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Bladder cancer prevention program (BCPP): A global initiative
13th Meeting of the EAU Section of Oncological Urology (ESOU)
Bladder cancer prevention program (BCPP): A global initiative M. Brausi, Modena (IT)
Background Bladder cancer is one of the most common malignancies in the world (1). Amongst patients diagnosed with bladder cancer, about 20% will eventually die of the disease. Treatment for bladder cancer requires lifelong surveillance, and is resource intensive. Treatment for invasive bladder cancer has very significant quality of life effects. About 75% of newly diagnosed tumors are non-muscle invasive (NMIBC), with a long survival but a high risk of recurrence. A significant proportion of patients have high grade tumors and are at risk for progression (2). Treatment of NMIBC consists of TUR followed by intra-vesicle instillations of chemotherapeutic agents or immunotherapy, continued for 1-3 years. Patients require long term surveillance for recurrence, usually with periodic cystoscopy. The remaining 25% of newly diagnosed bladder cancers are muscle invasive. These patients require surgical removal of the bladder with a urinary reconstruction, or radiotherapy with or without chemotherapy. About one third of these patients will die of cancer in spite of attempted curative therapy. This burden of therapy and follow up means that bladder cancer is one of the most expensive malignancies to manage in terms of total expenditures (3,4). Bladder cancer is responsible for approximately 250,000 deaths per year worldwide, and is diagnosed in approximately 900,000 men and women each year. Thus bladder cancer is a very significant public health problem, in terms of prevalence, mortality, impact on quality of life for individuals and their families, and economic cost. Bladder cancer is also highly preventable. At least 50% of bladder cancers, and 65% of invasive bladder cancers, are linked to smoking or industrial carcinogen exposure in the workplace (4). Bladder cancer is approximately 3 times more common in men than women. The reasons for this are multifactorial, including genetic predisposition and greater exposure by men to bladder cancer risk factors. Cigarette smokers have a 2 to 4 fold increased risk of bladder cancer compared to non-smokers (5) and the risk increases with increasing intensity and duration of smoking (6). Worldwide, approximately 20% of adults smoke cigarettes. Thus, this single factor is responsible for a massive incidence and mortality of bladder cancer. Smoking has many other adverse health effects, including lung cancer, peripheral vascular disease, and COPD. Smoking cessation is the single most cost-effective health intervention in the entire armamentarium of medicine. Nonetheless, smoking prevalence has remained stable in most countries in the world. Upon cessation of smoking the risk of bladder cancer falls more than 30% after 1-4 years and > 60% after 25 years but never returns to the level of risk of non-smokers (1). Occupational exposure to aromatic amines and other carcinogens is another important risk factor. Worker safeguards vary widely around the world. Workers exposed to aromatic amines and other carcinogens in the workplace warrant protection from this exposure. This would include, at a basic level, wearing gloves and face masks during activities which result in exposure to these chemicals. In patients at risk, urinalysis and urine cytology for screening may be warranted. Despite the well-known association between smoking, occupational exposure to carcinogens, and bladder cancer, urologists, who are the primary physicians who treat this disease, have played little role in risk reduction in this area. There are several likely reasons for this. Smoking cessation has not been part of the traditional ‘turf’ of urologists. Urologists have traditionally been oriented towards treatment of disease rather than prevention. However, urological practice is in transition, and a focus on men’s
13th Meeting of the EAU Section of Oncological Urology (ESOU)
health and prevention is an emerging theme. Urologists are well positioned to take an active role in bladder cancer prevention.
