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Special Focus on Bladder Cancer – Part 2: Context and Surveillance

This year’s Cancer System Quality Index (CSQI) will take a deeper look at bladder cancer in Ontario, from providing an overview of who in Ontario develops bladder cancer to examining treatment patterns in the province. Much of the information presented pertains to urothelial carcinoma, which is the most common histologic type of bladder cancer.

After [the doctor] told me that it is most definitely cancer, my whole world stopped. I couldn't comprehend, and I was so stunned that I couldn't pay attention after.

Anonymous, bladder cancer survivor

Understanding the basics: what is bladder cancer?

The bladder is an organ in the pelvis that is made up of multiple layers of muscle and connected to the kidneys via the ureters. The kidneys produce urine, which is stored within the bladder.

Bladder diagram

There are 3 main types of bladder cancer: urothelial carcinoma, squamous cell carcinoma and adenocarcinoma. Urothelial carcinoma, which is also called transitional cell carcinoma, is the most common type of bladder cancer, making up more than 90% of all bladder cancers. Urothelial carcinoma is caused by tumour growth on the inside lining of the bladder. The urothelium is the lining on the inside of the bladder, ureters, urethra and the renal pelvis.

Urothelial carcinomas may be non-invasive (only in the lining of the bladder) or invasive (growing into the muscle layers of the bladder wall). Over 70% of all newly diagnosed bladder cancers are non-muscle invasive bladder cancer (NMIBC), and this form of bladder cancer has a 60% to 70% recurrence rate [1].

I knew nothing about bladder cancer prior to my father’s diagnosis. I did the majority of the research for my father. I feel like the onus falls on the patient and caregiver to research and figure out what to ask the physicians, and a lot of this should come from the other direction: from physician to patient

Anonymous, family member

Incidence

According to the Ontario Cancer Statistics 2018 Report, the greatest disparities between the sexes in cancer incidence (outside of thyroid cancer) are expected to occur in bladder cancer [2]. Specifically, the male incidence rate will be 4 times higher than the female rate. This could be a result of risk factors such as a history of smoking and tobacco consumption: smokers are 2 to 3 times more likely to develop bladder cancer than non-smokers [3].

Bladder cancer incidence is projected to impact more males than females in 2018 (an estimated 3,947 cases among males compared to 1,216 cases among females), with the greatest incidence in males age 70 to 74 years (Figure 1). However, there was a small but steady decease in age-standardized incidence rates for bladder cancer (urothelial and non-urothelial carcinomas) in Ontario from 1981 to 2013 (Figure 2). There was a larger decline of bladder cancer incidence rates for men than women, but there was a greater incidence of urothelial carcinoma and non-urothelial carcinoma in men from the outset.

In 2013, the number of men diagnosed with urothelial carcinoma in Ontario was almost 3.4 times the number of women diagnosed. The incidence rates for urothelial carcinoma are the highest for men age 85 years and older (Figure 3).

Both my mother and father were diagnosed with bladder cancer within 6 months of each other. What I couldn't understand is how the same cancer affected each of them so differently. The cancer responded favourably to my dad after treatment, but poorly to my mom. Neither have smoked or worked around a chemical dye factory; they were an anomaly to the healthcare system.

Anonymous, family member

Figure 1. Projected new cases for bladder cancer, by sex and age group, 2018

More information regarding the methodology is available.

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Figure 2. Age-standardized incidence rates for all bladder cancers (including urothelial carcinoma) and urothelial carcinoma only, by sex, 1981 to 2013

More information regarding the methodology is available.

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Note:

  1. Rates are per 100,000 and standardized to the age distribution of the 2011 Canadian population
  2. Observed incidence rates are based on rates that have been adjusted to adhere to the International Association of Cancer Registries (IACR) standards for counting multiple primary cancers, to allow for direct comparisons of incidence rates over time.
  3. Urothelial carcinoma defined as bladder cases (C67) with histology codes 8020, 8031, 8082, 8120, 8122, 8130 and 8131

 

Figure 3. Age-specific incidence rates for bladder cancer (urothelial carcinoma), by sex, 2013

More information regarding the methodology is available.

