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Table of Contents
REVIEW ARTICLE
Year : 2018  |  Volume : 17  |  Issue : 3  |  Page : 99-105  

A review of bladder cancer in Sub-Saharan Africa: A different disease, with a distinct presentation, assessment, and treatment


1 Department of Surgery, Copperbelt University School of Medicine, Ndola, Zambia
2 Department of Pathology, Copperbelt University School of Medicine, Ndola, Zambia
3 Department of Surgery, Livingstone Central Hospital, Livingstone, Zambia
4 Department of Surgery, Ndola Teaching Hospital, Ndola, Zambia
5 Department of Surgery, University Teaching Hospital, Lusaka, Zambia

Date of Web Publication31-Aug-2018

Correspondence Address:
Dr. K Bowa
Copperbelt University School of Medicine, Ndola
Zambia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_48_17

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   Abstract 


Background: Cancer of the bladder is the ninth leading cause of cancer in developed countries. It is the second most common urological malignancy. Transitional cell carcinoma (TCC) is the most common histological subtype in developed countries. In most of Africa, the most common type is squamous cell carcinoma (SCC). Cancer of bladder guidelines produced by the European Urological Association and the American Urological Association, including the tumor, node, and metastasis staging is focused on TCC of the bladder. Objectives: The purpose of the study is to review the pathogenesis, pathology, presentation, and management of cancer of the bladder in Africa and to use this information to propose a practical staging system for SCC. Methods: The study used the meta-analysis guideline provided by PRISMA using bladder cancer in Africa as the key search word. The study collected articles available on PubMed as of July 2017, Africa Online and Africa Index Medicus. PRISMA guidelines were used to screen for full-length hospital-based articles on cancer of the bladder in Africa. These articles were analyzed under four subcategories which were pathogenesis, pathology, clinical presentation, and management. The information extracted was pooled and used to propose a practical staging system for use in African settings. Results: The result of evaluation of 821 articles yielded 23 full-length papers on hospital-based studies of cancer of the bladder in Africa. Cancer of the bladder in most of Africa is still predominantly SCC (53%–69%). There has been a notable increase in TCC in Africa (9%–41%). The pathogenesis is mostly schistosoma-related SCC presents late with painful hematuria and necroturia (20%). SCC responds poorly to chemotherapy or radiotherapy. The main management of SCC is open surgery. This review allowed for a practical organ-based stage of SCC of the bladder that can be used in Africa. Conclusion: Bladder cancer in Africa presents differently from that in developed countries. Guidelines on cancer of the bladder may need to take account of this to improve bladder cancer management in Africa.

   Abstract in French 

Résumé
Contexte: Le cancer de la vessie est la neuvième cause de cancer dans les pays développés. C'est le deuxième plus fréquent urologique malignité. Le carcinome à cellules transitionnelles (TCC) est le sous-type histologique le plus commun dans les pays développés. Dans la majeure partie de l'Afrique, le plus le type commun est le carcinome épidermoïde (SCC). Lignes directrices sur le cancer de la vessie produites par l'Association européenne d'urologie et American Urological Association, y compris la tumeur, le nœud, et la mise en scène de la métastase est axée sur le TCC de la vessie. Objectifs: Le Le but de l'étude est d'examiner la pathogenèse, la pathologie, la présentation et la gestion du cancer de la vessie en Afrique et d'utiliser cette information pour proposer un système de mise en scène pratique pour SCC. Méthodes: L'étude a utilisé la ligne de méta-analyse fournie par PRISMA en utilisant le cancer de la vessie en Afrique comme le mot clé de recherche. L'étude a recueilli des articles disponibles sur PubMed à partir de juillet 2017, Africa Online et Africa Index Medicus. Les directives PRISMA ont été utilisées pour dépister des articles hospitaliers complets sur le cancer de la vessie en Afrique. Ces articles ont été analysés sous quatre sous-catégories qui étaient la pathogenèse, la pathologie, la présentation clinique et la gestion. le les informations extraites ont été regroupées et utilisées pour proposer un système de mise en scène pratique à utiliser dans les contextes africains. Résultats: Le résultat de l'évaluation sur 821 articles, 23 articles complets ont été publiés sur les études hospitalières sur le cancer de la vessie en Afrique. Cancer de la vessie dans la plupart des L'Afrique est toujours principalement SCC (53% -69%). Il y a eu une augmentation notable du TCC en Afrique (9% -41%). La pathogenèse est principalement la SCC liée au schistosome se manifeste tardivement par une hématurie douloureuse et une nécroturie (20%). SCC répond faiblement à la chimiothérapie ou la radiothérapie. La gestion principale de SCC est la chirurgie ouverte. Cette revue a permis un stade pratique de la CEC de la vessie qui peut être utilisé. en Afrique. Conclusion: Le cancer de la vessie en Afrique présente différemment de celui des pays développés. Lignes directrices sur le cancer de la vessie Il faudra peut-être en tenir compte pour améliorer la gestion du cancer de la vessie en Afrique.