Role of the WUOF The World Urologic Oncology Federation (WUOF), formed in 2002, is an international association of 18 societies of Urologic Oncology . These Societies represent most regions in the world. The membership of these societies consists of urologists, medical oncologists, and radiation oncologists who have an interest in urologic cancer, including bladder cancer. The WUOF has an annual conference which brings together interested specialists in urologic oncology from around the world. More importantly, through its member societies, the WUOF has access to approximately 30,000 specialists worldwide. These specialists treat millions of patients, and also serve as educators for their trainees and for primary care physicians worldwide. Many of them have substantial influence with health policy organizations and governments in their countries. For healthy men in particular, seeing a urologist for urinating symptoms or an elevated PSA represents their first and only contact with the health care system. Urologists are taking an increasing role in men’s health. This, together with their interest in bladder cancer, means that urologists have a natural role in counselling patients regarding smoking cessation and occupational carcinogen exposure. The WUOF is therefore perfectly positioned to promote a global program of bladder cancer prevention. Primary Objective: The goal of this program is to encourage and influence the members of the Urologic Oncology Societies around the world to engage in bladder cancer prevention in their communities. Secondary Objective: To provide high quality materials on bladder cancer prevention to the Urologic Oncology Societies for translation and widespread distribution. Structure of the program: A steering committee of the WUOF has been struck. The initial members of this committee include the following: Maurizio Brausi (Italy), Laurence Klotz (Canada), Ed Messing (USA), Chris Cheng (Singapore), Roman Sosnowski (Poland). Further members will be added in the near future. The concept was presented to the WUOF executive for approval at the WUOF executive meeting in May 2013. The Steering Committee will develop a program on the following lines:
1. Materials Preparation a) an outstanding patient brochure describing the causative factors for bladder cancer, and the benefits of risk reduction, will be developed. This will be eventually distributed to every Uro Oncology Society in the WUOF, translated into the language(s) of each society’s region, and provided to all members of that society. b) A poster suitable for displaying in urologists’ offices will be prepared. This will emphasize the global nature of the program, and the importance of smoking cessation in bladder cancer prevention. This will also be distributed through the WUOF mechanism, for translation into local languages and distribution to Society members. c) An additional poster, suitable for a primary care physician’s office, will also be prepared for widespread distribution.
13th Meeting of the EAU Section of Oncological Urology (ESOU)
d) A media package to assist urologists in communicating the message of bladder cancer prevention through mass media will be developed.
2. Conference presentations a) The BCPP was launched at the WUOF conference in Vancouver on Sept 6 2013, in the context of a planned forum on Bladder Cancer risk reduction. b) Member societies were encouraged to include a discussion of the role of the urologist in smoking cessation and bladder cancer prevention at their annual conferences. Materials for such a presentation has been developed.
3. Liason The WUOF will liase with other Uro-Oncological Societies like ESOU European Section of Oncological Urology) and Italian Society of Urology (SIU) and the European and international organizations involved in smoking cessation efforts. These include, for example, the following: • World Health Organization • Framework Convention on Tobacco Control (A program dedicated to controlling the use of tobacco worldwide. • Campaign for Tobacco Free Kids (An NGO dedicated to stopping children from becoming smokers and helping those that are already addicted.) • Tobacco Prevention Division: International Union Against Tuberculosis and Lung Disease • International Union Against Cancer • Global Link (Tobacco control organization with a global focus. News, resources, network information, factsheets and calendars posted. • Tobacco Free Kids International Resource Center (An online resource center with the latest research in tobacco control, information about key tobacco control interventions, and relevant news. • Global Tobacco Control (Website offers free instructional training for policy makers, researchers, educators and the general public.) Many countries have smoking cessation organizations. For example, in the US, this includes: • The Foundation for a Smokefree America • The American Cancer Society • American Lung Association. • Tobacco Information and Prevention Resource: US Centers for Disease Control It is likely that similar organizations exist in many countries around the world. a) Member Societies will be encouraged to liase with their own national smoking cessation organizations to leverage activities and resources. b) Member societies will undertake to influence national and international urological associations to join this effort. Obvious targets include the SIU, EAU, AUA, and those Urological Associations where smoking is particularly prevalent. ESOU, through his chairman Maurizio Brausi has already started the information campaign during its stand alone meetings. Two lectures on the Bladder Cancer Prevention Program were given. Brausi, as principal investigator of this initiative, started a feasibility study in the province of Modena, Italy, based on smoking prevention in schools and smoking cessation. Urologists, general practitioners and media (TV, Radio and newspapers) have been involved. A second program with epidemiologists has been prepared for workers at risk. Regular visits to factories and industries where dyes are utilized have been programmed.
4. Industrial policy The WUOF will ask its member Societies to engage in this area. This would mean, for example, establishing a task force within each Society to determine the public policy in the area of worker
13th Meeting of the EAU Section of Oncological Urology (ESOU)
protection against bladder cancer carcinogens in their country, and the compliance with that policy. In countries where such policies are lacking or not enforced, the Society would be encouraged to engage government and other constituencies in an effort to change practice.
5. Program effectiveness Each Society would be requested to provide a report on their activities in bladder cancer prevention, initially on an annual basis. The steering committee would develop plans to evaluate effectiveness of the BCPP initiative. This might include outcome measures such as the following: a) b) c)
How effective are the communication materials? How have the member societies accepted the initiative, and validated the concept? Have brochures been translated and distributed? How many brochures/posters etc. have been distributed?
