Four cigarette companies are suing the food and drug authority over a soon to be enacted federal law that requires companies to place more graphic health warnings on their packaging. The lawsuit comes as a new study has found that the risk to women smokers of bladder cancer is much greater than previously thought. The report from the national institute of health suggests that smoking may be responsible for half of all bladder cancer cases in women. We assess the linkages between the two, why women are at greater risk and what options there are for treatment.


  • Lawrence Rzepka Executive director, Bladder Cancer Advocacy Network.
  • Dr. Neal Freedman Scientific investigator at the U.S. National Cancer Institute.
  • Dr. Douglas Scherr Clinical director of Urologic Oncology at the Weill Medical College of Cornell University.


  • 10:06:55

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. A new study has found that smoking may be responsible for half of all bladder cancer cases. And for the first time, the risk to women smokers of developing bladder cancer is equal to that of men. Here in the studio is, one of the authors of the study, Dr. Neal Freedman from the National Cancer Institute, Lawrence Rzepka of the Bladder Cancer Advocacy Network.

  • 10:07:35

    MS. DIANE REHMOn the line with us from New York is Dr. Douglas Scherr of New York Presbyterian Hospital. Throughout the hour, we'll take your calls, your comments and questions, 800-433-8850. Send us your email to Join us on Facebook or Twitter. Good morning to all of you.

  • 10:08:10

    MR. LAWRENCE RZEPKAGood morning.

  • 10:08:10

    DR. NEAL FREEDMANGood morning.

  • 10:08:11

    DR. DOUGLAS SCHERRGood morning.

  • 10:08:12

    REHMAnd, Dr. Freedman, if I could start with you, tell us about the study, how it was conducted and why you did it to begin with.

  • 10:08:23

    FREEDMANSure. In 2009, our colleagues at the National Cancer Institute observed evidence for the strengthening association between cigarette smoking and bladder cancer. It's been known that bladder cancer is caused by cigarette smoking, among other factors, for a long time. But they observed in their study that evidence for strengthening of the association. And so we wanted to look in another study to see if we could replicate these findings.

  • 10:08:51

    FREEDMANSo we looked in the very large NIH-AARP cohort, which was initiated by Arthur Schatzkin in 1995 and '96. And this was a study of nearly 500,000 members of AARP. In this study, current smokers were four times more likely to get bladder cancer than never smokers. And as part of our paper, we also looked to see in previous cohorts, previous studies that were performed in previous times.

  • 10:09:20

    FREEDMANSo these were studies that were initiated between the '60s and '80s.

  • 10:09:23

    REHMHmm. So how many people were looked at here?

  • 10:09:29

    FREEDMANIn our study, about 500,000.

  • 10:09:31

    REHMAnd most of these people then -- you said AARP -- so above the age of 50 to...

  • 10:09:39

    FREEDMANThat's right. To 71.

  • 10:09:41 71. What were the major findings, Dr. Freedman?

  • 10:09:47

    FREEDMANThe major findings, there were two of them. The first was that the risk for current smokers versus never smokers, that the current smokers were four times more likely to get bladder cancer than never smokers. And in previous studies, which were initiated in the United States in earlier time periods, current smokers were only three times more likely to get bladder cancer.

  • 10:10:06

    FREEDMANSo this provides evidence, similar to the 2009 study, that the strength of the association between cigarette smoking and bladder cancers increased.

  • 10:10:15

    REHMDoes your study actually prove a link between smoking and bladder cancer?

  • 10:10:24

    FREEDMANOur study doesn't prove it by itself. But there's many studies performed in different geographic areas and in combination with laboratory studies. And, together, the body of evidence strongly supports that cigarette smoking is a cause of bladder cancer.

  • 10:10:39

    REHMIt's so interesting, Dr. Freedman, because, as you well know, smoking in the United States has decreased in the last 30 years. So why hasn't the incidence of bladder cancer decreased?

  • 10:10:57

    FREEDMANThat's a great question. We don't really know. There's a couple of possibilities. One of them is, in addition to smoking causing bladder cancer, there's other risk factors for bladder cancer, and there may be an additional risk factor that we don't know of that's contributing towards the stability of the bladder cancer incidence rates.

  • 10:11:16

    FREEDMANThe other possibility is, because we're observing the evidence for strengthening of association between cigarette smoking and bladder cancer, it could be that, even though fewer people are smoking, the people that are smoking are at higher risk of bladder cancer, and that's contributing to the stability of the incidence rates over time.

  • 10:11:34

    REHMDr. Neal Freedman, he is one of the authors of a new report from the U.S. National Cancer Institute. Turning to you, Larry Rzepka, what do you make of this growing incidence of bladder cancer, especially among women smokers?

