|Year : 2016 | Volume
| Issue : 2 | Page : 751-754
A clinicoepidemiological study of young age bladder tumors: An eastern Indian scenario
Jitendra Pratap Singh, Vinod Priyadarshi, Dilip Kumar Pal
Department of Urology, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India
|Date of Web Publication||25-Jul-2016|
Dilip Kumar Pal
Department of Urology, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata - 700 020, West Bengal
Source of Support: None, Conflict of Interest: None
Introduction: Though, bladder cancer is one of the most common urological malignancies, studies addressing the young age group bladder tumors are rare. Present study was done to determine the clinicoepidemiological aspects of bladder tumor diagnosed in young age patients and to compare these aspects with elderly patients.
Patients and Methods: Patients with urinary bladder tumor were selectively divided into two groups; young (<40 years) and elderly (>60 years). Groups were compared on various parameters and statistically analyzed using Fisher's exact two-tailed test.
Results: Smoking, tea and coffee intake and exposure of dye were found significantly associated with development of bladder tumor. Most of the tumors in young age were small, solitary, and papillomatous. Transitional cell carcinoma (TCC) was the most common histological subtype, though most were of low grade and were non-muscle invasive in comparison to the tumors in elderly group.
Conclusion: The incidence of bladder cancer is common in younger age group. Active and passive cigarette smoking, tea, coffee intake, and exposure to organic dyes are major risk factor for younger age group bladder tumor in this part of world. TCC is most common histological subtype and most of them are in low grade without muscle invasion.
Keywords: Bladder tumour, radical cystectomy, trans urethral resection of bladder tumour, young age
|How to cite this article:|
Singh JP, Priyadarshi V, Pal DK. A clinicoepidemiological study of young age bladder tumors: An eastern Indian scenario. J Can Res Ther 2016;12:751-4
| > Introduction|| |
Bladder cancer is one of the most common urological malignancies. As per the Indian cancer registry data in men, it is the ninth most common cancer accounting for 3.9% of all cancer cases. Age, gender, and racial factors all affect the survival and prognosis of patients with bladder cancer. A variety of environmental, occupational, and lifestyle factors including physical activity, artificial sweeteners, alcohol consumption, and smoking have been reported to affect the risk of eventually developing urological malignancies. A review of the literature, performed on the major medical database search engines, reveals that there are only occasional studies that address the young age group bladder tumors. This study was done to determine the clinicoepidemiological aspects of bladder tumor diagnosed in young age patients and to compare these aspects with elderly patients.
| > Patients and Methods|| |
This prospective study was conducted from August 2010 to August 2012 in our institute. Of all the patients of bladder-space occupying lesion, only patients who were under 40 years of age or were above 60 years of age; during the study period, were included as two separate groups “young” and “elderly”, respectively. All cases of recurrent bladder tumors and all patients with bladder space occupying lesion (SOL) having age between 41 and 60 years, were excluded from the study. All the details of patients in term of epidemiological factors, symptoms and sign, radiological, endoscopic, histopathological features, various treatment modalities offered, and follow-up of patients were studied. The two groups “young” (age less than 40 year) and “elderly” (age more than 60 year) were compared on various parameters. Follow-up of cases ranged from 3 years to 1 year with a median follow-up of 2.3 years. All high grade lesions without muscle invasion were subjected to intravesical Bacillus Calmette-Guerin (BCG) therapy. In “young age” group 13 patients and in “older age” group 16 patients were subjected to intravesical BCG instillation. Follow-up protocol in our institute based on detailed history and clinical examination and check cystoscopy at 3 months interval in the 1st year, then 6 months interval at 2nd year, and then yearly once till 5 years of operation. All the patients were strictly followed by phone call and the defaulters were excluded from the study.
