Bladder Cancer

What is bladder cancer?

Bladder cancer is one of the most common types of cancer that affect hundreds of thousands of adults every year. Bladder cancer is more common in men than in women and it may occur at any age, but it mostly affects older adults.

Bladder cancer originates from the cells (urothelial cells) that line the lumen of your urinary bladder – a hollow, muscular organ located in the lower abdomen and stores the urine. While it occurs very commonly in the urinary bladder, it can also develop in other parts of the urinary system.

Approximately 7 of 10 documented bladder cancers are detected in the early stage when the cancer is highly treatable. However, even the early stage bladder cancer can relapse. Therefore, people with bladder cancer require follow up tests for many years after treatment regarding recurrence or progression of the bladder cancer.

What are signs and symptoms of bladder cancer?

Signs and symptoms of bladder cancer may include:

Blood in urine (hematuria)

  • Dysuria.
  • Pain in lower abdomen.

Your urine may look bright red or like coke  in color if you have hematuria. In seldom cases, there is no change in appearance of the urine, but blood can be seen in microscopic examination of the urine.

Following symptoms may also occur in patients with bladder cancer:

  • Backache
  • Urinary frequency

However, these symptoms also occur often in conditions other than bladder cancer.

When should you make an appointment with your doctor if you have the symptoms and signs of bladder cancer?

Schedule an appointment with your doctor to have your urine checked, if you have hematuria (blood in your urine). Make an appointment with your doctor if you have any other sign or symptoms that worries you.

What are causes of bladder cancer?

Bladder cancer is caused by an abnormal growth of cells in bladder. These cells mutate in ways making them grow uncontrollably or not to die rather than growing and dividing in a usual manner. These abnormal cells form a tumor.

Causes of bladder cancer are listed below:

  • Smoking and use of other tobacco products,
  • Exposure to chemicals, especially occupational exposure to chemical sbubstances.
  • Having a history of exposure to radiation
  • Chronic irritation of the interior wall of bladder
  • Infections caused by parasites, especially for people living or visiting certain countries outside the U.S.A.

Cause of the bladder cancer is not always obvious and some cases with bladder cancer have no clear risk factors.

What are types of bladder cancer?

Various cells of your bladder may become cancerous. The cell of the bladder where the cancer originates from determines the type of bladder cancer. Next, type of your bladder guides the treatment that is likely to provide the best curative result.

Types of bladder cancer are listed below:

Urothelial carcinoma. Urothelial carcinoma, formerly called transitional cell carcinoma, develops in the cells that line the inner wall of the urinary bladder. Urothelial cells expand when your bladder is full and contract when it is empty. These cells line interior surfaces of the ureters and urethra and tumors may also occur in these places. Urothelial carcinoma is the most common type of bladder cancer in the United States of America.

  • Squamous cell carcinoma. Squamous cell carcinoma is related to chronic irritation of bladder (for example, an infection or long term urinary catheterization). Squamous cell bladder cancer is rare in the United States of America. It is more common in some areas of the world where a certain parasitic infection (schystosomiasis) is common cause of the bladder infection.

Adenocarcinoma originates from the cells that form the mucus-secreting glands of the bladder. Adenocarcinoma of the bladder is rare in the United States of America.

More than one cell is involved in some bladder cancers.

What are risk factors of bladder cancer?

Following factors increase the risk of bladder cancer:

Smoking cigars, cigarettes or pipes may cause accumulation of hazardous chemicals in your urine, leading to increased risk of bladder cancer. When you smoke, your body processes the chemicals that are found in the fume and excreates some of them in the urine. These hazardous chemicals may damage the cells lining the interior surface of the bladder and increase the risk of cancer.

Aging. Your risk of bladder cancer increases as you get older. Bladder cancer can occur at any age, although it is rare in persons younger than 40.

  • White race. Risk of bladder cancer is greater in white race than in other races.

Being Male. Development of bladder cancer is more likely in men than in women.

Exposure to certain chemicals. Your kidneys play a key role in filtering the hazardous chemicals in your blood and flowing these chemicals to your bladder. Therefore, it is considered that exposure to certain chemicals increases risk of bladder cancer. Chemicals, such as arsenic and coloring agents and ones used in production of rubber, leather, textiles and paints, are some of the chemical that are linked to the risk of bladder cancer.