  • 10:11:58

    RZEPKAWell, Diane, it's interesting. We find the study extremely important. For the last six years, BCAN, the Bladder Cancer Advocacy Network, has been looking at all the other studies that have come out linking smoking to bladder cancer. So, once again, a monumental study has been released that strengthens that argument. In regards to more women being diagnosed, are we surprised?

  • 10:12:22

    RZEPKAWell, in our organization, we have a lot of anecdotal evidence that that's been happening. We get calls and emails all the time from women saying they have been missed diagnosed, not misdiagnosed, and there's a difference. The diagnosis has been missed, mainly because one of the main symptoms of bladder cancer is blood in your urine. So, for men, of course, when that happens, they might go to the doctor.

  • 10:12:52

    RZEPKAFor a woman, that is sometimes not unusual because of the menstrual cycle or a variety of other reasons. So when they go to their family physician or internist or GYN, they might say it's a urinary tract infection, and they treat it that way. So we find out, at least in some of the calls and emails we're getting, that women are saying, I went three times. They treated me three times for urinary tract infection. Then, finally, they did a test.

  • 10:13:24

    RZEPKASo I think this study that comes out that says women are smoking more, or at least as much as men -- and that is now documented. I think that whatever the cigarette companies may have done in regards to thinking they're making a healthier cigarette might not be the case. We don't know. The jury is out, and I'm not a scientist. But there seems to be a link that the incidents of bladder cancer have remained stable over these past 30 years.

  • 10:13:55

    REHMLawrence Rzepka, he is executive director of the Bladder Cancer Advocacy Network. And turning to you, Dr. Douglas Scherr, tell us about this notion of bladder cancer in women somehow being missed. Do you see -- obviously, you are seeing patients who have bladder cancer. But do you agree that, too often, it's being missed?

  • 10:14:30

    SCHERRWell, I think Lawrence had touched on a very important issue. In the most common presenting sign of bladder cancer being hematuria, or blood in the urine, is a much more "acceptable presence" in women than it is in men. And I think, you know, there needs to be an education not only with the population at hand, but also with the medical community as well, that hematuria, irrespective of gender, is something that needs to be evaluated and should be referred to the appropriate physicians for evaluation.

  • 10:15:03

    SCHERRBut I think the gender differences in bladder cancer have been, you know, evaluated for some time. And if we look at bladder cancer in general -- and this is, in part, maybe due to the later presentation. But I think, stage for stage and grade for grade, women tend to have a worse prognosis with bladder cancer than men.

  • 10:15:23

    REHMWhy is that?

  • 10:15:25

    SCHERRWell, I think there are several factors. I think one is what we had touched upon initially, that women tend to present later on and perhaps because of the later presentation or later referral. But even if we look at women who have higher stage disease -- for example, a stage IV disease is a disease that involves the bladder and adjacent organs, and women tend to do much worse for that stage disease than men.

  • 10:15:51

    SCHERRAnd I think, in part, that may be that the anatomy of the women or the female pelvis is such that there's a much thinner bladder wall. And bladder cancer can tend to spread outside the bladder at a more rapid pace in women than it can in men. I think there are likely to be some socioeconomic factors.

  • 10:16:11

    SCHERRAnd I think what's probably most important, there's probably a -- known to be a hormonal regulation of bladder cancer that's really only at its infancy in our ability to understand the hormonal manipulation of bladder cancer.

  • 10:16:25

    REHMI think that you've just pointed to one of my questions. The bladder cancer has always been referred to as an old man's disease. But what you're saying is that it has now become a female disorder. Does it normally strike older women? Or is it hitting younger women as well, Dr. Scherr?

  • 10:16:57

    SCHERRWell, clearly, it is a disease of an aging population. And I think the longer exposure, for example, to tobacco smoke, is a much higher risk factor for developing bladder cancer. But we do see it across all generations, both young and older patients, both men and women. If we look at pre-menopausal versus post-menopausal women, there's clearly a higher incidence of bladder cancer in post-menopausal women.

  • 10:17:23

    SCHERRAnd I think, as I mentioned earlier, the -- we're only beginning to understand the role of estrogens and androgens in not only the initiation, but the prognosis of patients with bladder cancer. And I think we will learn, as we know somewhat already, that estrogen clearly plays a role. Estrogen receptors play a role, androgens, testosterone play a role. There's an enzyme called aromatase, which converts testosterone to estrogen.

  • 10:17:53

    SCHERRAlso -- excuse me -- it converts estrogen to testosterone -- also plays a role. We know that tamoxifen, which is a medication many people are familiar with in the breast cancer world, may indeed have some role in controlling bladder cancer. So we're really learning about a lot of things in terms of hormonal manipulation of this disease.