Keywords: Africa, bladder carcinoma, squamous cell carcinoma, transitional cell carcinoma


How to cite this article:
Bowa K, Mulele C, Kachimba J, Manda E, Mapulanga V, Mukosai S. A review of bladder cancer in Sub-Saharan Africa: A different disease, with a distinct presentation, assessment, and treatment. Ann Afr Med 2018;17:99-105

How to cite this URL:
Bowa K, Mulele C, Kachimba J, Manda E, Mapulanga V, Mukosai S. A review of bladder cancer in Sub-Saharan Africa: A different disease, with a distinct presentation, assessment, and treatment. Ann Afr Med [serial online] 2018 [cited 2018 Nov 15];17:99-105. Available from: http://www.annalsafrmed.org/text.asp?2018/17/3/99/240187




   Introduction Top


There is a 15-fold variation in the incidence of cancer internationally.[1],[2] There is little written on cancer of the bladder in Africa in the literature. The predominant histological subtype of cancer of the bladder in developed countries is transitional cell carcinoma (TCC).[3],[4],[5] In much of Africa, the predominant subtype continues to be squamous cell carcinoma (SCC) of the bladder.[6],[7] Most of the literature has focused on TCC of the bladder.[8],[9] The staging and treatment guidelines focus almost exclusively on TCC.[10] Urologists and surgeons, practicing in Africa, are faced with the challenge of managing bladder cancer of SCC subtypes which presents in a different way from TCC. The aetiology of TCC is associated with working in the dye industry as well as smoking. On the other hand SCC occurs where countries have a high burden of Schistosomiasis. TCC is common in more industrialized countries while SCC is more common in less industrialized countries. The clinical presentation of TCC is mostly with painless hematuria, while in contrast, that of SCC presents with painful hematuria, bladder mass, and necroturia. Like most urological diseases in developing countries, SCC presents late to the urologist, when the disease is already advanced with muscular invasion.[11],[12] In contrast, most TCC presents relatively earlier with only mucosal involvement. This may relate in part to better access to urology services and better cancer screening programs in developed countries.[13],[14] The management of TCC is mostly by transurethral resection of bladder tumor and bladder instillation therapy. On the other hand, SCC is managed mostly by open surgery. The bladder cancer staging in wide usage is the tumor, node, and metastasis (TNM) staging, this is more suited to TCC rather than SCC. The reason, why this is the case, is that the staging guideline is specifically for TCC [15],[16] (European Urological Association guidelines and AUA guidelines). In addition, the pathogenesis of TCC suggests the disease spreading layer by layer from the mucosa to the serosal layer or inward to outward.[17],[18] In contrast, SCC with the schistosoma eggs implanted in the perivesical plexus; the pathology may be seen to spread in an opposite direction.[19],[20]


