In recognition of Bladder Cancer Awareness Month, Single-Use Endoscopy has published weekly articles exploring a different subject relating to bladder cancer. To wrap up our coverage of this important awareness month, we spoke with Dr. Cheryl Lee, a urologic oncologist specializing in bladder cancer at The Ohio State University, about some of the biases physicians should be aware of in diagnosing bladder cancer.

The American Cancer Society predicts 64,280 men and 19,450 women will be diagnosed with bladder cancer in the United States in 2021. About 90 percent of people diagnosed with this disease are over the age of 55.

Dr. Lee serves as chair of the department of urology and is a board member for the Bladder Cancer Advocacy Network. As a urologic surgeon, she works collaboratively with medical oncology and radiation oncology to improve treatments, quality of life, and survival rates for bladder cancer survivors. Dr. Lee came to Ohio State following 16 years at the University of Michigan.

SUE: Why do you think there has been what you’ve termed “an explosion” of interest in bladder cancer over the last decade? And why had awareness been so low when compared with other prevalent cancers?

Lee: One, it takes coordination and advocacy to gain attention for any disease. The Bladder Cancer Advocacy Network only started a little over 15 years ago. Before that, there wasn’t a nationally coordinated effort to advocate for the disease to the NIH, to other federal funding agencies (DOD, PCORI, etc.),  to the pharmaceutical industry,  to Congress, and to grateful patients. These efforts were important to stimulate funding opportunities. When there isn’t a significant commitment to funding a disease, there will be fewer researchers invested in that disease, which means  fewer discoveries.

Some of the early work in checkpoint inhibition identified bladder cancer as a promising target. This, on the heels of the TCGA project, started what I would call an explosion of interest in bladder cancer to apply those and other new agents. The TCGA project, was an important step for the federal government to invest in bladder cancer to better understand the molecular underpinnings of the disease.

Bladder cancer also finally caught the attention of big pharma. The field has been excited to experience so many clinical trials and newly approve drugs for some of our sickest patients. Increased funding opportunities have also emerged from Johns Hopkins, the Department of Defense, and the Bladder Cancer Advocacy Network, supporting innovative ideas and early career scientists. That’s really increased the awareness.

SUE: Bladder cancer is the fourth most-common cancer in men, but evidence suggests it’s more lethal to women. Why is that?

Lee: The issue is multifactorial. Some of it relates to delayed diagnosis with women misdiagnosed at a greater frequency and presenting for treatment later than men. Because women have a higher rate of urinary tract infection, a condition that can present with blood in the urine, medical providers may be more likely to presume they have this benign and common condition rather than considering a diagnosis of bladder cancer. Increasing bladder cancer awareness is critical to improve this. More recently, there is a growing literature about sex-based molecular alterations that may impact a patient’s tumor environment and response to treatment. We are surely making progress in our understanding of sex-based differences in this disease.

SUE: What would your message be to women experiencing any of those symptoms that could come from a urinary tract infection?

LEE: The main message I always have as it relates to bladder cancer for men and for women is that if you see blood in your urine, in other words red urine, that’s something that needs to be evaluated by a urologist. It’s not to say that someone has cancer when they have that, but we need to make sure that they don’t. We need to rule out some of the most serious conditions

Second, if you have a condition, some type of voiding dysfunction or urinary condition that’s not getting better with an initial treatment or conservative treatment, please seek a second opinion or challenge your physician to explore other possibilities.

The third thing I would say, again to both men and women, is that smoking increases your risk of developing bladder cancer. Half the patients with bladder cancer have an association with tobacco use or exposure. Smoking and bladder cancer are clearly linked, but this is not a message that is widely appreciated. Patients clearly associate tobacco use with lung cancer because of all of the public service announcements over the years and the information on the back of cigarette packages.  Beginning June 18, 2021, new cigarette health warnings will be required to appear prominently on cigarette packages and in advertisements, and for the first time, a bladder cancer warning will be included.

SUE: Are there any other proven causes of bladder cancer?

LEE: Chemical and industrial exposures are some of the other factors that can increase the risk of bladder cancer. These include certain solvents, cleaners, painting supplies, pesticides, benzidines, and aniline dyes.  In addition, the FDA has confirmed that medications such as Actos and Zantac could also be associated with an increased risk of developing bladder cancer.  Radiation, Agent Orange, certain chemotherapies, long-term bladder stones, and certain chronic bladder infections have also been linked to the disease.

Still, I don’t want to dilute the message. In my opinion, smoking would be the most important risk factor. It’s important that we acknowledge this so that we can aggressively encourage patients to quit smoking.

SUE: What would be your take-home message for both physicians and patients who may not be aware of the prevalence of bladder cancer?

LEE: I would say bladder cancer is more common than many people would know. The prevalence is high. Over 700,000 people are walking around with bladder cancer. Many of these patients have fully curable disease, too. Or, have disease that won’t threaten their life in the short term, so patients should seek treatment.