  • 10:18:12

    REHMDr. Douglas Scherr of New York Presbyterian Hospital. Here in the studio, Dr. Neal Freedman of the National Cancer Institute. And Lawrence Rzepka, he is executive director of the Bladder Cancer Advocacy Network. Do join us, 800-433-8850. A difficult problem to say the least, but one we need to look at more carefully. Stay with us.

  • 10:20:03

    REHMAnd welcome back. In this hour, we're talking about new studies from the National Cancer Institute, indicating a link -- not quite absolute -- between smoking and bladder cancer, but showing an increased risk for bladder cancer among women. While it used to be considered a disease of old men, clearly, women are now right up there and having their own problems with bladder cancer, especially in the diagnosis and, indeed, in the prognosis.

  • 10:20:53

    REHMThere is some question in my mind, Dr. Scherr, as to whether, considering this email, there may be some inherited quality. Here's Elise, who joins us on Facebook. She says, "Bladder cancer has killed every female of my mother's side, on up to my great grandmother, except for my mom, who died of inflammatory breast cancer when she was 32. I am 29. Every year, I get more and more concerned.

  • 10:21:35

    REHM"Doctors will not let me get a mammogram, citing that I'm not even 30." Can you talk about inheritance factors, Dr. Scherr?

  • 10:21:49

    SCHERRSure. You know, unlike some other diseases -- for example, breast cancer, prostate cancer, colorectal cancers, where we have, clearly, delineated familial patterns of inheritance -- bladder cancer is a disease where we have not yet identified a strict familial inheritance of this cancer. Although there can be some familial clusterings (sp?) of the disease, there hasn't been yet one gene identified that puts a patient at risk for bladder cancer.

  • 10:22:17

    SCHERRNow perhaps -- and, again, this goes into areas that we're not well-educated about. But perhaps there could be something, a tumor suppressor gene that somehow becomes inactivated by tobacco or other carcinogens that runs in families, and that perhaps puts those family members at greater risk of developing a disease, particularly if they're exposed to some of the potential carcinogens, in particular tobacco smoke.

  • 10:22:41

    SCHERRBut, again, we have not yet identified a strict familial or genetic pattern of this disease.

  • 10:22:47

    REHMLarry Rzepka, bladder cancer is apparently the fifth most common cancer. It doesn't receive nearly as much attention as breast cancer. Why is that?

  • 10:23:04

    RZEPKAWell, we're as stunned about it as you are, Diane. As you said, it's the fifth most common cancer. Yet when you look at the allocated research funds by the National Cancer Institute, and, among cancers, bladder cancer receives about the 24th amount of money allocated to do bladder cancer research. Now, we surely don't begrudge any of the other cancers, the funding they're getting. But it is quite common, and people still don't talk about it.

  • 10:23:36

    RZEPKAAnd it's quite a surprise, probably because it's one of those below-the-waist type of diseases that people don't like to discuss sometimes. But it's become more and more important, that the public be aware of all the signs and it becomes an open discussion. It can no longer be behind closed doors.

  • 10:24:01

    REHMWell -- and here's another message posted on Facebook by Sandra. She says, "My husband was diagnosed with bladder cancer. His surgeon said it was 100 percent caused by his years of smoking cigarettes. He knew about lung and heart problems, but bladder cancer? Who knew?" Dr. Freedman?

  • 10:24:32

    FREEDMANIn our study, we found that half of bladder cancer could be attributed to smoking in men and half in women. And, for men, this has been seen before. But for studies in women, they were performed in populations where women who smoked a lot less than men. But in our study and in the U.S. population now, men and women smoke similar amounts.

  • 10:24:52

    FREEDMANAnd so, because of that, we think that's why smoking now explains a similar proportion of bladder cancer in both men and women.

  • 10:25:00

    REHMAre young people beginning to smoke earlier in life than they used to, Dr. Freedman?

  • 10:25:11

    FREEDMANI can't answer that. I'm not sure. But I do know that the rates of smoking in young people are much higher than we would wish. We wish that no young child -- no young person is smoking.

  • 10:25:23

    REHMOf course.

  • 10:25:24

    FREEDMANBut the rates of smoking in young people now are just as high as they were five or 10 years ago.

  • 10:25:30

    REHMInteresting. Dr. -- go ahead, Larry.

  • 10:25:34

    RZEPKAWell, I'd like to add, you know, bladder cancer is really the quintessential poster child for the environment. For the environmental problems we have, as much as smoking has been a cause for 50 percent of it, as studies are showing, it could also be the general occupation some people have out there. I mean, there are chemicals and contagions that can affect the system and help cause bladder cancer.

