—By Vicki Hoenigke
On a per-patient basis, bladder cancer is the most expensive to treat of all carcinomas (incurring lifetime costs of $96,000 to $187,000), while it is the fifth most costly cancer with regard to healthcare expenditures nationwide
($3 billion annually). It also happens to be one of the most highly prevalent cancers among all persons, irrespective of pay grade: in the United States, bladder cancer is the fourth most common cancer among all men, and the tenth most common among women.
Yet despite these steep costs and high occurrence rates, treatment research for the disease is shamefully underfunded, and no new advances in therapy have been introduced for more than 20 years.
The low federal funding of bladder cancer research and stagnation of therapeutic advances can be attributed in part to a low level of disease awareness–among both the general public as well as the medical community. However, at a certain point–when the societal stakes are high enough and the unmet patient needs are obvious enough–poor disease awareness begins to closely resemble disease neglect.
While early diagnosis is always the best starting point for saving lives and improving the prognosis of patients with any malignancy, this is especially true in the case of bladder cancer. (The survival rate for patients with stage I bladder cancer is 88%, compared with the 45% to 50% survival rate for those with stage I lung cancer, for instance.) Prompt diagnosis, in turn, relies heavily on heightened disease awareness among the public. Unlike breast cancer and prostate cancer, screening for asymptomatic bladder cancer is not currently offered, making it crucial that individuals be able to recognize their symptoms on their own–particularly symptoms that might otherwise be dismissed as unimportant. The most common symptom is hematuria (blood in the urine); other symptoms are those that mimic the pain and frequent urination usually associated with ordinary bladder infections and UTIs. Although men are generally sufficiently concerned at the sight of blood in their urine, women are often unfazed by their own signs of hematuria, frequently mistaking it for the menstrual spotting that sometimes occurs between periods–especially those women who are older and experiencing perimenopause, when menstruation becomes more unpredictable. Unfortunately, perimenopause happens to coincide with the years when the risk of bladder cancer increases sharply. Women are also more prone to bladder infections than men, causing women with a prior history of UTIs to misattribute their urinary symptoms to the routine ailments of their youth.
Primary care physicians likewise need to have a more heightened suspicion about the symptoms of bladder cancer, and should be mindful that all patients who report hematuria require immediate referral to a urologist.
Knowing one’s own personal risk factors may also help prod patients who have symptoms to seek a diagnosis. The greatest risk factor is smoking, which accounts for half of all cases of the disease. Current smokers are four times more likely than non-smokers to develop bladder cancer, and former smokers as a group are twice as likely as non-smokers to acquire the disease (and also remain subject to a possible cancer “incubation period” for up to 25 years after smoking cessation). Current levels of awareness about the association between smoking and bladder cancer is abysmal: a recent study found that as few as 5% of persons realized that smoking was a risk factor for bladder cancer. The good news is that the risk of bladder cancer can nevertheless be reduced by as much as 40% within just 4 years after quitting smoking. Giving individuals yet another incentive to stop smoking is one obvious benefit to increasing disease awareness. But even for those who are unable to quit or who are already symptomatic, knowledge is power, and knowing one’s risk factors may be just what it takes to prompt that important diagnostic visit to the doctor.
Occupational exposure to carcinogens is the other most common cause of bladder cancer. Factory workers in rubber, chemical, and leather industries, for instance, are at substantially higher risk for the disease, but inhalation of the carcinogens known to cause the cancer is not limited to those engaged in manufacturing work; hairdressers, machinists, metal workers, painters, bus drivers, and taxi drivers are also placed at risk by the chemical composition of the fumes that they breathe on a daily basis. Again, incubation periods for the cancer persist for about 25 years among these blue collar professionals, so even retirees should maintain a high index of suspicion for any symptoms, however subtle.
Bladder cancer research has been stuck on the back burner for over two decades: gold standard treatments include Bacillus Calmette-Guerin (a weakened form of live cow tuberculosis) injections and chemotherapy, with strong chemotherapeutic agents administered via a urinary catheter-a grueling therapeutic regimen with side effects that can be harsh to the point of seeming punitive. Low awareness among the healthcare and scientific communities is largely to blame for the faltering progress of bladder cancer research and its low funding priority. A catch-22 then comes into play: a decline in young investigators interested in the field results in a low yield of pivotal studies–and, in turn, a decrease in new data on bladder cancer pushes disease awareness among scientists downward to still-lower levels. Research funding is likewise drawn into this downward cycle. Cancer biologists are likely to have received training in a well-funded area such as breast or prostate cancer, while the perception that a particular disease is of little or languishing clinical interest make it less likely that the disease will receive higher priority for funding.
Recently, in the face of this poor federal funding, some clinical investigators have attempted to partner with the pharmaceutical industry to advance bladder cancer treatment.
Funding has for too long been greatly disproportionate to the high cost of current bladder cancer treatment, as well as to the sheer numbers of patients suffering with this fatal disease. For this reason, in April of this year a bill was issued to Congress to designate a “National Bladder Cancer Awareness Month,” in the hopes of bringing to light the significant unmet needs of this patient group.