Summary Bladder cancer is an international public health problem which is highly preventable using simple measures, particularly smoking cessation and occupational carcinogen exposure reduction. Urologists, by virtue of their orientation towards men’s health and interest in bladder cancer, are well positioned to take a leadership role in bladder cancer prevention. By and large, however, this has not occurred. We believe that urologists can readily be influenced to engage their patients, primary care physicians, and communities in bladder cancer prevention. The WUOF, a federation of 18 regional/national societies of urologic oncology around the world, is well positioned to lead this global effort. The results would be an extremely cost effective program which has the potential to very substantially improve the health of the world’s population. References 1. 2.
3. 4. 5. 6. 7. 8. 9.
Colombel M, Soloway M, Akaza H. et al. Epidemiology, Staging, Grading, and risk stratification of Bladder Cancer. Eur Urol Suppl 2008; 7: 618-626 Brausi M, Witjes JA, Lamm D, et al. A review of current guidelines and best practice recommendations for the management of Nonmuscle Invasive Bladder Cancer by the International Bladder Cancer Group. J Urol 2011;186: 2158-2167 Botteman MF, Pashos CL, Redaelli A et al. The health economics of bladder cancer : a comprehensive review of the published literature. Pharmacoeconomics 2003; 21: 1315-1320. Burger M, Catto JW, Dalbagni G et al. Epidemiology of Bladder Cancer. Eur Urol 2012; in press Kirkali Z, Chan T, Manoharan M at al. Bladder cancer epidemiology, staging and grading and diagnosis. Urology 2005; 66:4 -34 Silverman DT, Devesa SS, Moore LE et al. Bladder Cancer. In: Schottenfeld D, Fraumeni J, editors. Cancer epidemiology and prevention, 3rd ed. New York, New York: Oxford University Press 2006 American College of Surgeons. Commission on Cancer National Data Base. http://www.facts.org/cancer/ncdb/index.hml.Accessed 7 Sep 2005 Vikers AJ, Bennette C, Kibel AS et al Who should be included in a clinical trial of screening for bladder cancer ? Cancer 2012; 00:1-7 Moyers BA on behalf of the US Preventive Task Force. Screening for bladder cancer: US Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 2011; 155 N4 : 246-253
Eur Urol Suppl 2016;15(2):44
Bladder cancer prevention program (BCPP): A global initiative M. Brausi, Modena (IT)
Background Bladder cancer is one of the most common malignancies in the world (1). Amongst patients diagnosed with bladder cancer, about 20% will eventually die of the disease. Treatment for bladder cancer requires lifelong surveillance, and is resource intensive. Treatment for invasive bladder cancer has very significant quality of life effects. About 75% of newly diagnosed tumors are non-muscle invasive (NMIBC), with a long survival but a high risk of recurrence. A significant proportion of patients have high grade tumors and are at risk for progression (2). Treatment of NMIBC consists of TUR followed by intra-vesicle instillations of chemotherapeutic agents or immunotherapy, continued for 1-3 years. Patients require long term surveillance for recurrence, usually with periodic cystoscopy. The remaining 25% of newly diagnosed bladder cancers are muscle invasive. These patients require surgical removal of the bladder with a urinary reconstruction, or radiotherapy with or without chemotherapy. About one third of these patients will die of cancer in spite of attempted curative therapy. This burden of therapy and follow up means that bladder cancer is one of the most expensive malignancies to manage in terms of total expenditures (3,4). Bladder cancer is responsible for approximately 250,000 deaths per year worldwide, and is diagnosed in approximately 900,000 men and women each year. Thus bladder cancer is a very significant public health problem, in terms of prevalence, mortality, impact on quality of life for individuals and their families, and economic cost. Bladder cancer is also highly preventable. At least 50% of bladder cancers, and 65% of invasive bladder cancers, are linked to smoking or industrial carcinogen exposure in the workplace (4). Bladder cancer is approximately 3 times more common in men than women. The reasons for this are multifactorial, including genetic predisposition and greater exposure by men to bladder cancer risk factors. Cigarette smokers have a 2 to 4 fold increased risk of bladder cancer compared to non-smokers (5) and the risk increases with increasing intensity and duration of smoking (6). Worldwide, approximately 20% of adults smoke cigarettes. Thus, this single factor is responsible for a massive incidence and mortality of bladder cancer. Smoking has many other adverse health effects, including lung cancer, peripheral vascular disease, and COPD. Smoking cessation is the single most cost-effective health intervention in the entire armamentarium of medicine. Nonetheless, smoking prevalence has remained stable in most countries in the world. Upon cessation of smoking the risk of bladder cancer falls more than 30% after 1-4 years and > 60% after 25 years but never returns to the level of risk of non-smokers (1). Occupational exposure to aromatic amines and other carcinogens is another important risk factor. Worker safeguards vary widely around the world. Workers exposed to aromatic amines and other carcinogens in the workplace warrant protection from this exposure. This would include, at a basic level, wearing gloves and face masks during activities which result in exposure to these chemicals. In patients at risk, urinalysis and urine cytology for screening may be warranted. Despite the well-known association between smoking, occupational exposure to carcinogens, and bladder cancer, urologists, who are the primary physicians who treat this disease, have played little role in risk reduction in this area. There are several likely reasons for this. Smoking cessation has not been part of the traditional ‘turf’ of urologists. Urologists have traditionally been oriented towards treatment of disease rather than prevention. However, urological practice is in transition, and a focus on men’s
13th Meeting of the EAU Section of Oncological Urology (ESOU)
health and prevention is an emerging theme. Urologists are well positioned to take an active role in bladder cancer prevention.