  • 10:26:01

    RZEPKAAnd, just for an example, even among men -- I mean, manufacturing workers, leather workers, painters, hairdressers, truck drivers, et cetera -- they are all exposed to certain chemicals and contagions out there that might be, or could be, and attribute -- can contribute to a diagnosis of bladder cancer.

  • 10:26:22

    RZEPKAOne of the studies, that was done several years ago, mentioned that our veterans and our current young men and women who are serving -- veterans are two times more likely to be diagnosed with bladder cancer than someone who has not served. Now, of course, they probably have smoked more. We understand that happens in the military. But on the naval yards and Army posts and Air Force bases, they are also exposed to many other chemicals.

  • 10:26:53

    REHMExactly. Dr. Scherr, as you know, five of America's six largest tobacco manufacturers sued the FDA to block the new requirement that graphic warnings cover half of every package sold by October 2012. Right here in front of me, I have three packages: two of Marlboro cigarettes and one of Romeo cigars. And these were actually purchased in Egypt.

  • 10:27:37

    REHMOn the front of each of these cigarettes is a fetus, and that fetus is clearly being damaged. On the front of the cigar package is a man with a ventilator mask over his face. And, clearly, in Arabic, there are written warnings. I'd be interested in your thoughts about more graphic warnings on cigarette packages, Dr. Scherr.

  • 10:28:17

    SCHERRWell, it's a very interesting topic. I think, putting my medical hat aside, I feel, you know, looking at some of the advertising we see, some of the TV commercials, particularly here in New York that I've seen of people suffering from emphysema and lung damages, and I see in my own children, who view these commercials, I think, clearly, are turned off to the effects of tobacco and I don't think ever would consider starting smoking.

  • 10:28:42

    SCHERRSo I think prevention is absolutely critical in this disease, not only for bladder cancer, for all smoking-related illnesses. So I think these can be very, very effective. And, you know, obviously, you can see where the tobacco companies are coming from 'cause they want to sell cigarettes.

  • 10:28:55


  • 10:28:56

    SCHERRI think these are effective. And I think what else needs to be evaluated -- and I think Dr. Freedman touched upon this in his paper -- is the composition of these cigarettes as well. I think we're seeing different cigarettes now than we saw 30, 40 years ago. And perhaps these can be more toxic, more damaging in terms of their ability to cause disease than what we've seen in the past. So I think the advertising platform is incredibly effective and should continue.

  • 10:29:22

    SCHERRBut I do think we should also begin to look at the composition of tobacco that we're seeing today as well.

  • 10:29:27

    REHMWhen you talk about the composition of tobacco, there have been some who've said that additives have been placed in the cigarettes to help make them less unhealthy. Could those additives themselves be at fault, Dr. Scherr?

  • 10:29:51

    SCHERRWell, again, I don't know the answer to that, but I think they certainly can be. And I think it's something that needs to be evaluated. And although -- and again, Dr. Freedman points this out in his paper. Although we begin to cut back on tar and nicotine, we've seen an increase in concentrations of other carcinogens, in particular the beta-naphthylamine, which is a known carcinogen, and other types of nitrosamines which can cause bladder cancer as well.

  • 10:30:17

    SCHERRSo one of the very interesting aspects is, you know, we, as the medical community, tend to evaluate smoking by something called pack years, where we talk about the number of packs a day a patient has smoked multiplied by the number of years. And I think what that does not capture is the intensity of tobacco exposure as well.

  • 10:30:35

    SCHERRSo, for example, someone who smokes a pack a day for 15 years, is that really the same as someone who smokes three packs a day for five years? So they're both considered a 15-pack-year history. But, in fact, my feeling is the intensity of tobacco exposure is probably more important than the total exposure itself.

  • 10:30:55

    REHMI have to tell you, I have to admit that I smoked two packs a day from the age of 15 to 25. At that point, my husband said to me, I cannot bear the smell of smoke in your hair, on your clothing. I had smoked through my son's pregnancy -- my pregnancy with my son and my daughter. They're both extraordinarily healthy. That was 50 years ago. It seems to me that the content of tobacco has changed.

  • 10:31:44

    REHMThe content of elements in the environment has changed. Doesn't that make a difference, Dr. Freedman?

  • 10:31:54

    FREEDMANI think it does. More research is needed, as Dr. Scherr mentioned, about the constituents of tobacco smoke, the constituents of cigarettes. But, you know, there's been lots of changes. In addition to the addition of the filter, there -- and the decreasing concentrations of tar, there's been many other changes, in terms of the type of tobacco that's used, how the tobacco is prepared, and even the inhalation practices that people use.

  • 10:32:20

    FREEDMANThere's a growing evidence that, with the addition of the filter, people are smoking more deeply and getting more smoke into them from the same cigarette. And all of this may contribute towards the increasing risk that we see with bladder cancer.

