A case of a 76-year-old woman is reported. Her symptoms include increased urination frequency, difficulty urinating, and foul-smelling urine.
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Clinical vignettes:
A case of a 76-year-old woman is reported. Her symptoms include increased urination frequency, difficulty urinating, and foul-smelling urine. No bacteria were found in two urine cultures performed. Regardless, empirical treatment with antibiotics has improved symptoms. Three months later, the patient developed hematuria and was referred to a specialist, who was diagnosed with transitional bladder cancer.
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What types of bladder cancer are there?
In developed countries, 90% of cancers are transitional cancers and the remainder are squamous cancers.
In endemic areas, 70% of cases are schistosomiasis-related squamous cell carcinoma.
20% of tumors have invaded muscle at the time of diagnosis, indicating a poor prognosis.
Risk factors are: smoking, chronic infections, radiation therapy, and (before regulation) industrial dyes.
Why was your diagnosis delayed?
Bladder cancer is more common in men and takes a long time to diagnose in women. The UK National Primary Care Cancer Diagnosis Audit (2009-10) estimated that 435 women had longer delays in diagnosis of cancer than men. There is little information in UK primary care services to explain the reasons for this delay.
There are currently no effective tools to detect it. Generally, diagnosis is symptomatic, with hematuria being the most common symptom in both sexes in primary care (odds ratio 59.95%, confidence interval 51 to 57).
The odds ratio summarizes the number of times a certain finding occurs in patients with bladder cancer relative to patients without cancer. A probability (ratio) of less than 10 (or less than 0.1) is considered a strong evidence factor to confirm (or rule out) the diagnosis.
A recurring finding in a study of outpatients with hematuria was the delay in diagnosis in women after the onset of hematuria. This study included a sample of 7,649 individuals over the age of 65 in the United States (female/male ratio 1:2.43).
The mean time to diagnosis was 85.5 days (95% confidence interval, 81.3 to 89.4) in women and 73.6 days (71.2 to 76.1) in men (P<0.001). This difference appeared to persist over time, with 26% of women experiencing delayed diagnosis at 3 months, 16% at 6 months and 23% at 9 months.
During the survey period, women underwent more urinalysis (1.39 vs. 1.19, P<0.001) and urine cultures (0.83 vs. 0.53, P<0.001) and had more positive results for urinary tract infection (odds ratio 2.32 , 95% confidence interval 2.07) to 2.59; P<0.001) Additionally, they received more antibiotics (40.1% vs 35.4% P<0.001) and fewer imaging studies (odds ratios 0.80, 0.71 to 0.89, P<0.001).
Bladder cancer is also associated with urinary disturbances and abdominal pain. Information from European primary care systems and gynecological services shows that in the year before diagnosis, women with these symptoms often receive empirical treatment without correct clinical assessment, compared with 47% of men (P<0.05) .
Although this information does not come exclusively from the primary care system, prolonged testing and treatment of UTIs during repeated consultations (without resolution of symptoms) appears to be a more common problem among women.
Why is this important?
Although there are well-established sex differences that influence tumor biology, bladder anatomy, and environmental and hormonal exposures, leading to different outcomes, there is evidence of an association between delays in primary care and poorer outcomes.
How common is bladder cancer in women?
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Prospective data collected from 1537 bladder cancer cases in the UK (1340 detailed stage, 633 detailed stage + cause of death) showed an association with longer time between onset of symptoms and referral to specialist , the higher the incidence rate, the lower the risk of bladder cancer invading muscle tissue by 5% (p=0.04).
Women with muscle invasion at diagnosis have lower 5-year survival rates. (P<0.001).
This study did not distinguish between delayed consultation and delayed referral to a specialist; longer delays before referring patients (>14 days vs <14 days) were associated with an increased risk of death and a 5% decrease in survival. At 5 years old. (P=0.02). Patients with delayed referral to specialists appear to be more severely ill and have worse prognosis.