Intended for healthcare professionals

Practice Easily Missed?

Bladder cancer in women

BMJ 2014; 348 doi: (Published 31 March 2014) Cite this as: BMJ 2014;348:g2171
  1. Brian D Nicholson, academic clinical fellow in primary care1,
  2. John S McGrath, consultant urological surgeon2, honorary senior lecturer3,
  3. Willie Hamilton, professor of primary care diagnostics3
  1. 1Department of Primary Health Care Services, Oxford University, Oxford OX2 6GG, UK
  2. 2Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
  3. 3University of Exeter Medical School, Exeter EX2 4SG, UK
  1. Correspondence to: B D Nicholson brian.nicholson{at}
  • Accepted 5 February 2014

A 76 year old woman reports recurrent urinary frequency, dysuria, and malodorous urine. No bacterial growth has been identified on two midstream urine samples, though empirical treatment with antibiotics has improved her symptoms. After three months, an episode of visible haematuria prompts referral and a transitional cell carcinoma of the bladder is diagnosed.

What are the types of bladder cancer?

In developed countries 90% of bladder cancers are transitional cell carcinomas; squamous cell carcinomas (SCC) make up most of the remainder.1 2 In endemic areas, squamous cell carcinoma related to schistosomiasis accounts for 70% of cases.1 Around 20% are muscle invasive at diagnosis and are associated with a significantly poorer prognosis.3 The major risk factor is smoking, though chronic infection, radiotherapy, and (before regulation) industrial dyes have been implicated.2 4

How common is bladder cancer in women?

  • Bladder cancer is the seventh most common cancer in the United Kingdom and the 11th most common in women5

  • In 2010 there were 10 324 new diagnoses of bladder cancer in the UK, with a female to male ratio of 2:5, accounting for 4900 deaths5

  • An average general practice expects to see one new diagnosis of female bladder cancer every 3.5 years

  • The average age at diagnosis is 715

Why is it missed?

Although bladder cancer is more common in men, women experience more delays: the English National Audit of Cancer Diagnosis in Primary Care (2009-10) estimated that annually 435 more women than men with bladder cancer experience a delay in diagnosis, but there are few data from UK primary care to explain this.6 With no effective screening tool for bladder cancer, it is usually diagnosed symptomatically, with haematuria being the most common presenting symptom for both sexes in primary care (likelihood ratio 59, 95% confidence interval 51 to 57).3 7 The likelihood ratio summarises how many times more (or less) likely …

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