   Methods Top


A meta-analysis was done using the PRISMA guidelines. All articles available on PubMed, African Index Medicus, and African Journals Online up to July 2017 for all available records to that date were searched. This was a simple search based on the default setting using the search phrase “Bladder Cancer in Africa.” The medical subject headings were used in the ordinary PubMed default mode as would be used by a routine researcher search in PubMed. The Boolean operations to combine terms and broaden the search were not used to avoid a wide nonspecific reach in the study area. A supplementary list of excluded papers is included in the supplementary data materials sent to the journal. The articles were reviewed for duplication and completeness. The inclusion criteria for articles in addition to the search term, where hospital-based studies, studies done in Africa, and publications with full articles available online. All articles that met these criteria were included in the study. The review looked at four subtopics under cancer of the bladder in Africa. These subtopics were pathogenesis, pathology, presentation, and management. These studies were pooled and entered into Epi Info 7.2.


   Results Top


There were 821 articles identified in the data search using the term “Bladder Cancer in Africa.” Using the PRISMA guidelines, 23 articles were included in the study. The PRISMA guide in [Flow Chart 1] shows the process and [Table 1] shows the articles identified through this search.

Table 1: Bladder cancer studies in Africa

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Pathogenesis

The review identified four key factors associated with bladder cancer in Africa. The key factors are listed in [Table 2].
Table 2: The factors associated with bladder cancer pathogenesis in Africa

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Pathology

The review itemized the key aspects of the pathology of the bladder in Africa which highlighted the site, the shape, the size, the grade, the stage, and lymph node spread. This is shown in [Table 3]. In addition, [Table 4] highlights the subtype and proportion by African country.
Table 3: The pathology findings in cancer of the bladder in Africa

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Table 4: The epidemiology of cancer of the bladder key subtypes in Africa countries

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Presentation

[Table 5] shows the clinical presentation of the patients based on age, sex, symptoms, and clinical stage.
Table 5: Clinical presentation of cancer of the bladder patients in Africa

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Management

[Table 6] shows the management of each major subtype with the three key parameters of surgery, chemotherapy, and radiotherapy.
Table 6: Management of cancer of the bladder in Africa

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   Discussion Top


The results show that SCC in Africa is still largely associated with schistosomiasis infection in up to 85% of cases. However, there is a changing pattern of SCC which is being influenced by smoking, industrialization, and schistosomiasis control.[21],[22],[23],[24] It has been noted, particularly in Egypt, that there has been an increasing habit of smoking, which is associated with an increased risk of cancer of the bladder. With increased schistosoma control, industrialization, and westernized lifestyles, the relative proportions of SCC and TCC are changing in favor of TCC.[25],[26],[27] There are notable changes in the proportion of SCC and TCC across individual African countries. In particular in Tanzania, where regions which are close to inland freshwater lakes continue to have high relative proportions of SCC relative to areas further away.[28],[29] In South Africa, they are marked differences across racial groups such as native populations, Asian, colored, and expatriate populations. In general, there appears to be a high proportion of SCC among native black population groups, where SCC is as high as 53%. In contrast among the Asian, colored, and white populations, SCC represents only 18%, 6%, and 2%. This may be related to genetic, social, and behavior factors.[28],[29],[30]

The pathology shows that SCC tends to be focally locate as an ulcerative and nodular mass in the bladder fundus. The mass being usually >3 cm in size at first presentation.[31],[32],[33] The SCC is also muscle invasive in 80% of cases at the time at first presentation.[34]