  • 10:32:34

    REHMDr. Neal Freedman, he is co-author of a report, a scientific investigator at the National Cancer Institute, looking at the correlation between smoking and bladder cancer. And you're listening to "The Diane Rehm Show." Here's a tweet from Ryan, who says, "Is there a notable difference in the chemical composition of a smoker's urine versus a non-smoker's?" Dr. Freedman.

  • 10:33:11

    FREEDMANYes, there is. There's a number of biochemical markers of smoking that you can measure in the urine and then also in the blood. You -- unfortunately, we can't use this to figure out which are the carcinogens that might be affecting the bladder because when you smoke, you're exposed to all of the different compounds in the cigarettes. But there are clearer things that you can measure in the blood and urine.

  • 10:33:31

    REHMCan you add to that, Dr. Scherr?

  • 10:33:36

    SCHERRWell, yes. I (sounds like) wouldn't entirely agree with that. And, in fact, we've been working on a home testing kit. You know, one of the most exciting aspects, I think, that's happening in bladder cancer right now is something called biomarker discovery.

  • 10:33:49

    SCHERRAnd what that is is evaluating things in the urine and in the blood or serum of patients to be able to do a real-time analysis of the presence or absence of certain "risk-factor molecules" that may sort of raise an eyebrow or indicate the presence of a bladder cancer.

  • 10:34:06

    SCHERRSo we're in the process of working with some of our engineers at Cornell University in Ithaca, where we're attempting to create a panel of approximately 25 biomarkers that, just with a single drop of urine, can be immediately detected and screen high-risk populations to determine whether or not they have some evidence of early bladder cancer.

  • 10:34:27

    REHMDr. Scherr, give us a sense of the signs of bladder cancer.

  • 10:34:35

    SCHERRWell, I think, as was alluded to earlier in the conversation, the most common finding in someone with bladder cancer is having microscopic or gross evidence of blood in the urine, and that is the first sign. In its more advanced stages with large tumors, we sometimes see the presence of back pain. And that could be one of the reasons the tumor could be obstructing the kidneys, and it can present almost as if you're having a kidney stone.

  • 10:35:02

    SCHERRAnd that could be one of the later signs of disease as it's progressed further. But microscopic or gross blood in the urine is, by far, the most common presentation of someone with bladder cancer. Occasionally, we also see what we call irritative urinary symptoms. Patients may complain of frequency, urgency, burning when they urinate, and these are some, also, early signs of the presence of bladder tumors.

  • 10:35:25

    SCHERRHaving said that, these are also the general signs and symptoms of particularly men who develop what we call lower urinary tract symptoms, which are consistent with an enlarged prostate.

  • 10:35:38

    REHMSo the prostate enlargement in men could somehow indicate that something is going wrong. But for women, you're saying it's only, perhaps, microscopic drops of blood in the urine?

  • 10:36:01

    SCHERRRight. And I think that's, in part, what creates a bit of a delay for presentation of women, in that mostly their symptoms are not obviously attributable to an enlarged prostate as women do not have a prostate. And I think many, many more men are in tune with urologists. I think the vast majority of men at some point in their life have visited with a urologist, mainly for urinary symptoms as they get older.

  • 10:36:24

    SCHERRWhereas women, obviously, you're not clearly going to see a urologist for prostatic symptoms. But I think the message needs to get out that any microscopic or, certainly, gross blood in the urine, although certainly can be from a urinary tract infection, I think bladder cancer needs to enter into the equation in the diagnostic algorithm.

  • 10:36:43

    REHMDo you want to add to that, Dr. Freedman?

  • 10:36:47

    FREEDMANNo. I think that's great.

  • 10:36:48

    REHMOkay. And Larry, any comment?

  • 10:36:52

    RZEPKANo, not at this time.

  • 10:36:54

    REHMSo the signs of bladder cancer that should absolutely initially take women and men to check out bladder cancer, the blood in the urine, but also for men, obstruction?

  • 10:37:16


  • 10:37:16

    REHMAnd also for men, perhaps even for women as well, a slower stream. All right. We've given you the outlines. Now, we invite your questions, comments. We'll take just a short break. We'll be right back.

  • 10:40:03

    REHMAnd welcome back. We have an email regarding breast -- bladder cancer on -- from Karen, who says, "My husband has not smoked for 40 years. He's in between chemotherapy for metastatic muscle-invasive stage III bladder cancer. The efforts to make yet another cancer a lifestyle choice is very disheartening.

  • 10:40:33

    REHM"There is the implication that cancer is something you bring on yourself, which is so unfair, especially as statistics show 40 percent of adults will develop cancer in their lifetime." Larry.