History of treatment for cancer in the past. Cyclophosphamide, a drug used in anti-cancer treatment, increases the risk of bladder cancer. Risk of bladder cancer is greater in patients with a history of radiation treatment to lower abdomen.

Chronic bladder inflammation. Chronic or recurrent urinary tract infections or inflammations (cystitis) – as it can develop after long term use of urinary catheter – may increase your risk of squamous cell bladder cancer. In various regions of the world, squamous cell carcinoma is linked to chronic inflammation of bladder due to a parasitic infection called schistosomiasis.

Personal or family history of cancer. If you were diagnosed with bladder cancer in the past, it is more likely for you to develop this disease again. Although inherited cases of bladder cancer are rare, your risk increases if personal history of your first degree relatives (mother, father, sibling or child) is notable for bladder cancer. A family history notable for hereditary non-polyposis colorectal cancer (also known as Lynch syndrome) increases your risk of urinary tract cancer as well as colon cancer, endometrial cancer, ovarian cancer and cancer in other organs.

What can you do to prevent development of bladder cancer?

Although there is no certain way to prevent bladder cancer, you can take several measures to reduce your risk. For example:

Do not smoke. Not smoking means the ability to prevent accumulation of chemical substances that are found in the fume and cause cancer in your bladder. If you do not smoke, never start. If you are smoking, consult your doctor for a plan that may help quit. Support groups, medicines and other methods may help you quitting.

Take measures for chemicals. If you work with chemical substances, follow all safety & security instructions to avoid exposure.

Prefer eating various fruits and vegetables. Follow a diet rich in various fruits and vegetables. Antioxidants in fruits and vegetables may help decrease your risk of cancer.

How is bladder cancer diagnosed?

Tests and procedures used to establish diagnosis of bladder cancer include:

  • Cystoscopy During a cystoscopy, your doctor inserts a small, narrow tube (cystoscope) through your urethra. Cystoscope is equipped with a lens that allows your doctor see your urethra and bladder and look for signs of a disease.

Your doctor may advance a special device through the cystoscope to obtain a cell sample for testing (biopsy) during cystoscopy. This procedure is sometimes called transurethral resection of bladder tumor (TURBT). TURBT may also be performed to cure the bladder cancer.

Urine cytology: Urine cytology involves examining your urine specimen under microscope to look for cancer cells.

Imaging tests. Imaging tests, such as Computerized Tomography (CT), urogram or retrograde pyelography, allow your physician to examine structures of your urinary system.

During CT urography, a contrast agent is injected through a vein in your hand and ultimately, it flows to your kidneys, ureters and bladder. Roentgenograms acquired during the test provide detailed images of your urinary tract and helps your doctor determine the areas that may be cancerous in nature.

Retrograde pyelography is an X ray imaging modality used for viewing upper urinary tracts in detail. During this test, your doctor inserts a narrow tube( catheter) into your bladder through your urinary tract to inject a contrast agent into your ureter. The contrast agent flows into your kidney while X-ray images are acquired.

How to identify stages (dissemination) of bladder cancer?

After your diagnosis of bladder cancer is verified, your doctor may recommend further tests to determine whether your cancer has spread to lymph nodes or other body parts.

These tests may include:

CT scans

MRI (Magnetic Resonance Imaging)

Bones scan

Chest X-ray

Cancer staging systems are still developing and it gets more complicated as long as doctors improve diagnosis and treatments of cancer. Your cancers stage is used by your doctor to determine the appropriate treatment options.

Grade of bladder cancer

Bladder cancers are classified more elaborately depending on how cancer cells appear under microscope.  This is known as tumor grade and your doctor can identify the bladder cancer as low or high-grade.

  • Low-grade bladder tumor. This type of tumor has cells close to the normal cells by means of appearance and organization (well-differentiated). Low-grade tumors generally develop in a slower way and they have less possibility to invade the muscle layer of wall of bladder comparing to high-grade tumors.
  • High-grade bladder tumor. This type of tumor has cells which appear abnormal and have disparate appearance from the normal tissues (poorly differentiated). High grade tumor tends to grow in a more aggressive manner comparing to low-grade tumor and it might have a higher possibility to spread to muscle layer of wall of bladder and other tissues and organs.