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Note:

  1. Rates are per 100,000.
  2. Observed incidence rates are based on the NCI SEER standards for counting multiple primary cancers, which were adopted by the Ontario Cancer Registry for cases diagnosed in 2010 and beyond.
  3. Urothelial carcinoma defined as bladder cases (C67) with histology codes 8020, 8031, 8082, 8120, 8122, 8130 and 8131

 

Figure 4. Age-standardized mortality rates for bladder cancer, by sex, 1981 to 2013

More information regarding the methodology is available.

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Note:

  1. Rates are per 100,000 and standardized to the age distribution of the 2011 Canadian population.
  2. Cancer deaths defined by SEER Cause of Death recode (see http://seer.cancer.gov/codrecode/1969+_d04162012/index.html).

 

Figure 5. Age-specific mortality rates for bladder cancer, by sex, 2013

More information regarding the methodology is available.

* Female rates for the 50-54 and 55-59 age group suppressed due to small cell counts (<6)

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Note:

  1. Rates are per 100,000
  2. Cancer deaths defined by SEER Cause of Death recode (see http://seer.cancer.gov/codrecode/1969+_d04162012/index.html).

 

Figure 6. Age-standardized 5-year relative survival ratio (RSR) for bladder cancer (urothelial carcinoma), by sex, 1993 to 2003 vs. 2009 to 2013

More information regarding the methodology is available.

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Note:

  1. Analysis restricted to cases diagnosed between the ages of 15 and 99
  2. RSR for 1999-2003 calculated using the cohort method, RSR for 2009-2013 calculated using the period method
  3. RSRs are age-standardized using the International Cancer Survival Standards (ICSS)
  4. Urothelial carcinoma defined as bladder cases (C67) with histology codes 8020, 8031, 8082, 8120, 8122, 8130 and 8131

 

Data Table 1. Projected new cases for bladder cancer, by sex and age group, 2018

Age at diagnosis Number of projected male cases Number of projected female cases
30 to 34 6.5 9.0
35 to 39 15.5 8.2
40 to 44 27.1 7.3
45 to 49 51.3 21.0
50 to 54 106.2 52.1
55 to 59 234.9 88.0
60 to 64 395.9 120.1
65 to 69 553.2 154.6
70 to 74 765.8 189.2
75 to 79 633.5 183.9
80 to 84 555.8 162.9
85+ 601.6 219.9

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Data Table 2. Age-standardized incidence rates for all bladder cancers (including urothelial carcinoma) and urothelial carcinoma only, by sex, 1981 to 2013

Year of diagnosis Male, bladder cancer (including urothelial carcinoma) Female, bladder cancer (including urothelial carcinoma) Male, urothelial carcinoma only Female, urothelial carcinoma only
1981 46.1 11.8 38.5 9.4
1982 42.2 10.6 35.3 8.4
1983 43.0 11.9 36.9 8.9
1984 44.7 11.2 38.2 9.0
1985 43.0 11.3 37.3 9.2
1986 42.7 10.5 36.2 8.7
1987 44.2 11.3 38.0 9.2
1988 44.2 11.9 39.1 9.7
1989 34.9 9.1 29.1 7.4
1990 33.1 9.5 27.8 7.2
1991 32.4 8.6 27.1 6.6
1992 36.1 8.4 29.8 6.6
1993 34.6 8.8 28.6 6.7
1994 33.1 8.7 27.6 6.8
1995 33.9 8.3 28.0 6.7
1996 30.8 8.3 25.3 6.3
1997 34.6 8.3 29.1 6.6
1998 30.4 9.0 24.9 7.1
1999 34.1 8.4 27.4 6.4
2000 32.9 8.7 27.0 6.9
2001 32.0 8.2 25.8 6.0
2002 29.7 8.5 23.9 6.2
2003 33.4 8.7 25.0 5.6
2004 31.9 8.4 25.4 6.1
2005 27.7 7.6 22.8 5.6
2006 27.0 7.3 22.5 5.7
2007 28.4 7.3 23.2 5.6
2008 28.7 6.8 24.4 5.2
2009 28.3 7.1 23.9 5.4
2010 29.9 7.2 26.6 5.7
2011 29.0 6.9 25.6 5.5
2012 27.3 6.9 24.1 5.8
2013 27.4 6.2 24.5 5.0

