RC is recommended for patients with non-muscle-invasive bladder cancer for whom BCG immunotherapy has failed – that’s around 50% of high-risk cases. However, many patients are unwilling to undergo RC because of its impact on quality of life. While bladder cancer is more common in men than women, women typically present later and therefore with more aggressive cancer, meaning that they are more likely to receive more radical treatment than men.
For women, classic RC involves en bloc removal not just of the bladder but also the ovaries, uterus and the upper part of the vagina. However, previous studies have found uterus invasion to be comparatively rare, in the range 0.3-12.5% (1).
In a new retrospective multicentre study (2) – believed to be the largest of its type – malignant gynaecological organ involvement (GOI) was seen in 6.6% of patients, 3% had involvement of more than one gynaecological organ, and none had a primary gynaecological malignancy detected incidentally at RC. Patients with GOI were more likely to have cT3/T4 stage than those without GOI. Furthermore, cT4 stage was found to be an independent predictor of malignant GOI (p>0.001).
The authors suggest that “in the absence of clinical or radiological evidence of sexual organ involvement, our results do not support their routine removal at the time of RC”.
Combat’s HIVEC® (intravesical hyperthermic chemotherapy) treatment offers a bladder-sparing alternative to patients with high-risk, non-muscle-invasive bladder cancer who don’t want to undergo RC if BCG therapy fails. A recent study found Combat’s HIVEC® was a “well-tolerated and safe bladder-sparing treatment… an alternative treatment option for patients who refuse or are unfit for RC” (3).
Bladder Cancer in Women
Bladder cancer suffers from lack of funding and awareness, despite it being the fifth most common cancer in Europe, with over 200,000 new cases diagnosed each year in Europe alone. There are distinct gender differences in its incidence and mortality rates. In women, bladder cancer is less common than in men, (women make up around 27% of cases in the UK), but it tends to be diagnosed at a more advanced stage and carries a worse prognosis.
NMIBC is classified as a bladder cancer that has not invaded the muscle layer of the bladder wall. This subtype accounts for around 75-85% of bladder cancer cases.
Risk Factors
Several factors increase the risk of developing bladder cancer in women. These include:
Smoking: The most significant risk factor, with smokers having a three to four times greater risk than non-smokers.
Occupational Exposures: Certain industries such as textiles, dye, rubber, and leather have higher incidences due to exposure to carcinogenic chemicals.
Genetic Predisposition: Family history of bladder cancer increases the risk.
Chronic Bladder Inflammation: Recurrent urinary tract infections (UTIs) and prolonged catheter use are contributing factors.
Diet and Lifestyle: Diets high in processed meats and fatty foods, and sedentary lifestyle may increase risk.
Diagnosis
Diagnosing NMIBC involves a combination of clinical evaluation, urine tests, imaging, and cystoscopy.
Urinalysis and Urine Cytology: These tests check for blood and cancer cells in urine.
Cystoscopy: A key diagnostic tool where a camera is inserted into the bladder to visualise tumours.
Imaging: Ultrasound, CT, and MRI scans help in assessing the bladder and surrounding structures.
Traditional Treatment Options
The primary goal in treating NMIBC is to remove existing tumours and prevent recurrence.
Transurethral Resection of Bladder Tumor (TURBT): This is the first-line treatment where the tumour is removed via cystoscopy.
Intravesical Therapy: Post-TURBT, treatments such as Bacillus Calmette-Guérin (BCG) or chemotherapy agents are instilled directly into the bladder to reduce recurrence.
Immunotherapy: Emerging as a promising treatment, especially for high-risk NMIBC.
Surgery: In cases where the cancer recurs or progresses, more extensive surgery like a radical cystectomy might be necessary.
Follow-up and Prognosis
Regular follow-up is vital due to the high risk of recurrence in NMIBC. This includes cystoscopy, urine cytology, and imaging studies at regular intervals. The prognosis for NMIBC is generally good, with a 5-year survival rate of about 70-80%. However, the risk of recurrence and progression underscores the need for lifelong surveillance.
Special Considerations in Women
Women with NMIBC face unique challenges:
Diagnostic Delays: Symptoms like hematuria (blood in urine) are often misattributed to benign conditions like UTIs, leading to delays in diagnosis.
Treatment Side Effects: Women may experience more profound effects on sexual and urinary function post-treatment.
Psychosocial Impact: The impact on body image, sexual health, and quality of life is more pronounced in women.
NMIBC in women is a complex condition requiring a multifaceted approach to management. Early detection, appropriate treatment, and regular follow-up are crucial for improving outcomes. Ongoing research and advancements in treatment strategies hold promise for further improving the care and prognosis of women with NMIBC.
For women, understanding the risk factors and symptoms of bladder cancer, and seeking timely medical advice if these symptoms occur, is key to early diagnosis and effective treatment. Moreover, lifestyle modifications such as smoking cessation, maintaining a healthy diet, and regular exercise can play a role in reducing the risk of bladder cancer.
Non-muscle-invasive bladder cancer in women is a significant health concern that requires increased awareness, early diagnosis, and effective management strategies. With advances in research and a better understanding of the unique aspects of this disease in women, there is hope for improved outcomes and quality of life for all those affected.
1. Huang et al. Is hysterectomy beneficial in radical cystectomy for female patients with urothelial carcinoma of bladder? A retrospective analysis of consecutive 112 cases from a single institution (2019), BMC Urology – https://bmcurol.biomedcentral.com/articles/10.1186/s12894-019-0461-9
2. Lobo et al. Gynaecological organ involvement in females undergoing radical cystectomy: a multicentre study (2024), BJUI – https://pubmed.ncbi.nlm.nih.gov/38105508/
3. Pijpers et al. Long-term efficacy of hyperthermic intravesical chemotherapy for BCG-unresponsive non-muscle invasive bladder cancer (2021), Urologic Oncology – https://pubmed.ncbi.nlm.nih.gov/34470725/
