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Bladder cancer risk factors

This page presents information on the risk factors for bladder cancer including by tobacco, occupation exposure, hair dyes, medicines and medical conditions, hormonal factors, family history and food and drink. Overall, it has been estimated that, in the UK, around 44% of bladder cancer cases in men and 37% in women are linked to lifestyle and environmental factors. The proportion is higher in men than women due to higher rates of smoking in men in the past, and higher exposure to occupational hazards among men.1

 

Tobacco

Smoking

Smoking cigarettes is the principal preventable risk factor for bladder cancer in both men and women. A study published in December 2011 estimated that 38% of bladder cancer cases in men and 34% in women in the UK in 2010 were caused by smoking.2

Current smokers have up to four times higher bladder cancer risk compared with never-smokers, a cohort study of people aged 50 and over showed,75 with the highest risks for people smoking for the longest, or smoking a greater amount of cigarettes each day.70-71

Smoking cessation reduces risk, but risk in ex-smokers remains higher than never-smokers for more than 20 years.70-71

Environmental tobacco smoke

In a recent European study, exposure to environmental tobacco smoke (ETS) during childhood increased the risk of bladder cancer by almost 40%.4 However, the body of evidence does not support a link between ETS exposure in adults and bladder cancer risk.49 A record linkage study of bladder cancer incidence in the offspring of men and women diagnosed with lung cancer found a significant increase in risk of bladder cancer in those whose mothers had lung cancer, but no increased risk for paternal lung cancer. The authors interpreted this as evidence that exposure to tobacco carcinogens in utero or while breastfeeding may lead to bladder cancer in later life.5

Smoking cessation after diagnosis may favourably alter the course of the disease but the evidence is incomplete.6 It has also been suggested that high fruit consumption may reduce the effect of smoking on developing bladder cancer.7

The precise mechanism by which cigarette smoking induces bladder cancer is unclear. Studies show that risk varies by type of tobacco, with a higher risk for black ‘air-cured’ than blond ‘flue-cured’ tobacco.8 Smokers of black tobacco have higher reported levels of aromatic amines in their urine than smokers of blond tobacco.9 These aromatic amines are known urothelial carcinogens and the ability to detoxify them is compromised in people who are ‘slow acetylators’ and it is suggested that these people are at higher risk than ‘fast acetylators’ (see Molecular biology and genetics section).10

Tobacco tars have been shown to induce bladder papillomas and carcinomas in mice.11 It is thought that prolonged exposure of the bladder to such urinary carcinogens during the excretory process may lead to the development of bladder cancer.

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section updated 01/03/06

 

Occupational exposures

It has been estimated that, in the UK, around 7% of bladder cancer cases in men and 2% in women are linked to occupational exposures.64,68 This proportion may be higher in countries with less-regulated industrial processes.

Aromatic amines

In 1895 Rehn reported cases of bladder cancer in a German aniline dye factory.12 This led to occupational studies in other countries but it was not until the 1950s that the risk from aromatic amines, particularly benzidine and a-and ß-naphthylamine, was established by Case.13

Aromatic amines were widely used in the manufacture of dyes and pigments for textiles, paints, plastics, paper and hair dyes, in drugs, pesticides and as antioxidants in the rubber industry.14 Production of ß-naphthylamine ceased in the UK in 1952 (its use was withdrawn from the rubber and cable industry prior to this in 1949)15 and in 1953 bladder cancer became, and still is, a prescribed industrial disease.16

Polycyclic aromatic hydrocarbons (PAH)

Exposure to polycyclic aromatic hydrocarbons (PAH), which are by-products of combustion processes and therefore present in a range of industries, has also been investigated. It is calculated that about 4% of bladder cancer cases in European men are due to exposure to PAH.17 A recent meta-analysis showed a risk increase of about 30% for bladder cancer in painters and the International Agency for Research on Cancer classifies occupation as a painter as a cause of bladder cancer.66,69

Diesel engine exhaust

In June 2012, IARC classified diesel exhaust as associated with an increased risk of bladder cancer. This was based on limited evidence mainly from studies of highly-exposed workers.72

section reviewed 01/03/06
section updated 01/03/06

Hair dye

The International Agency for Research on Cancer (IARC) classifies working as a hairdresser or barber as a probable cause of bladder cancer, based on limited evidence; this is mainly linked with exposure to chemicals in hair dyes.88,89 Bladder cancer risk is 30-35% higher in hairdressers compared with the general public, meta-analyses have shown; however it remains unclear whether this is limited to hairdressers working before some carcinogenic chemicals were banned from hair dyes in the 1970s.90,91 This is distinct from domestic personal hair dye use.

section reviewed 04/04/14
section updated 04/04/14

Previous cancer

Bladder cancer risk is higher in survivors of larynx and lung cancers (males and females); and head and neck, prostate, and kidney cancers (males), a cohort study in France showed.105

Bladder cancer risk is higher in male survivors of prostate, head and neck, and lung cancers (males), with no association with previous cancer in females, a cohort study in Australia showed.106

Genitourinary cancer risk is 1.7-2.7 times higher in children, teenagers and young adults who had any type of cancer in childhood, compared with the general population, a cohort study showed.109

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section updated 21/05/14

Ionising radiation

A very small proportion of bladder cancer cases are associated with therapeutic irradiation in the pelvic region, for example for testicular cancer21 or cervical cancer.22 Men with a history of prostate cancer, both those treated with and without radiotherapy, have an increased risk of bladder cancer.23-25 The risk of bladder cancer has been shown to be increased two-fold in women treated for cervical cancer without radiotherapy, which may be due to shared risk factors such as smoking. A risk increase was also seen in women treated with radiotherapy- the risk was almost six-fold for women treated for cervical cancer 40 or more years previously.50