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Note:

  1. Rates are per 100,000 and standardized to the age distribution of the 2011 Canadian population
  2. Observed incidence rates are based on rates that have been adjusted to adhere to the International Association of Cancer Registries (IACR) standards for counting multiple primary cancers, to allow for direct comparisons of incidence rates over time.
  3. Urothelial carcinoma defined as bladder cases (C67) with histology codes 8020, 8031, 8082, 8120, 8122, 8130 and 8131

 

Data Table 3. Age-specific incidence rates for bladder cancer (urothelial carcinoma), by sex, 2013

Age at diagnosis Age-specific male rate Age-specific female rate Number of male cases Number of female cases
30 to 34 2.1 * 9.0 *
35 to 39 3.2 1.5 14.0 7.0
40 to 44 7.4 2.3 34.0 11.0
45 to 49 14.9 1.9 76.0 10.0
50 to 54 23.4 10.6 125.0 57.0
55 to 59 50.3 14.9 232.0 71.0
60 to 64 91.3 27.3 350.0 111.0
65 to 69 174.2 46.0 550.0 157.0
70 to 74 250.5 58.5 558.0 149.0
75 to 79 340.4 65.0 570.0 131.0
80 to 84 411.9 83.7 494.0 136.0
85+ 458.6 89.0 421.0 161.0

* Suppressed due to small cell count (<6)

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Note:

  1. Rates are per 100,000.
  2. Observed incidence rates are based on the NCI SEER standards for counting multiple primary cancers, which were adopted by the Ontario Cancer Registry for cases diagnosed in 2010 and beyond.
  3. Urothelial carcinoma defined as bladder cases (C67) with histology codes 8020, 8031, 8082, 8120, 8122, 8130 and 8131

 

Data Table 4. Age-standardized mortality rates for bladder cancer, by sex, 1981 to 2013

Year of diagnosis Male Female
1981 13.2 3.8
1982 12.8 3.4
1983 12.0 3.4
1984 11.7 3.7
1985 12.7 3.3
1986 10.5 2.9
1987 12.4 2.9
1988 11.9 3.7
1989 12.3 3.2
1990 11.0 2.7
1991 11.9 3.0
1992 9.6 2.5
1993 9.8 3.1
1994 11.7 3.4
1995 10.4 2.7
1996 9.5 2.9
1997 10.6 2.6
1998 10.6 2.9
1999 11.5 2.9
2000 11.7 3.3
2001 11.5 3.1
2002 11.0 2.9
2003 10.6 3.1
2004 10.2 3.4
2005 9.6 3.2
2006 10.0 3.3
2007 9.5 3.1
2008 10.0 3.0
2009 10.0 3.1
2010 10.1 2.8
2011 9.6 3.0
2012 9.5 2.7
2013 9.6 2.5

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Note:

  1. Rates are per 100,000 and standardized to the age distribution of the 2011 Canadian population.
  2. Cancer deaths defined by SEER Cause of Death recode (see http://seer.cancer.gov/codrecode/1969+_d04162012/index.html).