What are treatment methods in bladder cancer?

Treatment options of bladder cancer depend on your general status of health and treatment preferences as well as type, grade and stage of cancer.

Treatment options of bladder cancer include the following:

  • Surgical intervention: Surgical intervention to remove the cancerous tissue.
  • Chemotherapy of bladder (intravesical chemotherapy), a chemotherapy method which is limited with wall of bladder however, is used to treat the tumors with high risk of recurrence or advance to a higher grade.
  • Reconstruction, forming a new route to empty out the urine from the body after extraction of bladder.
  • Chemotherapy for whole body (systemic chemotherapy), systemic chemotherapy to increase the chance of recovery of an individual undergoing a bladder removal surgery (cystectomy) or to be used as a primary therapy when surgery is not an option.
  • Radiation therapy. Radiation therapy as a frequently used primary therapy to destroy the cancer cells, in conditions when surgery is not an option or is not wanted.
  • Immunotherapy. Triggering the immune system of body to fight against cancer cells in bladder or whole body.

A combination of treatment methods can be recommended by your physician or members of care team.

Bladder Cancer Surgery

Bladder cancer surgery methods include the following:

  • Transurethral resection of bladder tumors (TURBT). TURBT is a procedure which is used to remove the bladder cancers which have not spread into internal layers of bladder or turned into muscle invasive cancer.  During TURBT, the surgeon advances a wire loop to the bladder through a cystoscope. This loop burns away the cancer cells with electrical current. As an alternative, high-energy laser can be used to destroy the cancer cells.

TURBT is performed under regional anesthesia (the medications numb only the lower part of your body) or general anesthesia (the medications makes you sleep during the surgery).  As the doctors perform the surgery through urinary tract, no incision is made on your abdomen.

Your doctor may recommend a single use of cancer-destroying medication (chemotherapy) to destroy cancer cells and prevent recurrence of tumor as a part of TURBT procedure. The medication will be kept in your bladder for almost an hour and it is drained afterwards.

  • Cystectomy surgery is performed to remove the whole bladder or a part of it. During partial cystectomy, the surgeon removes solely the part of your bladder containing a single tumor. Partial cystectomy can only be preferred if the cancer is limited with a single part of the bladder that can be removed without damaging the function of bladder.

Radical cystectomy is a procedure which is performed to remove the whole bladder, a part of ureters and surrounding lymph nodes. For male subjects, radical cystectomy frequently includes removal of prostate and seminal vesicles. For female subjects, it includes the removal of uterus, ovaries and a part of vagina.

Radical cystectomy can be performed with a single incision on pelvic region or with more than one small incisions using robotic surgery. The surgeon sits at a console nearby the operation area and uses hand controls to perfectly control the robotic surgery tools during robotic surgery.

Cystectomy has risk of bleeding and infection. For men, removal of prostate and seminal vesicle can cause erectile dysfunctions. However, your surgeon may preserve the nerves necessary for erection. For women, removal of ovaries causes infertility and early menopause.

  • Neobladder reconstruction. Following radical cystectomy, a new route should be created by your surgeon to empty out the urine (urinary diversion). The first choice for urinary diversion is to build a new urinary bladder.  Your surgeon creates a sphere-like chamber from a part of your intestine. This chamber is frequently called as neobladder, it stays inside your body and it is adherent to urethra. In most of the cases, the neobladder allow you to void normally. A low number of individuals with neobladder experience difficulty in emptying bladder and they may need to use catheter intermittently to empty the whole urine from neobladder.
  • Ileal conduit. For this type of urinary diversion, the surgeon creates a tube (ileal conduit) using a part of your intestine.  The tube passes the urine in your kidney through your ureters which have the duty of emptying, and empties it outside the body and into a sac (urostomy bag) you place on your abdomen.
  • Continent urinary diversion.  During this type of urinary diversion procedure, the surgeon uses a part of your intestine to create a small chamber (pouch) holding the urine inside your body. You drain the urine inside the pouch several times a day through an opening in your abdomen via catheter.

Chemotherapy

Chemotherapy means use of medication to kill cancer cells. In bladder cancer, chemotherapy generally includes a combination of two or more chemotherapy drugs.