Role of the WUOF The World Urologic Oncology Federation (WUOF), formed in 2002, is an international association of 18 societies of Urologic Oncology . These Societies represent most regions in the world. The membership of these societies consists of urologists, medical oncologists, and radiation oncologists who have an interest in urologic cancer, including bladder cancer. The WUOF has an annual conference which brings together interested specialists in urologic oncology from around the world. More importantly, through its member societies, the WUOF has access to approximately 30,000 specialists worldwide. These specialists treat millions of patients, and also serve as educators for their trainees and for primary care physicians worldwide. Many of them have substantial influence with health policy organizations and governments in their countries. For healthy men in particular, seeing a urologist for urinating symptoms or an elevated PSA represents their first and only contact with the health care system. Urologists are taking an increasing role in men’s health. This, together with their interest in bladder cancer, means that urologists have a natural role in counselling patients regarding smoking cessation and occupational carcinogen exposure. The WUOF is therefore perfectly positioned to promote a global program of bladder cancer prevention. Primary Objective: The goal of this program is to encourage and influence the members of the Urologic Oncology Societies around the world to engage in bladder cancer prevention in their communities. Secondary Objective: To provide high quality materials on bladder cancer prevention to the Urologic Oncology Societies for translation and widespread distribution. Structure of the program: A steering committee of the WUOF has been struck. The initial members of this committee include the following: Maurizio Brausi (Italy), Laurence Klotz (Canada), Ed Messing (USA), Chris Cheng (Singapore), Roman Sosnowski (Poland). Further members will be added in the near future. The concept was presented to the WUOF executive for approval at the WUOF executive meeting in May 2013. The Steering Committee will develop a program on the following lines:
1. Materials Preparation a) an outstanding patient brochure describing the causative factors for bladder cancer, and the benefits of risk reduction, will be developed. This will be eventually distributed to every Uro Oncology Society in the WUOF, translated into the language(s) of each society’s region, and provided to all members of that society. b) A poster suitable for displaying in urologists’ offices will be prepared. This will emphasize the global nature of the program, and the importance of smoking cessation in bladder cancer prevention. This will also be distributed through the WUOF mechanism, for translation into local languages and distribution to Society members. c) An additional poster, suitable for a primary care physician’s office, will also be prepared for widespread distribution.
13th Meeting of the EAU Section of Oncological Urology (ESOU)
d) A media package to assist urologists in communicating the message of bladder cancer prevention through mass media will be developed.
2. Conference presentations a) The BCPP was launched at the WUOF conference in Vancouver on Sept 6 2013, in the context of a planned forum on Bladder Cancer risk reduction. b) Member societies were encouraged to include a discussion of the role of the urologist in smoking cessation and bladder cancer prevention at their annual conferences. Materials for such a presentation has been developed.