 

Data Table 5. Age-specific mortality rates for bladder cancer, by sex, 2013

Age at diagnosis Age-specific male rate Age-specific female rate Number of male cases Number of female cases
50 to 54 2.4 * 13.0 *
55 to 59 3.5 * 16.0 *
60 to 64 10.2 4.4 39.0 18.0
65 to 69 18.4 3.5 58.0 12.0
70 to 74 31.0 7.9 69.0 20.0
75 to 79 54.9 12.4 92.0 25.0
80 to 84 75.9 24.6 91.0 40.0
85+ 191.7 44.8 176.0 81.0

* Female rates for the 50-54 and 55-59 age group suppressed due to small cell counts (<6)

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Note:

  1. Rates are per 100,000
  2. Cancer deaths defined by SEER Cause of Death recode (see http://seer.cancer.gov/codrecode/1969+_d04162012/index.html).

 

Data Table 6. Age-standardized 5-year relative survival ratio (RSR) for bladder cancer (urothelial carcinoma), by sex, 1993 to 2003 vs. 2009 to 2013

Year of diagnosis Males Lower confidence interval Upper confidence interval Females Lower confidence interval Upper confidence interval
1999 to 2003 71.7 70.1 73.3 66.6 63.8 69.2
2009 to 2013 71.4 69.4 73.3 65.2 61.3 68.8

Report date: January 2018

Data source: Ontario Cancer Registry (November 2016), CCO

Prepared by: Surveillance, Analytics and Informatics, CCO

Note:

  1. Analysis restricted to cases diagnosed between the ages of 15 and 99
  2. RSR for 1999-2003 calculated using the cohort method, RSR for 2009-2013 calculated using the period method
  3. RSRs are age-standardized using the International Cancer Survival Standards (ICSS)
  4. Urothelial carcinoma defined as bladder cases (C67) with histology codes 8020, 8031, 8082, 8120, 8122, 8130 and 8131

 

Mortality

Similar to incidence, bladder cancer mortality is also expected to have the greatest disparity between males and females in 2018. The age-standardized mortality rate for males will be more than 3 times the female rate. In 2013, the age-standardized mortality rate per 100,000 people for bladder cancer for males was 3.8 times more than it was for females (9.6 vs. 2.5) (Figure 4).

From 1981 to 2013, there was a slow decline in mortality rates for both males and females. In 2013, those over the age of 85 had the highest age-standardized mortality rates (191.7 for males and 44.8 for females) (Figure 5).

The only knowledge of bladder cancer I had prior to my diagnosis was that it was a serious cancer and there weren't many treatment options.

Anonymous, bladder cancer survivor

Survival

Five-year age-adjusted relative survival ratio (RSR) determines the likelihood of a person’s survival 5 years after their cancer diagnosis compared to individuals of the same age in the general population. It determines the extent that cancer affects the life expectancy of a person

The 5-year RSR for bladder cancer has decreased for both males and females since the period of 1999 to 2003. The survival rate for all males with bladder cancer (urothelial carcinoma) in Ontario was 71.7% from 1999 to 2003; it declined slightly to 71.4% from 2009 to 2013. The 5-year RSR for females also shows a slight decline: it was 66.6% from 1999 to 2003 compared to 65.2% from 2009 to 2013. Despite males having a greater incidence of bladder cancer, they have higher survival rates than females. This could be a result of more advantage stage of diagnosis compared to males as a result of delayed diagnosis, metabolic differences or a greater number of sex steroids in females that can affect cancer progression [4].

The Ontario Cancer Statistics 2018 Report highlights how the 3-year RSR for bladder cancer decreased significantly for the period of 2011 to 2015 with increasing Charlson Comorbidity Index (CCI) scores. The 3-year RSR decreased from 77.6% for people with bladder cancer and no comorbidities to 36.4% for those with bladder cancer and 3 or more comorbidities [2].

Overall, these data indicate that survival rates for bladder cancer are not improving, highlighting the need for system-level improvements in diagnosis and follow-up care post-treatment among people with bladder cancer.