In contrast, TCC tends to be multifocal small and papillary like with little or no muscle invasion at fi rst presentation.[35] SCC also has a lower grade usually Grade 1 when patients are fi rst seen in the hospital.[35] TCC on the other hand tends to be of Grade 2 or 3 at first presentation. TCC also spreads early to the lymph nodes, whereas SCC spreads late possibly due to fibrosis of the lymphatic channels caused by the schistosoma eggs.[35],[36] In SCC, only in 2% to 10% is lymph node spread observed.[35],[36] In clinical presentation, patient with SCC tends to be younger and male. In contrast, TCC has a higher proportion of females and presents in an older age group.[35],[36] The most frequent clinical presentation of TCC is of painless hematuria, in a person older than 40 years of age. With SCC, the patient presents with painful hematuria associated with irritative symptoms, necroturia, or a bladder mass.[37],[38] In relation to treatment, the two subtypes of cancer of the bladder tend to be treated very differently. Closed surgery by transurethral resection is most frequent mode in TCC, and this is supplemented by chemotherapy and radiotherapy depending on the tumor grade. On the other hand, SCC is generally radio- and chemoresistant. It is managed mainly by open surgery with partial or total cystectomy. TCC has a better 5-year survival of about 90% in 5 years compared to SCC which has a 5-year survival of close to 70%.[37],[38],[39] Up to 27% of SCC may be fixed and inoperable, especially if located below intraureteric bundle of Mercier.[38],[39]

Staging

The differences in the pathogenesis, pathology, clinical presentation, and management between the two common subtypes of cancer of the bladder in Africa suggest that the approach to the two may need to be varied. In particular, while the TNM classification is well suited to the staging of TCC, it may not be as well suited to SCC. The TNM is a histological-based staging, which focuses on the luminal spread of the cancer across the bladder wall. This is better and easily applied to TCC. However, with SCC, an organ-based staging is more suitable of SCC. The Africa papers appear to suggest that SCC is locally invasive and spread along the bladder from the fundus to the bladder neck area.[38],[39] Therefore, the staging instead of being transmural should be vertical from the fundus to the bladder neck. [Box Chart 1] shows an organ-based staging, which follows the method of cancer spread. [Figure 1] is a small cancer <3 cm confined to the bladder fundus. [Figure 2] is cancer >3 cm without involvement of the ureters or the serosa. [Figure 3] is cancer which has invaded either one or both ureters. [Figure 4]a is cancer which has invaded the serosa or the Trigone area of the Bladder. This cancer is only partially fixed. [Figure 4]b is cancer that has invaded the pelvic organs and is fixed. [Figure 5] is distant metastasis.

Figure 1: Cancer <3 cm in longest width not invading the serosa (no fixity)

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Figure 2: Cancer >3 cm in longest diameter with ureteric invasion (hydronephrosis) (no fixity)

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Figure 3: Cancer <3 cm involving the trigone area not invading the serosa (no fixity)

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Figure 4: Cancer which has invaded the serosa. (a) With partial fixity. (b) With complete fixity

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Figure 5: Systemic disease

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Most cases of bladder cancer in Sub-Saharan African countries are predominantly SCC subtype. In developed countries, on the other hand, SCC is uncommon while TCC represents over 90% of bladder cancer type. The main causes of bladder cancer in developed countries are smoking and industrial chemicals.

In many developing countries, however, there has been a notable increase in the proportion of TCC with the increase in industrialization. In spite of this change, SCC continues to be the predominant subtype in much of Sub-Saharan Africa. It occurs especially in predominantly high burdened schistosomiasis areas. It is proportionately a disease of men and presents at a mean age of 50 years. On the other hand, TCC presents a decade later with an almost equal male-to-female ratio. The SCC presents late with painful hematuria or other bladder symptoms. This is in contrast to TCC which presents earlier with painless hematuria and with minimal symptoms. In over 70% of cases, the bladder muscle wall is invaded at the time of presentation, while in TCC, over 90% of cases present with nonmuscle invasive disease. In practice, most urologists in Africa will use an organ-specific staging to plan for bladder cancer management due to this early muscular invasion.[40]


   Conclusion Top


SCC has little or no pelvic node involvement at presentation. In contrast, TCC spreads early to pelvic nodes, once it has invaded the muscle wall. SCC is mostly radioresistant and does not respond to chemotherapy. TCC, on the other hand, shows a good response to radiotherapy, bacillus Calmette-Guérin or mitomycin instillation, and chemotherapy. This study proposes a simple practical organ-based staging based on current knowledge of SCC pathology in Africa.[41],[42]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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