Four years.
That is how much time passed between when Andrea Harris first presented to her GP with a suspected bladder infection, and when she was diagnosed with advanced, muscle-invasive bladder cancer.
Ms Harris went back to the doctor multiple times over these four years, wanting to understand more about the root cause of her symptoms.
At one stage, Ms Harris recalls being "in tears" in the doctor's office, pressing for more extensive testing.
"I'd have a seven-day lot of antibiotics, and I'd be good for six or seven weeks and then I'd start to get symptoms again," she said.
By the time she was finally diagnosed in March 2024, Ms Harris's cancer had advanced to stage three.
In Australia, three in four people diagnosed with bladder cancer are men, but experts are concerned about the number of women, like Ms Harris, presenting with late-stage bladder cancer.
Alison Zhang, a medical oncologist at Macquarie University Hospital, said although bladder cancer symptoms, like blood in the urine and a frequent need to wee, were similar in both sexes, they were easy to misdiagnose as urinary tract infections (UTIs) or perimenopause in women.
Bladder cancer in Australia
About 3,345 cases of bladder cancer were estimated to be diagnosed in Australia last year.
But unlike most other cancers, the five-year survival rate has dropped since 1987.
Women diagnosed with bladder cancer in Australia face about a 50 per cent chance of living five years post-diagnosis, while men have an almost 60 per cent chance.
"Women tend to present later with later-stage disease, which is a real problem," Dr Zhang said.
Magdalena Simonis, a practising GP and women's health expert from the University of Melbourne, said men often had their bladder cancer symptoms — especially blood in the urine — escalated quickly as UTIs were far less common in men, and therefore unlikely to be the cause.
"If a man shows up with microscopic, that is, invisible blood in the urine, or visible blood in the urine, we would immediately advance that person to further investigations," she said.
"When a woman presents with the symptoms of bladder cancer, the symptoms are not dissimilar to those of a UTI; they might have a burning sensation with urination or blood in their urine."
Christine La Rose, a patient and support lead for advocacy group BEAT Bladder Cancer Australia, said there needed to be "more focus, more urgency and awareness" on improving outcomes for women.
Ms La Rose, a bladder cancer survivor herself, faced a short diagnostic delay after initially being told the blood in her urine had been caused by a UTI.
Other common symptoms of bladder cancer include a sudden change in urine colour, loss of appetite and weight loss.
Need for better referral pathways
There are a few things that experts agree will help improve outcomes for women.
The first, Dr Zhang said, was to increase community awareness about the symptoms of bladder cancer.
The second, Dr Simonis said, was that women who presented with recurrent UTIs — more than two within six months or three within a year — needed their symptoms investigated further with additional testing and/or a referral to a urologist.
"Women have traditionally been dismissed if they've got pain or ongoing symptoms," she said.
"Any level of discomfort that is continuous is something that we shouldn't really put up with."
Dr Simonis said GPs needed to consider risk factors of bladder disease, such as smoking and age, when treating female patients presenting with UTI-like symptoms.
"If they're a smoker, and they've got ongoing symptoms and recurrent symptoms, then alarm bells should ring a lot earlier," she said.
Ms La Rose said although bladder cancer was "traditionally seen as an older man's disease", she had met women in their 20s, 30s and 40s who had been diagnosed with it.
"Go back or go and get a second opinion. You really need to advocate for yourself and push for answers."
Margaret Blake was one of the many Australian women who needed to do just that.
Ms Blake saw three different GPs within the space of six months, concerned about her frequent need to urinate and finding blood in her urine.
She said her third GP was the first one to take her symptoms seriously, referring her for a series of tests, which eventually led to her bladder cancer diagnosis.
Survivors Ms Harris, Ms La Rose and Ms Blake all live with the ongoing consequences of treatment.
Ms La Rose has a neo-bladder, built by a surgeon using a piece of her intestine, which she is grateful to be able to empty easily and maintains a good quality of life.
"I'm really lucky. And I also know how lucky I am to still be here, given the diagnosis," she said.
