Table 1. The Percentage of Patients Diagnosed With ≤T1 or ≥T2 Bladder Cancer on the Basis of Age^[7,8]

Table 2. Clinical Summary of Selected Studies Evaluating the Role of Aging in Bladder Cancer Outcomes

Box 1. Assessment Tools and the Meaning of Scores

Table 3. Summary of the Basic Science Studies Assessing the Mechanistic Interactions Between Bladder Cancer and Aging

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Author(s)

John A. Taylor, III, MD

Assistant Professor of Surgery, Division of Urology, University of Connecticut Health Center, Farmington, Connecticut

Disclosures

Disclosure: John A. Taylor III, MD, has disclosed no relevant financial relationships.

George A. Kuchel, MD, FRCP, AGSF

Professor of Medicine; Director, University of Connecticut Center on Aging, University of Connecticut Health Center, Farmington, Connecticut

Disclosures

Disclosure: George A. Kuchel, MD, FRCP, AGSF, has disclosed no relevant financial relationships.

CME Author(s)

Charles P. Vega, MD, FAAFP

Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine

Disclosures

Disclosure: Charles P. Vega, MD, FAAFP, has disclosed that he has served as an advisor or consultant to Novartis, Inc.

CME

Bladder Cancer in the Elderly: Clinical Outcomes, Basic Mechanisms, and Future Research Direction

Authors: John A. Taylor, III, MD ; George A. Kuchel, MD, FRCP, AGSF
THIS ACTIVITY HAS EXPIRED FOR CREDIT

Start Activity

Target Audience and Goal Statement

This activity is intended for primary care physicians, urologists, oncologists, radiation oncologists, and other physicians who care for patients with bladder cancer.

The goal of this activity is to describe the interaction between age and bladder cancer as well as treatment outcomes of bladder cancer among older adults.

Upon completion of this activity, participants will be able to:

Describe the epidemiology of bladder cancer
Identify the outcomes of treatment of bladder cancer among older adults
Specify valuable predictors of poor treatment outcomes among elderly patients with bladder cancer
Describe possible genetic mechanisms explaining the interaction between bladder cancer and age

Disclosures

Author(s)

John A. Taylor, III, MD

Assistant Professor of Surgery, Division of Urology, University of Connecticut Health Center, Farmington, Connecticut

Disclosures

Disclosure: John A. Taylor III, MD, has disclosed no relevant financial relationships.

George A. Kuchel, MD, FRCP, AGSF

Professor of Medicine; Director, University of Connecticut Center on Aging, University of Connecticut Health Center, Farmington, Connecticut

Disclosures

Disclosure: George A. Kuchel, MD, FRCP, AGSF, has disclosed no relevant financial relationships.

CME Author(s)

Charles P. Vega, MD, FAAFP

Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine

Disclosures

Disclosure: Charles P. Vega, MD, FAAFP, has disclosed that he has served as an advisor or consultant to Novartis, Inc.

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Summary and Introduction

Summary

The association between aging and cancer is well exemplified by bladder cancer: with advancing age, the risk of developing bladder cancer increases, and patients' clinical presentation and outcomes worsen. Care for elderly patients with bladder cancer requires specific knowledge of many key geriatric clinical issues in order to determine optimal treatment plans. While numerous studies have tried to address the role of urologic intervention for elderly patients with bladder cancer, many studies fail to incorporate a component of true functional assessment. Evaluation tools that incorporate comorbidities, disabilities and functional status will need to be developed, as chronological age is a poor predictor of treatment outcomes. Additionally, further research is necessary to better understand the basic mechanisms that predispose elderly patients to develop this costly and life-threatening disease. This Review examines the current literature evaluating the clinical and mechanistic interactions between aging and bladder cancer, and suggests the formulation of a research agenda to address the issues raised.