  • 10:40:52

    RZEPKAWell, it alludes to what we talked about earlier today, that it is more than just smoking. But smoking is, right now, the major cause of bladder cancer. And, please, stop if you have started, or don't even start. But in saying that, it's the environment over the last 40, 50 years, carcinogens in the -- some of our drinking water, et cetera, that can be a cause. So people should not feel that they are responsible for it at all.

  • 10:41:19

    RZEPKAWhat they should feel is that they should take responsibility now to go talk to their doctor, and if -- know the signs of what bladder cancer is.

  • 10:41:29

    REHMAll right. Let's go to Caroline in San Antonio, Texas. Good morning to you.

  • 10:41:36

    CAROLINEGood morning. I had an experience with bladder cancer. Last year, I developed a UTI infection, urinary tract infection, and it did not heal. I took everything. I couldn't take some of the antibiotics. Anyway, this went on and on, and at the -- after about three-and-a-half, four months, I was sent to a urologist. He did a cystoscopy and discovered that I had a tumor. And he immediately said it is from cancer -- I mean, from smoking.

  • 10:42:13

    CAROLINEAnd I was just shocked. I had no idea that I've had anything like that, but I was so frustrated with the UTI that it didn't respond to antibiotics. And it was a blessing because I never had a single sign of anything wrong with my bladder.

  • 10:42:31

    REHMInteresting. Now, Caroline, what kind of treatment did you receive?

  • 10:42:37

    CAROLINEHe did -- almost immediately, he removed it surgically, and there were...

  • 10:42:43

    REHMHe removed what?

  • 10:42:44

    CAROLINEThe tumor...

  • 10:42:45


  • 10:42:45 my cancer...

  • 10:42:46


  • 10:42:47

    CAROLINE...I mean, in my bladder. And then, also, I had a few little red spots, which are sort of precancerous apparently, and he treated those by laser. And that was the end of it. And I went back for -- I've been back for regular checkups, and I have no more sign of anything, thanks be to God. But I also have a male friend, and I'm -- I was 81 at the time that I developed this, or that I found it.

  • 10:43:17

    CAROLINEAnd I have a male friend who happens to be homosexual, and he also has been -- has had bladder cancer. His was discovered when he actually saw blood in his urine. And for many years, he's been treated every three months. He goes in. They check, and every so often, he has to have BCG, I believe it is, injections of BCG fluid into his -- it's like a chemo for the bladder.

  • 10:43:47

    REHMInteresting. Caroline, I'm so relieved for you. Dr. Scherr, how unusual is it that at her age she would have had this kind of cancer?

  • 10:44:07

    SCHERRI would say it's not unusual at all. And, in fact, that's probably the most common presentation that we see in women who've had recurrent and recalcitrant urinary tract infections that are not successfully treated with antibiotics. And I think anyone with recurrent urinary tract infections should be evaluated cystoscopically to evaluate the internal part of the bladder.

  • 10:44:29

    SCHERRAnd I think, fortunately, in this woman's case, this was a superficial tumor. And, in fact, 70 percent of all bladder cancers we diagnose, fortunately, fall into the superficial category and could be managed, just like her tumor was managed, with what we call a transurethral resection of a bladder tumor, which is an outpatient procedure, that we scrape the inner lining of the bladder, including the tumor out.

  • 10:44:53

    SCHERRAnd we get adequate staging, in that we need to biopsy several layers of the bladder to insure that the tumor has not transgressed the wall of the bladder. And the two features that we really look at, from both the prognostic and the therapeutic standpoint, are what we call the stage and the grade. Stage is a reference to how deeply into the bladder wall it goes, and grade is a reference to the biologic aggressiveness of the cells themselves.

  • 10:45:21

    REHMAll right.

  • 10:45:22

    SCHERRI would say this is a very common presentation.

  • 10:45:24

    REHMCaroline, thanks for calling. I'm so glad that you're now well. Let's go to Hollis (sp?) in Morrisville, N.C. Good morning to you.

  • 10:45:38

    HOLLISWell, I'm 49 years old and a non-smoker. My father died in his 50s from bladder cancer. And a couple of years ago, my aunt has -- was diagnosed with bladder cancer and is doing fine. My question is -- I get frequent urinary tract infections, and they're resolved with medications. But, I guess, is there any sort of test that I should be doing once a year since I do have this history of bladder cancer?

  • 10:46:12

    REHMLet me ask, did your mother and -- sorry -- your father and aunt smoke?

  • 10:46:20

    HOLLISNo, they did not.

  • 10:46:21


  • 10:46:21

    HOLLISThey did come from a family, though. My grandparents were very heavily smokers.

  • 10:46:27

    REHMAnd, of course, that brings up the question of secondhand smoke, Dr. Freedman, but, also, are there tests she can take?