The Statistical analysis was done using Fisher's exact two-tailed test. P value of less than 0.05 was taken as significant.
| > Results|| |
A total of 227 patients were diagnosed and treated as bladder tumor from August 2010 to August 2012. Their distribution in age groups has been shown in [Figure 1]. Among them, 31 patients (13.65%) were found younger than 40 at the time of presentation and all these 31 patients were included in study [Table 1]. In this group, mean age at diagnosis was 33.9 (ranged from 20 to 40). Majority of patients presented with gross hematuria in both the age group (87.06 vs77.21%). Patients of both the age group were associated with number of diseases, but their association was not statistically significant [Table 2]. Among the multiple exposed risk factors to young age group patients, only smoking (P-value 0.014), passive smoking (P-value 0.0035), tea and coffee intake (P-value 0.035), and exposure of organic dyes (P-value 0.024) were found significantly associated [Table 3]. None of them had association with upper tract transitional cell carcinoma (TCC) [Table 4]. Majority of tumor in both age groups were less than 3 cm in size. On imaging study and endoscopy, most of the young age group tumors were solitary (77.4%), less than 3 cm (87.09%) and papillary pedunculated type (93.6%) [Table 4]. TCC was the predominant histological subtypes in both the sub age group (80.64 and 92.4%, respectively) [Table 5]. Seventy-six percent of the urothelial carcinoma was of low grade in young age group and 80.64% of young age bladder tumors were non-muscle invasive [Table 6]. Most of the young patients (30) underwent transurethral resection of bladder tumors (TURBTs) as definitive treatment [Table 7]; whereas, only one patient underwent radical cystectomy (RC) that had muscle invasion. Twenty-nine patients received intravesical BCG therapy and none of them had recurrence during the follow-up period.
|Table 3: Association of different lifestyle and the bladder cancer risk factors|
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|Table 4: Distribution and significance of different patient characteristics in two groups|
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|Table 5: Histopathological types of bladder sol in young age group (20-40 year) and elderly (>60 year) age group|
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| > Discussion|| |
Men are three to four times more likely to develop urothelial carcinoma of bladder than women. The incidence and severity of diseases vary between the genders and may be related to differences in carcinogenic exposures, enzymatic processing of environmental substances, and cellular and physiologic responses. In this study, the incidence of bladder tumors were common in male patients of young as well as old age group (59.88 and 84.81%, respectively, P value 0.0021). Cigarette smoking is the most important risk factor for urothelial bladder carcinoma, accounting for 50% of cases in men and 35% in women. A meta-analysis reported that current cigarette smokers have a risk of 2.57 (95% confidence interval (CI) 2.20–3.00) compared with nonsmokers. A positive dose–response relationship was found with both number of cigarettes smoked daily and number of years of smoking. The risk for non-TCC is also increased in smokers. At present, there is no evidence that environmental tobacco smoking increases to risk of urothelial carcinoma. In this study, history of smoking was present in 67.74% young age and 39.24% old age group patients. It was a significant associated risk factor for bladder cancer (P-value 0.014). History of passive smoking with smoker colleague was statistically significant associated risk factor for bladder cancer in young age group (P-value 0.0035). Many studies have evaluated the role of alcoholic beverage consumption on urothelial carcinoma risk and have provided inconsistent results. A recent meta-analysis indicated no effect for alcohol consumption with odds ratio (OR) for alcohol consumption being 1.3 (95%CI 0.9–2.0) for men and 1.0 (95%CI 0.6–1.7) for women. In our study, the effect of alcohol was not found as significant risk factor for younger age group bladder cancer (P-value 0.11). The role of coffee consumption in urothelial carcinoma is not clear in spite of several epidemiological studies. A meta-analysis found an OR for coffee consumption of 1.26 (95%CI 1.09–1.46) for men, 1.08 (95%CI 0.79–1.46) for women, and 1.18 (95%CI 1.01–1.38) for men and women combined. In this study, we found that excessive coffee intake was present in 35.5% of the young age patients and it was a significant risk factor (P-value 0.033). The results of the studies evaluating the effect of tea consumption on urothelial carcinoma are also inconsistent. A recent meta-analysis has not found any association between tea consumption and urothelial carcinoma. In this study we found 87.8% of patient had history of tea and coffee intake with a significant associated risk factor (P-value 0.035). The effect of physical activity was investigated in a cohort study including 37,459 women followed for 13 years in USA. Women who reported regular physical activity presented a decreased risk of urothelial carcinoma compared with more sedentary individuals (RR = 0.66, 95%CI 0.43–1.01). We could not found it as significant risk factor for bladder tumor (P value 0.173). Almost all cohort  and case–control , studies examining the association between personal use of hair dyes and bladder cancer risk found no significant effect, though a population-based case–control study in Los Angeles reported an elevated risk for women with frequent and long-term permanent dye use. The results of the Spanish Bladder Cancer Study did not support these findings. Similarly, our study failed to show any association between hair dye and bladder cancer (P-value 0.54). The pattern of urothelial bladder carcinoma risk among women is similar to that in men. A pooled analysis observed an excess risk among women working in the manufacturing industries, particularly those involving tobacco (OR: 3.0, 95%CI 1.2–7.4), wood products (OR: 3.5, 95%CI 1.0–12.1), and other nonmetallic mineral products (OR: 3.6, 95%CI 1.2–10.7). Similarly, we found exposure of dye and similar substances as statistically significant risk factor (P-value 0.024).