3. Liason The WUOF will liase with other Uro-Oncological Societies like ESOU European Section of Oncological Urology) and Italian Society of Urology (SIU) and the European and international organizations involved in smoking cessation efforts. These include, for example, the following: • World Health Organization • Framework Convention on Tobacco Control (A program dedicated to controlling the use of tobacco worldwide. • Campaign for Tobacco Free Kids (An NGO dedicated to stopping children from becoming smokers and helping those that are already addicted.) • Tobacco Prevention Division: International Union Against Tuberculosis and Lung Disease • International Union Against Cancer • Global Link (Tobacco control organization with a global focus. News, resources, network information, factsheets and calendars posted. • Tobacco Free Kids International Resource Center (An online resource center with the latest research in tobacco control, information about key tobacco control interventions, and relevant news. • Global Tobacco Control (Website offers free instructional training for policy makers, researchers, educators and the general public.) Many countries have smoking cessation organizations. For example, in the US, this includes: • The Foundation for a Smokefree America • The American Cancer Society • American Lung Association. • Tobacco Information and Prevention Resource: US Centers for Disease Control It is likely that similar organizations exist in many countries around the world. a) Member Societies will be encouraged to liase with their own national smoking cessation organizations to leverage activities and resources. b) Member societies will undertake to influence national and international urological associations to join this effort. Obvious targets include the SIU, EAU, AUA, and those Urological Associations where smoking is particularly prevalent. ESOU, through his chairman Maurizio Brausi has already started the information campaign during its stand alone meetings. Two lectures on the Bladder Cancer Prevention Program were given. Brausi, as principal investigator of this initiative, started a feasibility study in the province of Modena, Italy, based on smoking prevention in schools and smoking cessation. Urologists, general practitioners and media (TV, Radio and newspapers) have been involved. A second program with epidemiologists has been prepared for workers at risk. Regular visits to factories and industries where dyes are utilized have been programmed.
4. Industrial policy The WUOF will ask its member Societies to engage in this area. This would mean, for example, establishing a task force within each Society to determine the public policy in the area of worker
13th Meeting of the EAU Section of Oncological Urology (ESOU)
protection against bladder cancer carcinogens in their country, and the compliance with that policy. In countries where such policies are lacking or not enforced, the Society would be encouraged to engage government and other constituencies in an effort to change practice.
5. Program effectiveness Each Society would be requested to provide a report on their activities in bladder cancer prevention, initially on an annual basis. The steering committee would develop plans to evaluate effectiveness of the BCPP initiative. This might include outcome measures such as the following: a) b) c)
How effective are the communication materials? How have the member societies accepted the initiative, and validated the concept? Have brochures been translated and distributed? How many brochures/posters etc. have been distributed?
Summary Bladder cancer is an international public health problem which is highly preventable using simple measures, particularly smoking cessation and occupational carcinogen exposure reduction. Urologists, by virtue of their orientation towards men’s health and interest in bladder cancer, are well positioned to take a leadership role in bladder cancer prevention. By and large, however, this has not occurred. We believe that urologists can readily be influenced to engage their patients, primary care physicians, and communities in bladder cancer prevention. The WUOF, a federation of 18 regional/national societies of urologic oncology around the world, is well positioned to lead this global effort. The results would be an extremely cost effective program which has the potential to very substantially improve the health of the world’s population. References 1. 2.
3. 4. 5. 6. 7. 8. 9.
Colombel M, Soloway M, Akaza H. et al. Epidemiology, Staging, Grading, and risk stratification of Bladder Cancer. Eur Urol Suppl 2008; 7: 618-626 Brausi M, Witjes JA, Lamm D, et al. A review of current guidelines and best practice recommendations for the management of Nonmuscle Invasive Bladder Cancer by the International Bladder Cancer Group. J Urol 2011;186: 2158-2167 Botteman MF, Pashos CL, Redaelli A et al. The health economics of bladder cancer : a comprehensive review of the published literature. Pharmacoeconomics 2003; 21: 1315-1320. Burger M, Catto JW, Dalbagni G et al. Epidemiology of Bladder Cancer. Eur Urol 2012; in press Kirkali Z, Chan T, Manoharan M at al. Bladder cancer epidemiology, staging and grading and diagnosis. Urology 2005; 66:4 -34 Silverman DT, Devesa SS, Moore LE et al. Bladder Cancer. In: Schottenfeld D, Fraumeni J, editors. Cancer epidemiology and prevention, 3rd ed. New York, New York: Oxford University Press 2006 American College of Surgeons. Commission on Cancer National Data Base. http://www.facts.org/cancer/ncdb/index.hml.Accessed 7 Sep 2005 Vikers AJ, Bennette C, Kibel AS et al Who should be included in a clinical trial of screening for bladder cancer ? Cancer 2012; 00:1-7 Moyers BA on behalf of the US Preventive Task Force. Screening for bladder cancer: US Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 2011; 155 N4 : 246-253
Eur Urol Suppl 2016;15(2):44