A study published in December 2011 has estimated that 2.6% of bladder cancer cases in men and 2.3% in women in the UK in 2010 were linked to radiation exposure, with most of these cases linked to exposure to diagnostic radiation.67

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section updated 01/03/06

 

Medical conditions and treatments

Chemotherapy

In addition to aromatic amines, there are other established bladder carcinogens including phenacetin and certain cancer chemotherapeutic agents including cyclophosphamide.19,20

Disability

Paraplegics have a greatly increased risk of squamous cell carcinomas of the bladder, due to their disposition to chronic urinary tract infection. Kidney and urinary stones may also slightly increase risk.26

Gastric ulcers

There is limited evidence that a history of gastric ulcer increases risk.30,31

section reviewed 01/03/06
section updated 01/03/06

Diabetes

The risk of bladder cancer is up to around a third higher in diabetics than non-diabetics, meta-analyses have shown.76-79,86 Diabetes treatment is likely to explain much of this increased risk, though treatment type often relates to diabetes stage, which may further confound findings, and detection bias may play a part.108

Bladder cancer risk is around 20% higher in diabetics using pioglitazone compared with diabetic non-users, meta-analyses of observational studies have shown; meta-analysis of randomised controlled trials indicates a stronger risk increase.80-82,87 Bladder cancer risk among diabetics is not associated with use of rosiglitazone, meta-analyses have shown.80-82,87 Bladder cancer risk among diabetics may be slightly lower in insulin users compared with non-users, meta-analyses have shown, though evidence remains mixed.95,96 Bladder cancer risk among diabetics is not associated with metformin use, a meta-analysis has shown.104

section reviewed 11/08/14
section updated 11/08/14

Infections

Human papillomavirus (HPV)

One study showed a doubling in risk of bladder cancer in patients with condylomata acuminata (genital warts).60 Genital warts are caused by infection with the human papillomavirus (HPV), and a meta-analysis showed a three-fold increased risk associated with HPV infection.61

section reviewed 01/03/06
section updated 01/03/06

Schistosomiasis

Schistosomiasis is a parasitic infection that occurs throughout Africa and the Middle East. One form of the parasite, schistosoma haematobium, is linked to bladder cancer and was estimated to cause around 10,600 cases of the disease worldwide in 2002.65

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Immune system

Organ transplant

Bladder cancer risk is around threefold higher among renal transplant recipients, compared with the general public, a meta-analysis showed.100

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section updated 01/05/14

 

Reproductive factors

Women who have given birth at least once have a 27-31% lower risk of bladder cancer compared with those who have never given birth, meta-analyses have shown.83,84 The link is stronger in never-smokers than ever-smokers.84 Women who had early menopause (younger than 43-49) have a 49% increased bladder cancer risk compared with those who had menopause later, though being post-menopausal is not in itself associated with risk.83 Late age at menarche (older than 15) was associated with 43% decreased bladder cancer risk in a large US cohort study.85 Links with hormone replacement therapy (HRT) use remain unclear, while use of oral contraceptives is not associated with risk increase.83-85

section reviewed 05/12/13
section updated 05/12/13

 

Family history and genetic conditions

Most studies show between two and six times the risk of bladder cancer in first-degree relatives of bladder cancer patients, with a higher risk if the relative was diagnosed before the age of 45.53-55

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section updated 01/03/06

 

Diet

Higher intake of fruit has been associated with a small but significant reduction in the risk of bladder cancer. An increase in fruit consumption of 100 grams a day is estimated to reduce risk by approximately 20%.32-34 However, some studies have shown no association with fruit intake and it is not possible to say there is a definite protective association.56-58

Two Chinese cohort studies have reported a significant increase in risk with higher consumption of soya foods.35,36 This association is not clearly understood: one theory is that the chemical reaction of chlorine in water with humic substances in beans during fermentation may act as a bladder carcinogen.

Results of a pooled analysis of 10 European studies show that heavy coffee consumption (more than 10 cups per day) is associated with a significantly increased risk of bladder cancer in men and women37 but there is no evidence of risk increase with moderate consumption.38,39

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section updated 01/03/06

Bladder cancer risk is not associated with total fluid intake, cohort studies have shown.101-103 Case-control studies have returned inconsistent results,41,59,62,102 with possible effect moderation by smoking,103 and urination frequency.63

Bladder cancer risk may be higher in people who drink the most tap water, meta-analyses have shown;41,42 the association may reflect the effect of chlorination, and may apply to males only.41-43

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Bladder cancer risk may be slightly decreased (27%) in people with a high-folate diet, however this effect is limited to case-control studies.93

section reviewed 04/04/14
section updated 04/04/14

Arsenic

Exposure to arsenic and inorganic arsenic compounds is classified by IARC as a cause of bladder cancer.97

Bladder cancer risk is only increased with high level, long-term arsenic exposure.98 Bladder cancer risk is not increased at lower-dose arsenic exposure, a meta-analysis showed.99

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section updated 22/04/14

Factors shown to decrease or have no effect on bladder cancer risk

Decrease

Bladder cancer risk is 15% lower in the most physically active people, compared with the least, a meta-analysis showed.107

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section updated 26/06/14

No effect

Bladder cancer risk is not associated with the following factors, meta- and pooled analyses or systematic reviews have shown:

  • Personal hair dye use.92
  • Systemic lupus erythematosus.94

section reviewed 14/04/14
section updated 14/04/14

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References for bladder cancer risk factors

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Updated: 21 May 2014