A chronic urinary infection caused by Schistosoma haematobium is associated with urothelial carcinoma of bladder. The evidence linking this infection with urothelial carcinoma came from studies in Africa, showing higher incidence of squamous cell carcinoma in areas with high prevalence of S. haematobium infection compared with areas with low prevalence. Several case–control studies have shown significant positive associations, with risks ranging from 2 to 14. In this study, 38.70% had recurrent urinary tract infection (UTI) in young age group and 32.9% had UTI in old age group, but this association was not statically significant (P-value 0.6553). The role of urinary tract stones on urothelial carcinoma risk is controversial. Several case–control  and cohort  studies have found an increased risk in patients with a history of urinary stones. However, other case–control studies could not show a significant effect. Similarly, our study could not find any role of bladder calculus in urothelial bladder carcinoma (P-value 1.00).
Our results indicated that the young patient group was much less likely to have advanced cancer stages (the percentage of invasive tumor, that is, T2 or above, 19.4 vs 80.6%, P < 0.01), less likely to have high-grade cancers (the percentage of high-grade tumor, 24 vs 76%, P < 0.01). This young patients group also had lower rates of disease recurrence and progression, and longer intervals from initial TURBT to the first recurrence. These findings were the same as others reported., In our study, 76% of young age group urothelial carcinoma were low grade vs 57.5% of older age group. Seventy-eight percent of total low grade young age urothelial carcinomas were non-muscle invasive type. This was statistically significant on comparing with older age group patient (P-value 0.026) most non-muscle-invasive bladder cancers (~75%) are stage Ta and confined to the bladder mucosa. Low-grade Ta tumors rarely progress to muscle invasion. However, stage T1 tumors, particularly those that are high-grade such as grade 3 and carcinoma in situ represent tumors with much greater malignant potential. Stage T1/G3 tumors have already extended beyond the mucosa into the lamina propria. Stage T1 tumors represent approximately 30% of all non-muscle-invasive bladder tumors, and a significant number of these are high-grade. Transurethral resection and intravesical BCG therapy are main stay of treatment for superficial urothelial carcinoma. RC is considered as treatment of choice for muscle-invasive bladder carcinoma. RC with urinary diversion is a safe and effective treatment for properly selected patients with invasive bladder carcinoma who are in reasonably good health. In our study, RC was done in one patient of younger age group and five patients of older age group. All of them were doing well in median follow-up of 9 months, though the follow-up period was short to comment on prognosis after RC.
| > Conclusion|| |
The incidence of bladder cancer is common in younger age group. Its incidence is higher in male. Hematuria is the main presenting feature in both young as well as older age group patients. Active and passive cigarette smoking, tea and coffee intake, and exposure of dye are major risk factor for younger age group bladder tumor in this part of world. Majority of bladder tumor are solitary, less than 3cm in diameter, and papillary pedunculated type. Majority of young patients present in earlier stage (Ta and T1). TCC is most common histological subtype and most of them are in low grade without muscle invasion. TURBT alone or with combination of intravesical BCG is most common treatment modalities in younger age group. The older patients are in higher invasive stage at the time of presentation. RC and chemoradiation are relatively commonly indicated treatment modalities in older patients.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]