Some disease sites have a true team interdisciplinary approach, where key disciplines are identified for inpatient and outpatient follow-up. Bladder cancer can definitely benefit from having this approach

Anonymous, family member

Risk factors for bladder cancer

A risk factor is an attribute, characteristic or exposure that increases the chance of developing cancer. There are a few known risk factors for bladder cancer.

As highlighted in the above figures, the risk of developing bladder cancer increases with age. Men also are more likely to develop bladder cancer than women.

Smoking is the most important risk factor for bladder cancer, but other known risk factors are cyclophosphamide (chemotherapy drug), pelvic radiation, history of bladder cancer, ongoing bladder irritation, and bladder birth defects [5].

Some environmental and work-related exposures also are known to increase the risk of developing bladder cancer, including arsenic in drinking water and aromatic amines and polycyclic aromatic hydrocarbons (PAHs) in industrial dyes, hair dyes, paints, fungicides, plastics and rubber [6–8]. Work in the aluminum and metal production industry also has been linked to increased risk of bladder cancer [9]. PAHs account for about 30 bladder cancer cases each year in Ontario; the occupations with the highest number of PAH-associated bladder cancers are machine operators and assemblers in manufacturing.

I was a smoker for 42 years and I worked in a textile mill, which included working with dyes and other chemicals.

Anonymous, bladder cancer survivor

 

Although the most consistent evidence has been found for PAHs, diesel exhaust also is cited as a probable occupational risk factor for bladder cancer [10]. About 300 000 workers (5% of the working population) in Ontario are exposed to diesel exhaust, the majority of whom are drivers of diesel engine vehicles or heavy equipment, including firetrucks and ambulances. As highlighted in the Burden of Occupational Cancer in Ontario: Major Workplace Carcinogens and Prevention of Exposure Report, which is based on 2011 cancer statistics, occupational exposure to diesel exhaust accounts for over 45 bladder cancer annually [11].

Notes

  1. Isharwal S, Konety B. Non-muscle invasive bladder cancer risk stratification. Indian J Urol. 2015;31(4):289–296.
  2. Cancer Care Ontario. Ontario Cancer Statistics 2018 [Internet]. Toronto (ON): Cancer Care Ontario; 2018. Retrieved from here.
  3. Ferrence RG. Sex differences in cigarette smoking in Canada, 1900–1978: a reconstructed cohort study. Can J Public Health. 1988;79(3):160–5.
  4. Dobruch J, Daneshmand S, Fisch M, Lotan Y, Noon AP, Resnick MJ, et al. Gender and bladder cancer: a collaborative review of etiology, biology, and outcomes. European Urology. 2016;69(2):300–10.
  5. Bladder Cancer [Internet]. [place unknown]: American Cancer Society; 2016 (updated 2016 May 23). Available from here.
  6. Olfert SM, Felknor SA, Delclos GL. An updated review of the literature: risk factors for bladder cancer with focus on occupational exposures. South Med J. 2006;99(11):1256–1263.
  7. Kiriluk KJ, Prasad SM, Patel AR, Steinberg GD, Smith ND. Bladder cancer risk from occupational and environmental exposures. Urol Oncol. 2012;30(2):199–211.
  8. International Agency for Research on Cancer. Volume 92: some non-heterocyclic polycyclic aromatic hydrocarbons and some related exposures [Internet]. Lyon (FR): International Agency for Research on Cancer; 2010. Available from here.
  9. International Agency for Research on Cancer. Volume 98: painting, firefighting and shiftwork [Internet]. Lyon (FR): International Agency for Research on Cancer; 2010. Available from here.
  10. International Agency for Research on Cancer. Volume 105: diesel and gasoline engine exhausts and some nitroarenes [Internet]. Lyon (FR): International Agency for Research on Cancer; 2013. Available from here.
  11. Cancer Care Ontario. Burden of occupational cancer in Ontario: major workplace carcinogens and prevention of exposure [Internet]. Toronto (ON): Cancer Care Ontario; 2017. Co-published by the Occupational Cancer Research Centre. Available from here.