Case-Based Review

Noninvasive Bladder Cancer: Diagnosis and Management

Journal of Clinical Outcomes Management. 2014 September;21(9)

Author(s):

References

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From the William Beaumont Hospital, Royal Oak, MI.

Abstract

Objective: To review the diagnosis and management of noninvasive bladder cancer.
Methods: Literature review.
Results: Nonmuscle invasive bladder cancer is a common malignancy that affects more men than women. It is estimated that smoking accounts for half of all cases. Direct visualization of the bladder mucosa remains the standard in diagnosing bladder malignancy. The natural history of superficial bladder cancer is characterized by disease recurrence and disease progression. First-line treatment of patients with noninvasive bladder cancer is transurethral resection of bladder tumor. Adjuvant treatment with intravesical chemotherapy and immunotherapy has become an important component of therapy.
Conclusion: The results of ongoing studies are eagerly anticipated and will improve our understanding of the disease.

Nonmuscle invasive bladder cancer is a common malignancy and the second most common urologic malignancy after prostate cancer. It accounts for approximately 73,500 new cancer diagnoses yearly in the United States [1]. An estimated 14,880 persons die each year as a result of the disease. Despite improvements in diagnosis and management of noninvasive bladder tumors, the risk of both recurrence and progression remains significant. In this article, we review the etiology, diagnosis, and management of noninvasive bladder cancer.

Epidemiology And Risk Factors

Bladder cancer affects men more commonly than women, with an approximate 3 to 4:1 ratio [1,2].The incidence in men over the past 8 years has been stable, and the incidence in women has decreased by 0.3% over the same time period. Bladder cancer affects Caucasians twice as often as African Americans, and affects Hispanics and Asians even less frequently than African Americans [2]. More than 90% of patients diagnosed with bladder cancer will be older than 55 years of age.

Histologically, urothelial (transitional cell) carcinoma accounts for over 90% of all diagnosed bladder cancers [3].Other subtypes in order of prevalence include squamous cell carcinoma, adenocarcinoma, and small cell carcinomas. Of those diagnosed with urothelial carcinoma, nonmuscle invasive (superficial) bladder cancer (NMIBC) accounts for almost 75% of cases [2]. Muscle invasion is seen in 20% of newly diagnosed cases, and metastatic disease is seen approximately 5% of the time.

It is estimated that smoking accounts for half of all cases of bladder cancer, with smokers having a 2- to 6-fold greater risk of bladder cancer as compared with nonsmokers [4–6]. At 25 years after smoking cessation, the risk of bladder cancer continues to decrease but is still higher than that of nonsmokers [7]. Continued smoking despite the diagnosis of urothelial carcinoma increases the risk of recurrence 2.2-fold [8].

Environmental exposures also have been linked to the development of urothelial carcinoma, particularly exposure to aromatic amines [9]. Occupations associated with an increased risk of bladder cancer include tire/rubber workers, leather workers, textile workers, hairdressers, painters, dry cleaners, and chemical workers.

Exposure to certain medications has been associated with an increased risk of bladder cancer, including the analgesic phenacetin, which has since been taken off the market [10]. Additionally, patients treated with the chemotherapeutic agent cyclophosphamide have a higher risk of bladder cancer, with a dose-response relationship between cyclophosphamide and the risk for bladder cancer [11,12]. The increased risk of bladder cancer and risk of hemorrhagic cystitis associated with cyclophosphamide therapy is secondary to exposure to the urinary metabolite acrolein. Concomitant administration of sodium 2-mercaptoethanesulfonate (MESNA) provides regional detoxification of acrolein in the urinary tract [13].