Alan Thompson - The Royal Marsden

The Royal MarsdenBladder cancer:who, when, where andhowMr Alan ThompsonHead of Urology Unit,Consultant Urologist Surgeon

The Royal MarsdenWho ?

The Royal MarsdenHow common is bladder cancer ?• Bladder cancer (BC) is 7 th most common overallcancer in the UK4 th most common in men – 7,300 cases12 th most common in women – 2,800 cases• Approx 10,100 diagnosed with BC in 2007 – 28/day• More than 2 x as many men get BC than women• 80% cases of BC occur over age 65 years

The Royal MarsdenHow many people survive bladder cancer ?• Bladder cancer survival rates have improved over thelast 30 years or so57% of men - survive > 5 years47% of women - survive > 5 years• Approx half of patients diagnosed are likely to survivefor at least 10 years• Survival rates are higher for patients diagnosed at ayounger age

The Royal MarsdenHow many people die from bladder cancer ?• Bladder cancer is the eighth most common cause ofcancer death in the UK• Approx 5000 deaths in 2008 – 96/week• Approx 90% deaths are in patients over age 65 years• From a peak in 1990 death rates in men have fallenby 1/3

The Royal MarsdenSummary – incidence, survival & deaths

The Royal MarsdenBladder cancer – main causes/risk factors• Tobacco – main preventable risk2/3 cases in men1/3 cases in women• Smokers have 2 – 6 x increased risk (length & number)• Cessation reduces risk – > 20 years ‘til risk end• Environmental tobacco smoke during childhoodincreases risk of BC by nearly 40%

The Royal MarsdenBladder cancer – main causes/risk factors• Age• Family History – 1 st degree esp. if diagnosed under 45• Occupational exposure (5-10% in men in Europe)Polycyclic aromatic hydrocarbons• Hair dyes?• Medicines/irradiation – chemotherapy. Testicular/cervical• Medical Conditions – Schistosomiasis/paraplegics/Earlymenopause/diabetics/HPV

The Royal MarsdenWhere ?

The Royal MarsdenCentral referrals – The Royal MarsdenPhone 0800 731 2325Fax 020 8661 3149Emailrmh.referrals@nhs.net

The Royal MarsdenWhen ?

The Royal MarsdenWhen

The Royal MarsdenDiagnosis - Haematuria• Paediatric population – 1%• Young Adults – 5%• Adults over 50 – 10%• Macroscopic haematuria is the commonest presentation ofbladder cancer• Almost all patients will have macro or microhaematuria• Degree of bleeding is not proportional to stage• Bleeding due to infection – some patients will have necroticinfected element within a tumour not just inflammation

The Royal MarsdenBladder cancer - symptoms• Commonest symptom is painless haematuria• DO NOT IGNORE painful haematuria• Pronounced irritative symptoms (? cis/invasive)• Loin pain (ureteric obstruction) - rare• Pelvic mass & cachexia – very rare

The Royal MarsdenDefinition - Haematuria• According to Renal Association and British Associationof Urological Surgeons blood in the urine is eitherdefined as• Visible haematuria (VH) – macroscopic or gross• Non visible haematuria (NVH) - microscopic• NVH is subdivided into symptomatic –s-NVH andasymptomatic a-NVH• Definition of NVH varies from >3 rbc/hpf spun to >5rbc/microlitre (dipstick + is >10 rbc/hpf)

The Royal Marsden

The Royal MarsdenDipstick testing - pitfalls• Dip testing is based on the alteration of a chromagenby the peroxidase activity of haemoglobin• False positives - myoglobinuria/oxidisingagents/peroxidases• False negatives – high levels ascorbic acid/nitrite/pH

The Royal MarsdenHaematuria – evidence for investigation2 studies• 1930 pts attending haematuria clinic (1994-97)• 61% patients no pathology / 13% UTI / 2% stone disease• 12% bladder cancer• Macroscopic – 24% / microscopic – 9.4%• 4020 pts• Incidence of bladder cancer• Macroscopic haematuria 19% / microscopic 5%

The Royal MarsdenScreening for bladder cancer: Is it effective ?• Dipstick testing in 2356 men over 60 years (1992)• 20% had recurrent haematuria (n=474)• 319 agreed to urological examination• 17 (5.3% of cohort / 0.7% of tested) asymptomatic mendiagnosed with cancer• Large no. investigations• Prohibitive cost• Targeted screening – smokers 3.3% (inc. cytol/NMP22)

The Royal MarsdenHow ?

The Royal MarsdenDiagnosis – In clinic• History/examination• MSU• Urine Cytology (specificity 95%, sensitivity 49%)Other urinary markers – NMP22/BTA/Telomerase• Flexible cystoscopy• Upper tract imaging (USS)/CTU• TURBT (transurethral resection of bladder tumour) – followedby single dose Mitomycin C

The Royal MarsdenBladder cancer – cell types?• Transitional cell carcinoma – 95%• Squamous cell carcinoma – 3% (Egypt 75%)• Adenocarcinoma (primary or urachal) – 1-2%• Rarely metastases from uterus, rectum, breast andovary

The Royal MarsdenSuperficial Bladder Cancer

The Royal MarsdenSuperficial Bladder Cancer

The Royal MarsdenSuperficial Bladder Cancer• Up to 80% patients present with superficial disease• In such patients risk of distant disease is low• Natural history of bladder cancer based on 2 separate butrelated processesTumour recurrence - 50 to 70% overall (Grossman H,Oncology: 1996). This high recurrence rate in distantfields, so called polychronotropism suggests ‘field defect’in the entire lining epitheliumTumour progression to a higher stage (10 - 15%)

The Royal MarsdenSuperficial Bladder Cancer - management• Management requires a long term commitment• Follow-up may be for life• Most cases “routine” but important to recognisethose with disease that will progress• Such patients must be identified early and selectedfor more aggressive therapy e.g.cystectomy/radiotherapy

The Royal MarsdenSuperficial Bladder Cancer• Superficial bladder cancer is a stage grouping of 3distinct tumours– pTa (papillary and non invasive)– pT1 (invading lamina propria only)– pTis (cis - carcinoma in situ)• They are grouped together as they can be managedin a similar way; endoscopically and usingintravesical therapy

The Royal MarsdenBladder Cancer - G1pTa

The Royal MarsdenMuscle Invasive Bladder Cancer

The Royal MarsdenMuscle Invasive Bladder Cancer

The Royal MarsdenMuscle Invasive Bladder Cancer• Stage Grouping T2-T4• Historical standard treatment – radical surgeryNow treatment options are• Neo-adjuvant chemotherapy then radical surgery• Radical surgery then adjuvant chemotherapy• Chemo-radiotherapy

The Royal Marsden

The Royal MarsdenSurgical Solutions after Radical Cystectomy• Incontinent cutaneous urinary diversion– ileal (or other) conduit• Continent stomal diversions– Mitrofanoff, Indiana, Kock• Orthotopic neobladder– Ileal (Studer, Hautman), Hemi-Kock, Ileocaecal• Ureterosigmoidostomies

The Royal Marsden

The Royal Marsden

Fin – Thank youAlan ThompsonConsultant Urological Surgeon