This study assessed the prevalence, mode of presentation, treatment and risk factors associated with bladder cancer in 115 patients referred to a South African academic hospital over an eleven-year period (2010 and 2020). The aim was to identify potential patterns or predisposing factors that could help reduce the significant morbidity and mortality associated with this cancer. This study provided the basis for analysing the prevalence, risk factors, treatment modalities, and outcomes of bladder cancer within this healthcare setting, with a particular focus on identifying any trends that could improve patient management and reduce mortality rates associated with bladder cancer. The reported data clearly show that the mean age of 60.7 ± 14.9 years, suggesting that bladder cancer is associated to aging. The most common risk factors associated with bladder cancer complications included smoking, male gender, Black ethnicity, and increasing age. This is consistent with the findings of several studies, such as Kamal et al. [14] and Koti et al. [15], which reported a median age at diagnosis for urinary bladder cancer of 60 years (range: 40–80 years). These studies highlighted a high incidence and prevalence of cancer of urinary bladder are evident in the sixth decade of life, with a peak occurring in the seventh and eighth, indicating that BCa predominantly affects the elderly population [14]. Similarly, studies from India [12] and Iran [23], found that older age groups had a higher incidence of BCa, with mean ages of 60.2 and 61.9 years, respectively. These consistent findings across regions suggest that aging significantly increases the risk of bladder cancer. Given this association, there is need for enhanced disease management and comprehensive care for elderly bladder cancer. Radiation oncologists and healthcare providers should increase awareness efforts within this high-risk age group, focusing on early detection and prevention strategies. By targeting these older populations, healthcare systems may be able to reduce the morbidity and mortality rates, ultimately improving patient outcomes.

The study found that the overall prevalence of bladder cancer was higher in males (n = 70 (60.9%)) than in females. These findings highlight the importance of targeted screening and prevention strategies for high-risk groups, particularly older males with a history of smoking. This aligns with existing literature, where sex is well-established determinant in bladder cancer. Several studies, such as those Sung et al. [21] and Yavari et al. [23], have reported that bladder cancer is significantly more common in men than women. Sung et al. [21] observed that the incidence and mortality rates for bladder cancer are four times those of women globally, with rates of 9.5 and 3.3 per 100,000 men and women, respectively. Burger et al. [4] also supported this finding, attributing the higher incidence in men to the role of male sex hormones in interfering with the body’s ability to fight bladder cancer. Additionally, men are more likely to engage in cancer-predisposing behaviours such as smoking [16]. Sex steroids and their receptors may also play a role in the variable behaviour of TCC between genders, with being a male is associated with higher risk of bladder cancer [14].

Another critical factor is race. Is there a link between race and prevalence of bladder cancer? Race also played a critical role in the prevalence of bladder cancer, consistent with previous research. The study found a significant association between race and bladder cancer, as observed in the Groeneveld et al. [11] study in greater Durban, South Africa, which reported that bladder cancer was about six times more common in Caucasians than in Africans. This could be attributed to the notion that Caucasians are known to have the highest rate of new cancers, and the predominance of black patients with bladder cancer in this study may reflect patterns in healthcare access, where black patients might primarily seek care at this particular hospital, while other races go elsewhere.

The study also highlighted smoking as a significant risk factor for TCC, aligning with literature that estimates smoking accounts for approximately 50–65% of new BCa cases each year. Smoking has been strongly associated with increased risk of TCC (due to exposure to carcinogenic compounds like aromatic amines and N-nitroso compounds found in tobacco, which can cause DNA damage in the form of double-stranded breaks, base modifications, and bulky adduct formation [22, 24]. It has been observed that smoking reflects the socio-demographic characteristics of westernised lifestyles, which are linked to the prevalence of TCC. Westernized lifestyles often include behaviors such as smoking, which is a well-established risk factor for bladder cancer, particularly TCC. A study examining the relationship between smoking and development of bladder cancer found that patients with bladder cancer had a significantly higher smoking index compared to controls. The mean smoking index for BCa was 7.77 ± 3.76 compared to 3.08 ± 1.88 for the control group (P < 0.001) [14]. This finding highlights the strong correlation between smoking intensity and bladder cancer risk, reinforcing the need for targeted interventions to reduce smoking as part of bladder cancer prevention strategies. The smoking index, which reflects both the duration and intensity of smoking, serves as an important marker of cancer risk in this population.

A study by Zheng et al. [24] reported that the prevalence of cigarette smoking among men was 77% for TCC cases, 69% for SCC cases, and 65% for controls. Their findings suggested a significant association between cigarette smoking and an increased risk of TCC, with an adjusted odds ratio (OR) of 1.8 (95% confidence interval [CI], 1.4–2.2). Interestingly, smoking was not significantly associated with SCC in their study. Furthermore, the study highlighted those smokers who used cigarettes and pipes had a considerable risk of developing TCC and SCC, with an OR of 2.9 (2.1–3.9) for TCC and 1.8 (1.2–2.6) for SCC. These findings underscore the strong link between smoking and the risk of bladder cancer, particularly TCC and suggest that combined smoking habits further elevate the risk. While there may be some differences in the exact prevalence rates observed across studies, these data collectively support the hypothesis that smoking history remains a strong risk factor for developing the TCC subtype of bladder cancer. The impact of smoking on SCC appears to be less pronounced, further emphasizing the distinct etiological pathways between these two bladder cancer subtypes.