Chemotherapy drugs can be given as follows:

  • Through a vein in your arm (intravenous)
  • Through a tube which is directly passed from your urethra to your bladder (intravesical therapy)

Chemotherapy is frequently used prior to cystectomy to increase the chance of treating the cancer.  Chemotherapy can also be used to destroy the cancer cells that might remain in body following the surgery. Sometimes chemotherapy can be used with radiation therapy as an alternative to surgery for selected cases.

Intravesical chemotherapy can be a primary therapy only for superficial bladder cancer which means that the cancer cells have solely affected the bladder wall and have not affected the deeper muscle tissue. Or sometimes, immunotherapy can be applied as a intravesical therapy for superficial bladder cancer.

Radiation therapy

Radiation therapy uses high-energy beams targeting the cancerous region to damage your cancer cells. In general, radiation therapy is given with a machine that moves around your body and sends the energy beams to meticulously identified points.

For selected cases, radiation therapy is combined with chemotherapy as an alternative to surgery or if surgery is not an option.

Immunotherapy

Immunotherapy (sometimes called as biological therapy) works by sending signals to immune system of body to help it fight against cancer cells.

In bladder cancer, immunotherapy is typlically applied to bladder directly through the urethra (intravesical therapy).  To treat the bladder cancer, one of the immunotherapy drugs used in treatment is Bacillus Calmette-Guerin (BCG) which is actually a bacterium used in tuberculosis vaccine.  One another immubotherapy drug is the synthetic form of interferon which is a protein produced by your immune system to help fighting against infections. This sythetic form, called interferon alpha-2b (Intron A) is sometimes used with BCG.

Atezolizumab (Tecentriq) is a new immunotherapy option for bladder cancer which do not response after chemotherapy or for locally advanced or metastatic bladder cancer. Intravenous (IV) drug works by triggering the immune system to attack to cancerous tumor. Atezolizuman is also studied as a possible initial therapy for people with urinary cancer who are not suitable for chemotherapy.

Bladder preservation

Urinary bladder can be preserved in some cases of muscle-invasive disease with use of three-prong treatment. Treatment approach known as trimodality therapy includes TURBT, chemotherapy and radiation therapy.

First of all, your surgeon practices a TURBT procedure to remove as much cancerous tissue as possible from your bladder by preserving the function of bladder. Following TURBT; you receive a chemotherapy regimen with radiation therapy which will be given within the first several weeks.

Unless all cancers are destroyed following trimodality treatment or if there is possibility of recurrence of muscle-invasive cancer, your surgeon may recommend radical cystectomy.

Upper urinary tract disease

This cancer (ureothelial cancer) which causes most of the urinary bladder cancers can develop in upper urinary system and affect the following:

  • Thin tubes draining the urine from your kidneys to bladder (ureters)
  • The region where urine accumulates before being drained to ureter (renal pelvis),
  • Other urinary tract structures where urine producing begins in deep parts of kidney

Similar to treatment of bladder cancer, treatment of upper urinary tract cancer depends on many factors such as size and location of cancer, your general status of health and preferences.

Treatment of upper urinary tract cancer generally includes a surgical intervention for removal of cancer and chemotherapy and radiation therapy as follow-up therapies to kill the cancer cells and prevent recurrence.

You may have only one functional kidney after the surgery if one of your kidneys should necessarily be removed. In case of this, your physician will probably recommend regular testing of renal to investigate the function of your remaining kidney.

Following treatment of bladder cancer

Bladder cancer can recur. Therefore, people with bladder cancer need follow-up tests for years after a successful therapy.  Types of tests and frequencies of them depend on type of bladder cancer and way of treatment alongside the other factors.

Ask your doctor to prepare a follow-up plan for you. Generally, doctors recommend a test examining the urethra and urinary bladder (cystosopy) to be performed at three or six-month intervals for the first several months after treatment of bladder cancer. After several months of observation without recurrence of cancer, you may need to present for cystoscopy examination only at annual intervals. Your doctor may recommend other tests at specific intervals.

Individuals with aggressive cancer may need to have tests at more frequent intervals. Individuals with less aggressive cancer may need to have tests at more rare intervals.