  • 10:46:39

    FREEDMANWe should check with Dr. Scherr, but I'm not aware of screening tests for bladder cancer at this time. Development of early detection tests for cancers, of course, really important, but for many cancers, such tests don't exist.

  • 10:46:52

    REHMDr. Scherr.

  • 10:46:54

    SCHERRWell, there's -- there are a few tests that can be done. Certainly, an analysis of the urine would be indicated. And what we look for, obviously, is for evidence of microscopic blood in the urine when you're not having a urinary tract infection. And, two, there's a test called a urine cytology.

  • 10:47:10

    SCHERRAnd a urine cytology is when a cytopathologist, someone who's specially trained in looking at the cells within the urine, can determine whether there are actual cancer cells present in the urine. And it can be a very effective and very specific test for bladder cancer.

  • 10:47:26

    SCHERRAnd someone who's had frequent urinary tract infections, with a family history, it's probably not unreasonable to be evaluated by a urologist for these tests and, perhaps, even have a cystoscopic evaluation to evaluate the inside of your bladder.

  • 10:47:43

    REHMI'm sure, Larry Rzepka, you'd be in favor of that kind of periodic testing.

  • 10:47:51

    RZEPKAOh, very much so. In fact, I would encourage and easily agree with what Dr. Scherr said, that if you have a concern like that after several times of being treated for a urinary tract infection, you have some history in your family, please, talk to your doctor and ask, can they recommend a urologist or who would they suggest you see? So you can, one, bring up the conversation which is important, and two, have him know what your concerns are, or she.

  • 10:48:20

    REHMAbsolutely. To Nancy in Mountain City, Tenn., you're on the air.

  • 10:48:28

    NANCYGood morning, Diane. Thank you for taking my call.

  • 10:48:31

    REHMOf course.

  • 10:48:31

    NANCYMy husband died four years ago of bladder cancer.

  • 10:48:35


  • 10:48:35

    NANCYAnd he was one of those who did never, ever smoke. He was a veteran of 30 years in the Army and served in Vietnam. And his doctors at Duke University, when he was early diagnosed, said he had the most aggressive type of bladder cancer. And he had documentation of being exposed not only to Agent Orange in Vietnam, but more importantly to something they called Agent Blue, which was basically arsenic.

  • 10:49:04

    NANCYAnd it was used heavy in Cambodia, which, of course, politically, at the time, we didn't admit being in Cambodia. But more and more veterans are showing up with this aggressive type of bladder cancer who were, in fact, exposed to chemicals in Vietnam. And I'm wondering -- we're talking about maybe 40 years ago. I'm wondering if your experts there have any comment about the distance, the length of time it took for this cancer to develop.

  • 10:49:38


  • 10:49:39

    RZEPKAWell, I really can't address the issue of length of time. Though considering the way chemicals enter your bladder, they don't necessarily are all totally dissolved. So you could have been exposed to something many years ago, even smoking or other toxic chemicals, and still, 20 to 30 years later, have some repercussions from that.

  • 10:50:00

    RZEPKAIn regards to the Agent Orange and Agent Blue, the only thing I can say to you is, even today, the Veterans Administration has not recognized Agent Orange as a cause for bladder cancer. They have recognized it as a cause for other cancers, but not bladder cancer yet. And they have not recognized Agent Blue very well at all, mainly because of the political implications.

  • 10:50:24

    RZEPKASo, right now, I can concur. And I've heard your story many times from other veterans. But there's no legal evidence at this time that could say that Agent Orange caused it. That's the best I can tell you.

  • 10:50:43

    REHMDr. Scherr.

  • 10:50:45

    SCHERRWell, I guess, first off, I'm sorry to hear about your husband.

  • 10:50:47

    REHMI should say.

  • 10:50:49

    SCHERRI think that, you know, there's a lot to this process we just simply don't understand. We do realize and understand that there's a latency period. And the exposure to the carcinogen can, as mentioned, be 30 to 40 years later for the presentation of the bladder cancer. Now, whether your husband's bladder cancer is related to some of these military chemicals that he may have been exposed to, I think, we'll never know the answer to that.

  • 10:51:15

    SCHERRI think the other issue, you know, back then, clearly, there were tons of people smoking. And although he was not a smoker himself, I'm sure he was exposed to a lot of other smokers around him. So it's a very, very different -- I should say, very, very difficult thing to sort of work out in terms of isolating which carcinogen was the culprit here, and I don't think we'll ever understand that.

  • 10:51:36

    SCHERRThe other issue is, you know, although 95 percent of bladder cancers are what we call transitional cell cancers, which are these classic smoking-related cancers, there are less common forms of bladder cancers called adenocarcinomas and squamous cell carcinomas. Squamous cell carcinoma, in particular, is very common in areas in the Middle East where a schistosomiasis is endemic in the water.