Introduction

Cancer is a disease that occurs more frequently in later life, and the proportion of cancers that occur in the elderly is increasing relative to younger age groups. By 2030, over 70% of all cancers are expected to occur in people aged over 65 years.^[1] Proposed mechanisms for the increased incidence of cancer in the aging population include an accumulation of genetic and cellular damage, prolonged exposure to carcinogens, and fundamental changes in the host environment. Cancer and aging are intimately linked at the most basic level: convergent mechanisms protect against both aging and cancer (e.g. antioxidant defenses), while the pathways regulating cellular proliferation typically exert divergent or opposing effects; specifically, protecting from cancer but promoting aging.^[2] The presence of age-related physiological changes in elderly patients, plus common comorbid conditions, presents clinicians with challenges that require specific knowledge of geriatric oncology.^[3]

Bladder cancer illustrates well the association between cancer and aging, and occurs most commonly in the elderly: the median age at diagnosis is 69 years for men and 71 years for women.^[4] Bladder cancer is also the fourth and eighth most common malignancy in men and women, respectively, and the number of diagnosed cases is increasing annually in the US (Figure 1).^[5] In 2008, a Californian tumor registry study showed that the incidence of bladder cancer peaks at the age of 85 years, with a rate of increase roughly 10-fold higher than that seen in younger age groups.^[6] Advanced age may be associated with worse outcome, but stage and grade at diagnosis remain key determinants of prognosis. Advanced age seems to increase the risk of higher-stage cancer (Table 1), and also of high-grade disease if the cancer is found to be superficial.^[7–9] High-grade or muscle-invasive tumors are much more likely to progress and metastasize than low-grade, low-stage cancers, and the 5-year survival rates in patients with high-grade or muscle-invasive tumors are as low as 6%.^[10] The overall probability of developing invasive disease increases with age, rising from 0.01–0.02% before age 40 years, to 1.2–3.7% for those aged over 70 years (Figure 2).^[5]

Figure 1.

Enlarge

The number of new bladder cancer cases by year in the US (based on data from the American Cancer Society Cancer Facts & Figures 2002–2008).^[5]

Figure 2.

Enlarge

TThe probability of developing invasive bladder cancer by age group (based on data from the American Cancer Society Facts & Figures 2008).^[5]

The management of high-grade disease in the elderly is costly and challenging. The current standard of care for superficial high-grade or recurrent low-grade disease remains intravesical immunotherapy with bacillus Calmette–Guérin (BCG). Cystectomy with reconstructive surgery is the current standard of care for invasive or recurrent superficial disease. Chemotherapy and radiation therapy can be used in conjunction with cystectomy, as either bladder-sparing therapy or as palliative treatment. The annual costs of caring for patients with muscle-invasive bladder cancer can exceed $35 million.^[11]

The goal of this article is to review the current literature addressing both the clinical and mechanistic interactions between bladder cancer and aging, while also encouraging future progress in these fields through the formulation of a research agenda.

Page 1 of 5

Clinical Outcomes in Elderly Patients With Bladder Cancer

Summary and Introduction
Clinical Outcomes in Elderly Patients With Bladder Cancer
Mechanistic Interactions Between Bladder Cancer and Aging
Future Directions and Research Priorities
Conclusions

Table 1. The Percentage of Patients Diagnosed With ≤T1 or ≥T2 Bladder Cancer on the Basis of Age[7,8]

Table 2. Clinical Summary of Selected Studies Evaluating the Role of Aging in Bladder Cancer Outcomes

Box 1. Assessment Tools and the Meaning of Scores

Table 3. Summary of the Basic Science Studies Assessing the Mechanistic Interactions Between Bladder Cancer and Aging

References

Faculty and Disclosures

Author(s)

John A. Taylor, III, MD

George A. Kuchel, MD, FRCP, AGSF

CME Author(s)

Charles P. Vega, MD, FAAFP

CME

Bladder Cancer in the Elderly: Clinical Outcomes, Basic Mechanisms, and Future Research Direction

Target Audience and Goal Statement

Disclosures

Author(s)

John A. Taylor, III, MD

George A. Kuchel, MD, FRCP, AGSF

CME Author(s)

Charles P. Vega, MD, FAAFP

Accreditation Statements

For Physicians

Instructions for Participation and Credit

Bladder Cancer in the Elderly: Clinical Outcomes, Basic Mechanisms, and Future Research Direction

Summary and Introduction

Summary

Introduction

Figure 1.

Figure 2.

Table of Contents

Table 1. The Percentage of Patients Diagnosed With ≤T1 or ≥T2 Bladder Cancer on the Basis of Age^[7,8]