cigarette smokers, and workers exposed to carcinogens. Urologists should circulate details of the initial symptoms of bladder cancer to their patients and communities in the attempt to detect tumors as early as possible. Early detection with the subsequent proper treatment and follow-up could have an important and beneficial effect on the mortality rate and can reduce the costs of cancer. Conflicts of interest: The author has nothing to disclose.
References [1] Colombel M, Soloway M, Akaza H, et al. Epidemiology, staging, grading, and risk stratification of bladder cancer. Eur Urol Suppl 2008;7:618–26. [2] Brausi M, Witjes JA, Lamm D, et al. A review of current guidelines and
2.
Early diagnosis
best practice recommendations for the management of nonmuscle invasive bladder cancer by the International Bladder Cancer Group.
The second important goal in bladder cancer is early diagnosis. Detection of bladder cancer at an early stage, prior to muscle invasion or metastasis, could determine a significant improvement in patient morbidity and outcome. Consequently, survival can be positively affected, and there is evidence of this. Data from the US National Cancer Data Base, including >70 000 patients, shows that the overall 5-yr survival for patients with stage 0 and stage I is 72% and 65%, respectively. This drops to 38.5% for stage II and to 12% for patients with metastatic disease [7]. Screening is a possible tool to achieve these results; however, screening programs in bladder cancer have been discussed and criticized. It is not sufficient to show that cancers detected earlier will improve survival. A test that can identify these tumors in the early stages is needed. This test should have reasonable sensitivity and specificity and a high positive predictive value to identify the majority of
J Urol 2011;186:2158–67. [3] Botteman MF, Pashos CL, Redaelli A, et al. The health economics of bladder cancer: a comprehensive review of the published literature. Pharmacoeconomics 2003;21:1315–20. [4] Burger M, Catto JWF, Dalbagni G, et al. Epidemiology and risk factors of urothelial bladder cancer. Eur Urol 2013;63:234–41. [5] Kirkali Z, Chan T, Manoharan M, et al. Bladder cancer epidemiology, staging and grading and diagnosis. Urology 2005;66(Suppl 1):4–34. [6] Silverman DT, Devesa SS, Moore LE, et al. Bladder cancer. In: Schottenfeld D, Fraumeni J, editors. Cancer epidemiology and prevention, ed. 3. New York, NY: Oxford University Press; 2006. [7] National Cancer Data Base. American College of Surgeons Web site. http://www.facs.org/cancer/ncdb/. Updated March 28, 2011. [8] Vikers AJ, Bennette C, Kibel AS, et al. Who should be included in a clinical trial of screening for bladder cancer? Cancer. In press. http:// dx.doi.org/10.1002/cncr.27692. [9] Moyer VA, US Preventive Services Task Force. Screening for bladder cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med 2011;155:246–53.