  • 10:52:02

    SCHERRAnd so there are other types of bladder cancers that can be very, very aggressive that may indeed not be, per se, carcinogenic related. So it's a very complex picture.

  • 10:52:13

    REHMAll right. Let's go now to Suffolk, Va. Good morning, Cynthia.

  • 10:52:19

    CYNTHIAGood morning, Diane. I'm a 69 -- well, I was 69 last year when I was diagnosed with bladder cancer, and it started the same way, with the repeated UTIs. And then I ended up having a cystoscopy in which the doctor said it looked -- he had two tiny tumors. And so I had those removed, and then the biopsy -- they decided to do the biological immune treatment for six weeks.

  • 10:52:59

    CYNTHIAAnd then I had another biopsy. And the pathologist said there's something wrong with this, and said I have something that only 8 percent of patients get. And it was starting to attack the muscle wall. So I'm 70 years old, and I have lost my bladder. I had a major cystoscopy, you know, a hysterectomy, a -- an ileal conduit. And, you know, it all started with this UTI thing.

  • 10:53:30

    REHMOh, Cynthia, I'm so sorry for what you've gone through. But I'm glad the doctors did get to it. Now, Dr. Scherr, that sounds like an extreme, when the bladder cancer has begun to invade the muscular walls and all of that kind of surgery has to take place. How frequently does that happen?

  • 10:53:59

    SCHERRWell, fortunately, that's not the most common presentation for bladder cancer, although we do see that. The vast majority of tumors, as I mentioned, are superficial. But in a significant percentage of patients, we do see invasive bladder cancer where it does invade into the muscle or beyond. And that does require more definitive surgical means.

  • 10:54:18

    SCHERRIn particular, as the listener just described, it requires removal of the bladder, called a radical cystectomy, and, in women, that also includes removal of the uterus and the ovaries. And so this, obviously, can be a life-altering event. I think we're fortunate now that we've sort of been able to improve upon the surgery. Oftentimes, this can be done laparoscopically or robotically.

  • 10:54:38

    SCHERRBut it's a major life-altering event, and it can be curative in a significant subset of patients. So, you know, I think in patients like this, where we see it begin to invade the muscle, this really needs to be addressed seriously and, oftentimes, requires multiple forms of therapy, surgery being one, potentially combined with chemotherapy as well.

  • 10:54:58

    REHMAnd, final question for you, Dr. Scherr, you talked earlier about a scientist you're working with at Cornell University to develop an at-home screen test for bladder cancer. How far along are you? How soon do you think it might be available to the public generally?

  • 10:55:22

    SCHERRWell, I think we're in the early stages of this, but these things tend to happen very quickly. And I think this, ultimately -- it would never be cost-effective, really, to screen the entire population. But I think this really would be focused for the "at-risk individuals," in that those patients who've had some environmental exposures, in particular, tobacco smoke, firefighters who also have exposure to smoke, these would be the focus of this test.

  • 10:55:44

    SCHERRAnd I would say we're probably about two years away from having a product that can be utilized.

  • 10:55:50

    REHMSo what you just said puts me in mind of the question about secondhand smoke. Is that going to be as potentially lethal as smoking cigarettes?

  • 10:56:05

    SCHERRWell, I think that remains to be seen. I think secondhand smoke can be a big problem. And, certainly, there are carcinogens in secondhand smoke that, if inhaled by bystanders, can have some of the same effects. I think, clearly, the intensity of the exposure is not as great as the firsthand smoker, but I think secondhand smoke can be problematic, without question.

  • 10:56:26

    REHMEspecially for very young people, I would think, Dr. Freedman.

  • 10:56:30

    FREEDMANYes, I agree, though -- exactly -- though the intensity of the smoke from secondhand smoke is not as intense as if you're smoking the cigarette yourself. You're still exposed to all of the same carcinogens, and many of the carcinogens are known carcinogens for the bladder.

  • 10:56:45

    REHMDr. Neal Freedman of the National Cancer Institute, Dr. Douglas Scherr of New York Presbyterian Hospital and Lawrence Rzepka. He's with the Bladder Cancer Advocacy Network. Thank you all so much.

  • 10:57:05

    RZEPKAThank you.

  • 10:57:05

    SCHERRThank you very much.

  • 10:57:06

    REHMAnd thanks for listening. I'm Diane Rehm.

  • 10:57:11

    ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture, Monique Nazareth, Sarah Ashworth, Lisa Dunn and Nikki Jecks. The engineer is Tobey Schreiner. A.C. Valdez answers the phones. Visit for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information.

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