When comparing histological subtypes, TCC was more prevalent than SCC in this cohort and patients with TCC were more likely to be older, white, and male. White patients were four times more likely to have TCC than black patients, and males were more than twice as likely as females to have TCC. These findings suggest that older age, male gender, and white race are significant factors associated with a higher likelihood of TCC compared to SCC in this cohort. This contrasts with studies in sub-Saharan Africa (SSA), where SCC is more prevalent. TCC is more prevalent in high HDI countries due to higher exposure to carcinogenic chemicals [1]. Groeneveld et al. [11] reported a striking difference in the histological subtypes of BCa between Africa and Caucasian patients. In their study, SCC accounted for 53% of BCa cases in African patients, while TCC constituted 95% of the cancers in Caucasians. This difference likely reflects underlying risk factors unique to each population. In countries like Egypt or other African nations such as Sudan, Kenya, Uganda, Ghana, and Senegal, BCa is predominantly of the squamous cell type. This high prevalence of SCC in these regions is largely attributed to chronic infections, particularly schistosomiasis or bilharziasis [7]. This highlights the critical role that environmental and infectious disease factors play in the epidemiology of bladder cancer in Africa, necessitating targeted public health interventions, such as schistosomiasis control, to reduce the burden of bladder cancer. Another study reported that among the confirmed cases, 689 were diagnosed as SCC, accounting for 35% of cases, 1,197 were TCC (60%). Additionally, 102 (5%) was classified other type of primary bladder cancer cases The study also highlighted the most prevalent comorbidities within the patient cohort, which included hypertension, chronic kidney disease, and diabetes mellitus. These comorbid conditions can complicate the management of bladder cancer, as they may influence both the patient's overall health and their ability to tolerate cancer treatments. The presence of these comorbidities underscores the importance of a holistic approach to patient care, addressing not only the cancer but also the management of these additional health conditions to improve patient outcomes.

Finally, the stage of BCa at diagnosis is crucial of patient outcomes and survival. Early detection and treatment at a less advanced stage can significantly reduce mortality. In our study, the majority presented with advanced stage of the disease, with 53.0% (n = 61), having MIBC and 45.0% (n = 52) presenting MUC, reflecting late presentation (98%). Only a smaller percentage of the patients (2%) were diagnosed at an early stage, such as NIMBC. Late-stage presentation limits treatment options, often necessitating palliative care rather than curative interventions. Could these patients have been more appropriately assisted at early-stage of the disease? However, in resource-limited settings, where access to early screening and diagnostic services may be constrained, improving early-stage detection is essential. Research has shown that this is not a straightforward issue. A study by Krimphove et al. (2019) reported that female patients with non-muscle invasive bladder cancer (NMIBC) tend to present late with more advanced tumour stages compared to males. Additionally, female patients are more likely to experience early recurrences of the diseases. This delayed presentation in women may be due to several factors, including potential differences in symptom recognition, healthcare-seeking behavior, or biological differences that contribute to more aggressive disease progression in females. However, in the context of Africa, treating late-stage bladder cancer presents a significant challenge, particularly due to limited resources. The scarcity of specialized healthcare services, diagnostic tools, and advanced treatment options in many African countries complicates the management of bladder cancer, especially when patients present with advanced disease stages like Muscle-Invasive Bladder Cancer (MIBC) or metastatic cancer. It is suggested that stage at diagnosis for bladder cancer is critical for providing patients with prompt and effective treatment. Early detection can significantly improve outcomes by enabling timely interventions, such as surgery or localized therapy, before the disease progresses to more advanced stages. Afterwards, care should be kept consistent and continuous, with a focus on maintaining treatment according to established guidelines. To achieve this, healthcare systems should strive for efficiency by streamlining processes and ensuring seamless transitions between different care settings, from initial diagnosis to treatment and follow-up. This requires coordinated efforts across various levels of healthcare, including primary care, specialized oncology services, and post-treatment monitoring. Implementing standard guidelines and protocols can help ensure that patients receive timely, evidence-based care, ultimately reducing bladder cancer morbidity and mortality.

As mentioned above, radiotherapy was the primary treatment modality for BCa in this study, primarily due to its availability compared to other treatment in the region. Patients from district hospitals were often referred to specialists at the academic for radiotherapy. This approach allowed for more comprehensive assessments and facilitated the identification of cases where TURBT and cystectomy of the bladder cancer might be appropriate.

Our indications for palliative treatment in patients with bladder cancer, therefore, include the following situations:

Treatment of bladder cancer, while necessary, unfortunately still carries significant treatment adverse effects and toxicities. The nature and severity of these side effects vary depending on the type of treatment received, such as surgery, chemotherapy, or radiotherapy. These treatment-related toxicities can significantly impact patients' quality of life and may limit the ability to tolerate aggressive therapies, particularly in elderly or comorbid patients. Ongoing research aims to develop more targeted therapies and supportive care strategies to minimize these adverse effects while maintaining effective cancer control.

As a result of the retrospective study, it is critical to note that some of the possible reasons contributing to the prevalence rate include delayed access to healthcare services, detection, and appropriate treatment in healthcare settings. The higher number of symptoms per patient, the more advanced disease and the more challenging in the natural history prognosis.

One limitation of the present study was the retrospective design, which only included data from a single oncological unit, may limit data’s generalizability. Additionally, the study may contain inherent biases such as incomplete patient-related factor recording and possible exclusion of patients from other departments at the academic hospital. Despite these limitations, the study aimed to highlight information on the epidemiology of bladder cancer, which could potentially be helpful in the prevention of bladder cancer. Furthermore, a lack of multicentre data. A retrospective multicentre study would provide a clearer picture of bladder cancer in South Africa. Another drawback was the lack of information on date of death (missing data on mortality), which potentially hindered the ability to analyse survival outcomes fully. However, the study provides valuable insights into the epidemiology, risk factors, and treatment of BCa in a South African setting. The findings highlight the importance of early detection, targeted awareness efforts, and tailored treatment strategies, particularly for high-risk group such as older male smokers.