title: Heavy Cigarette Smoking and Aggressive Bladder Cancer at Initial Presentation.
abstract: OBJECTIVE
  To identify the impact of smoking intensity on tumor characteristics at the time of initial bladder cancer diagnosis.
  
  
  METHODS
  We retrospectively reviewed our institution's prospective database of patients diagnosed with bladder cancer from 1987 to 2009. Only patients with urothelial cell carcinoma and recorded tobacco history were included. Patients were stratified by tobacco history into nonsmokers, light smokers (≤ 30 pack-years), and heavy smokers (> 30 pack-years). An additional analysis was performed looking at patients meeting National Lung Cancer Screening Trial (NLCST) criteria (55- to 74-year-old patients with ≥ 30 pack-years smoking history and < 15 years since smoking cessation). Clinicopathologic characteristics of the initial bladder tumor at time of diagnosis were analyzed.
  
  
  RESULTS
  We identified 197 (26.6%) nonsmokers, 251 (33.9%) light smokers, and 292 (39.5%) heavy smokers. Males were more likely to be heavy smokers (44.5% vs 23.6%, P ≤ .01). Compared with nonsmokers and light smokers, the initial tumors in heavy smokers were more likely to be high grade with a more advanced clinical stage. Heavy smokers were more likely to present with muscle-invasive bladder cancer (MIBC) at initial diagnosis. When compared to nonsmokers, the odds ratio for presenting with MIBC was 1.18 (95% confidence interval = 0.68-2.1) for light smokers and 1.38 (95% confidence interval = 1.06-1.8) for heavy smokers. Of 793 patients with adequate information for analysis, 184 (23.2%) met NLCST criteria. Those meeting NLCST criteria were most likely to be male, to present with gross hematuria, and to have initial tumors that were high grade and muscle invasive. NLCST criteria eligibility remained associated with MIBC on multivariate analysis.
  
  
  CONCLUSIONS
  Heavy smokers and patients meeting NLCST criteria are more likely to have high-grade tumors with detrusor muscle invasion at initial presentation.
authors.affiliation: Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA. Electronic address: Eugene.pietzak@gmail.com.
authors.forename: Eugene J
authors.initials: EJ
authors.lastname: Pietzak
authors.affiliation: Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Phillip
authors.initials: P
authors.lastname: Mucksavage
authors.affiliation: Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Guzzo
authors.affiliation: Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: S Bruce
authors.initials: SB
authors.lastname: Malkowicz
mesh_terms: D017677:Age Distribution; D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000453:epidemiology* / Q000209:etiology* / Q000473:pathology; D016001:Confidence Intervals; D016208:Databases, Factual; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D016017:Odds Ratio; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D017678:Sex Distribution; D012907:Smoking / Q000009:adverse effects* / Q000453:epidemiology; D015996:Survival Rate; D014481:United States / Q000453:epidemiology; D001749:Urinary Bladder Neoplasms / Q000453:epidemiology* / Q000209:etiology* / Q000473:pathology