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Release: June 25, 2002

UI physician working on bladder cancer awareness, treatments

Public awareness of cancer has increased over the years. However, bladder cancer still is poorly understood by the average person and underestimated as a health risk, said a University of Iowa Health Care physician-scientist.

"Bladder cancer is likely underreported," said Michael O'Donnell, M.D., a UI associate professor of urology who treats patients with bladder cancer and is director of the Urologic Oncology Program in the Holden Comprehensive Cancer Center at the UI. "There also is no major patient or public policy advocacy group for bladder cancer as there is for breast or lung cancer, which contributes to a lack of awareness."

O'Donnell has worked with Wendy Sheridan, webmaster of Bladder Cancer Webcafe at www.blcwebcafe.org, to increase public understanding of bladder cancer, which the National Cancer Institute (NCI) reported in 1995 had become more common than lung cancer in frequency.

Nearly 600,000 people nationwide have bladder cancer at any given time, and 54,000 new cases occur each year. Approximately 12,500 individuals annually die of the disease. Bladder cancer strikes people on average when they are in their late 60s or early 70s, although people as young as 40 may also get the disease.

Cigarette smoking is the leading cause of bladder cancer and may be responsible for up to three out of four cases, O'Donnell said. In addition, pesticide use and occupational exposure to gasoline, dyes and rubber may play a role in this form of cancer. Bladder cancer may also be one of the most preventable cancers because of its connection to smoking and chemical exposure.

"Smoking contributes to bladder cancer because carcinogens in the lungs are filtered by the kidneys, and these toxins then get concentrated in the urine," O'Donnell said. "This stagnant pool of carcinogens builds up in the surface layer of the bladder and can cause cancer."

Nearly 80 percent of all bladder cancers remain within the bladder lining, or mucosa. This type of cancer, known as superficial bladder cancer, is treatable but reoccurs in 80 percent of all cases. In invasive cases, the cancer spreads to the bladder muscles, then to other organs and bones, including the reproductive organs and the pelvis.

Treatments are improving but the number of cases is increasing as the U.S. population ages and long-term smokers face the effects of years of smoking, O'Donnell said. Former Minnesota senator and Vice President Hubert Humphrey died from the disease, but no other individuals of "celebrity" status have declared their affliction with bladder cancer, according to O'Donnell.

Men are diagnosed with the disease three times more often than women are; yet women are more likely to die of bladder cancer because they sometimes are not diagnosed when their cancer is at the early stage.

"In women, bladder cancer can be misdiagnosed as post-menopausal bleeding, simple cystitis or a urinary tract infection," O'Donnell said. "As a result, diagnoses in women can be missed for a year or more."

Last October, he and colleagues published a report showing promising results from a clinical trial of a non-surgical treatment for an aggressive form of superficial bladder cancer that had already failed conventional therapy at least once. The study showed that 55 percent of patients treated with a combined immunotherapy of interferon-alpha and a bacteria known as bacillus Clamette-Guerin (BCG) were disease-free two and a half years after treatment. In contrast, less than 20 percent of patients treated with another non-surgical (chemotherapy) method were disease-free after the same time period.

O'Donnell now co-leads a related study that involves 1,200 participants at nearly 60 sites nationwide. That study will further examine the effectiveness of the BCG plus interferon as a treatment, and also involves a component to determine if a high antioxidant vitamin supplement is beneficial.

He also leads a study to help identify patients who would be the best candidates for the combined bladder cancer treatment. He developed a specialized computer system to analyze diverse information, from patients' use of supplements to their smoking status.

In addition to investigating ways to improve bladder cancer treatment, O'Donnell is collaborating with Aaron Holley, M.D., a 2001 graduate of the UI Roy J. and Lucille A. Carver College of Medicine, to study bladder cancer rates in the United States. The team is analyzing various national databases including the Surveillance, Epidemiology and End Results program, which is maintained by the NCI. The findings will be available later this year.

When cancer invades the entire bladder, removal of the organ may be required. O'Donnell said that rebuilding bladders first was attempted about 15 years ago. These orthotopic or neo-bladders are made from a person's own tissue, but are not fully functional. The new bladder canhold urine but requires abdominal pressure or an assistive device to replace natural emptying functions.

Organs such as kidneys, lungs and livers can be transplanted. However, bladder transplantations and completely functional rebuilt bladders are not possible due to the complex nerve system that connects the bladder to the lower spine.

Warning signs of bladder cancer include visible blood in the urine (occurs in 70 to 80 percent of patients). A small number of people, about 10 to 15 percent of all people eventually diagnosed with bladder cancer, will also have unexplained urinary frequency or burning, sometimes without any blood whatsoever.

Because blood in the urine can also be caused by benign problems, physicians may do additional tests to rule out bladder cancer. Imaging tests such as CAT scans, MRIs, ultrasound and intravenous pyelogram (a dye study of the kidney and bladder drainage tract) can detect some tumors, but not smaller ones, which require a cystoscopy (tube inserted into the bladder).

In addition to its health impacts, bladder cancer is among the most costly cancers to treat, O'Donnell says. A typical case may result in $59,000 in medical costs from date of diagnosis to death.

"Looked at another way, each year more than $3,000 is spent on each patient with bladder cancer. Yet less than $30 per patient is annually devoted to bladder cancer research, accounting for only 0.6 percent of the National Cancer Institute's cancer research portfolio," O'Donnell said. "It seems increased awareness for bladder cancer is desperately needed at all levels."

The Holden Comprehensive Cancer Center is Iowa's only National Cancer Institute (NCI)-designated comprehensive cancer center. NCI-designated comprehensive cancer centers are recognized as the leaders in developing new approaches to cancer prevention and cancer care, conducting leading edge research and educating the public about cancer. Visit the Holden Cancer Center at www.uihealthcare.com/depts/cancercenter/

University of Iowa Health Care describes the partnership between the UI Roy J. and Lucille A. Carver College of Medicine and UI Hospitals and Clinics and the patient care, medical education and research programs and services they provide. Visit UI Health Care online at www.uihealthcare.com.