Every year, nearly 75,000 Americans are diagnosed with bladder cancer and more than 15,500 will die from the malignancy. A new study by UCLA and USC has found that a crucial factor for increasing survival is the quality of the initial biopsy. They published their findings on October 20 in the early, online edition of the journal Cancer.
With the two-year study, the investigators have shown for the first time that the quality of diagnostic staging from the initial biopsy in patients with bladder cancer is directly related to survival, meaning those that do not receive optimal biopsies are more likely to die from their disease. The study revealed that about 50% of bladder cancer patients who were biopsied had insufficient material. These biopsies did not contain any bladder wall muscle; thus, the cancer was not accurately staged. In addition, the researchers found that a suboptimal biopsy and incorrect tumor staging was associated with a significant increase in deaths from bladder cancer noted first author Dr. Karim Chamie, an assistant professor of urology and surgical director of the bladder cancer program at UCLA.
Dr. Chamie, who is also a researcher at UCLA’s Jonsson Comprehensive Cancer Center, explained, “These findings are very important because while patients know about the stage of their cancer, they rarely question the quality of the biopsy. We hope these findings will help empower patients to ask about the quality of their biopsy and, if it is suboptimal, then urge their doctors to repeat the biopsy prior to deciding on what type of treatment to prescribe.” He noted that many times, biopsies only take tissue from the inner lining of the bladder itself; thus, the specimen lacks the underlying muscle wall. If the cancer has started to invade, tissue from the muscle wall needs to be examined to determine the next course of treatment.
For the study, the investigators reviewed the medical records of every patient diagnosed with “non-invasive” (cancer that had yet not spread into the muscle) bladder cancer during the years 2004 and 2005 at medical facilities in Los Angeles County. Biopsy and surgery reports were reviewed. They found that about 50% of the time, the surgeon either did not do an adequate biopsy or the pathologist did not clearly state the extent of the cancer invasion. When patients had aggressive tumors and their surgeons and pathologists appropriately staged them, the likelihood of dying of bladder cancer at five years was 8%. However, if the surgeon did not adequately stage the malignancy, but the pathologist alerted the physician of inadequate staging, the five-year mortality rate was 12%. Moreover, if the pathologist did not comment on the extent of the cancer invasion, the five-year mortality was 19%.
Dr. Chamie stressed, “Appropriately staging patients with bladder cancer is a skill set that every urologist and pathologist should have in his or her armamentarium. We believe the next step is to change the staging system for bladder cancer to incorporate the quality of staging. Not all stage I cancers are alike. Some patients may have stage II cancer, but because the biopsy was insufficient, these patients were inaccurately staged and may be undertreated. I really do believe that one reason why we have yet to see significant improvement in bladder cancer survival over the last two decades may, in part, be attributed to inadequate staging.”
The study group comprised 1,865 patients, 335 urologists, and 278 pathologists from medical facilities in Los Angeles County. Muscle was reported as present in 972 (52.1%), absent in 564 (30.2%), and was not mentioned at all in 329 (7.7%) of initial pathology reports.
A bladder cancer patient, Barbara James, 77, of Three Rivers in Central California was diagnosed bladder cancer a year ago by a local urologist, who also performed a biopsy and later removed the cancer. She noted, however, that the urologist waited four months before going back in to check to ensure all the cancer was removed. More cancer was found and the urologist wanted to go in and remove more. She said, “It made me really nervous. I felt like he didn’t know what he was doing. I decided I needed to go somewhere else.” A friend, a neurosurgeon at UCLA, referred Ms. James to Dr. Chamie, who performed a more thorough biopsy, which found that she had invasive bladder cancer that was missed in the first biopsy. As a result, her bladder had to be removed and a new bladder built for her using a portion of her intestine. She is currently recovering and advises anyone with bladder cancer to go to a major medical center for biopsy and staging.
The study authors wrote: “The omission of muscle in the specimen or its mention in the pathology report in nearly half of all diagnostic resections is associated with increased mortality, particularly in patients with aggressive disease. Because urologists cannot reliably discern between aggressive and indolent disease, we recommend that patients with bladder cancer should undergo adequate muscle sampling at the time of biopsy.”
For more than 50 years, the urology specialists at UCLA have continued to make advances and set the standards of care for patients suffering from urological conditions. In collaboration with research scientists, UCLA’s internationally renowned physicians are pioneering new, less invasive methods of delivering care that are more effective and less costly. UCLA’s is one of only a handful of urology programs in the NATION that offer kidney and pancreas transplantation. In July of 2014, UCLA Urology was once again ranked fourth in the nation by U.S. News & World Report, a ranking it has held for the last 15 years.