Commentary on Association of Clinical Prostate and Bladder Cancers
Article Outline
In the preceding article Singh et al report that men with prostate cancer are at increased risk for bladder cancer and vice versa. Interestingly, there was no increase in other malignancies such as lung, kidney or colon cancer. The authors conclude that there may be a common carcinogenic pathway between prostate and bladder cancers that should be further explored.
More importantly, and perhaps clinically relevant, the authors acknowledge that hematuria after prostate cancer treatment should not be assumed to be a benign treatment related side effect. Previous retrospective studies have demonstrated that patients with bladder cancer often have a delay in diagnosis. While in the current study there was no statistical difference in stage distribution of primary or secondary bladder cancers, there did appear to be a trend towards diagnosis before muscle invasive disease in the secondary cancers. Mommsen et al reported on the time to diagnosis in 212 consecutive patients with bladder cancer.1 They found that the mean time from initial symptom to treatment was 28 weeks, with the longest time delay for patients with cystitis and women with hematuria. Mansson et al similarly reported a greater delay in diagnosis in women compared to men and those with only urgency compared to those with hematuria and pain.2 Other authors have demonstrated a poorer outcome for patients with more than a 3-month delay until cystectomy.3, 4 Thus, Singh et al appropriately conclude that patients with hematuria following prostate cancer should be evaluated appropriately and in a timely fashion for the possibility of urothelial cancer.
Singh et al also stratified the risk of urothelial cancer after prostate cancer by treatment with or without radiation therapy, and found no difference in the standardized incidence ratio (SIR). However, the sample size in this analysis was small and therefore not generalizable. However, this finding is in contrast to multiple other population based studies that have clearly documented an increased risk of urothelial cancer following radiation therapy for prostate cancer. Neugut et al evaluated the records of 141,761 men from the SEER (Surveillance, Epidemiology and End Results) database in the pre-prostate specific antigen era (1973 to 1990) and demonstrated a relative risk of 1.5 of developing bladder cancer after radiotherapy for prostate cancer.5 Brenner et al also evaluated a relatively similar cohort of men from the SEER database from 1973 to 1993 and reported that radiotherapy for prostate cancer was associated with an increased risk of bladder cancer (up to 34%) compared to prostatectomy.6 More recently, Boorjian et al used data from the CaPSURE® database to evaluate the risk of bladder cancer in a more contemporary group of patients diagnosed with prostate cancer from 1989 to 2003.7 In a multivariate analysis that adjusted for comorbidity and smoking status, the authors found a lower relative risk of bladder cancer among patients who underwent prostatectomy compared to radiotherapy (odds ratio 0.51). They also found an overall cumulative incidence of bladder cancer of 1.5% among all patients with prostate cancer.
Thus, the study by Singh et al is important for several reasons. It highlights a possible carcinogenic pathway between 2 urological cancers, it may stimulate physicians to be more vigilant in evaluating any hematuria following prostate cancer and it suggests that some patients with prostate cancer (ie smokers and those who have received radiation therapy) should potentially be screened for urothelial cancer.
References
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- . Time lag to diagnosis of bladder cancer—influence of psychosocial parameters and level of health-care provision. Scand J Urol Nephrol. 1993;27:363
- Cystectomy delay more than 3 months from initial bladder cancer diagnosis results in decreased disease specific and overall survival. J Urol. 2006;175:1262
- . Effect of preoperative delay on survival in patients with bladder cancer undergoing cystectomy in Quebec: a population based study. J Urol. 2006;175:78
- . Bladder carcinoma and other second malignancies after radiotherapy for prostate carcinoma. Cancer. 1997;79:1600
- . Second malignancies in prostate carcinoma patients after radiotherapy compared with surgery. Cancer. 2000;88:398
- Bladder cancer incidence and risk factors in men with prostate cancer: results from Cancer of the Prostate Strategic Urologic Research Endeavor. J Urol. 2007;177:883
PII: S0022-5347(08)00553-3
doi:10.1016/j.juro.2008.03.011
© 2008 American Urological Association. Published by Elsevier Inc. All rights reserved.