Bladder Cancer

What is Bladder Cancer?

Bladder cancer is the sixth most common cancer in the United States. For the year 2013 it is estimated that 72,570 Americans will be diagnosed with bladder cancer and 15,210 will die of the disease. In recent decades there has been a steady increase in the incidence of bladder cancer. However, doctors are making progress in treatment, and survival rates are improving.

What are the symptoms?

Blood in the urine (hematuria) is the most common symptom. It eventually occurs in nearly all cases of bladder cancer and is generally described as “painless”. Although the blood may be visible during urination, in most cases, it is invisible except under a microscope. In these, the blood is usually discovered when analyzing a urine sample as part of a routine examination. Blood in the urine, similar to blood in the stool or coughing up blood, is a potential warning sign of cancer, and should not be ignored.

Hematuria does not by itself indicate or confirm the presence of bladder cancer. Blood in the urine has many possible causes. For example, it may result from a urinary tract infection or kidney stones rather than from cancer. It is important to note that hematuria, particularly microscopic, might be entirely normal for some individuals. A diagnostic investigation is necessary to determine whether bladder cancer is present. Other symptoms of bladder cancer may include frequent urination and pain upon urination (dysuria). Such “irritative” symptoms are less common. When present in the absence of a urinary infection (which may have similar or identical symptoms) exclusion of a bladder cancer as the possible cause is mandatory.

Can you prevent bladder cancer?

Healthy lifestyle and tobacco cessation

What causes bladder cancer?

Smokers develop bladder cancer at two to three times the rate of non-smokers. People who work with dyes, metal, paints, leather, textile and organic chemicals may be at a higher risk. People who have chronic bladder infections may also be at higher risk.

How is bladder Cancer diagnosed?

The diagnostic investigation begins with a thorough medical history and a physical examination. The doctor will ask the patient about past exposure to known causes of bladder cancer, such as cigarette smoke (either through personal smoking or through “second-hand” smoke) or chemicals. Also, because hematuria can come from anywhere in the urinary tract, the doctor typically order radiological imaging of the kidneys, ureter and bladder to check for problems in these organs. Diagnostic tools to check for bladder cancer include various types of urinalysis. In one type, the urine is examined under a microscope to look for cancer cells that may have been shed into the urine from the bladder lining (urinary cytology). Urine cytology is analogous to a Pap Smear, in this case looking for cancer cells that are sloughed off in the urine. Urine can also be tested for substances known to be closely associated with cancer cells (tumor markers).

The urologist’s most important diagnostic tool is cystoscopy, which is a procedure that allows direct viewing of the inside of the bladder. This is most commonly performed as an office procedure under local anesthesia or light sedation. First, a topical anesthetic gel is applied, so the patient will feel little or no discomfort. The doctor then inserts a viewing instrument called a cystoscope through the urethra and into the bladder. Looking through the cystoscope, the doctor is able to examine the bladder’s inner surfaces for signs of cancer. Modern cystoscopes are soft and flexible, and this procedure is generally well tolerated.

If tumors are present, the doctor notes their appearance, number, location and size. As removal (resection) of the tumors cannot usually be done under local anesthesia, the patient is then scheduled to return for a surgical procedure to remove the tumor under general anesthesia or spinal anesthesia. In a manner as before, the doctor inserts an instrument, called a resectoscope, into the bladder. This is a viewing instrument similar to the cystoscope, but contains a wire loop at the end for removing tissue. This procedure is done through the urethra and is called a transurethral resection of bladder tumors. The removed tissue is sent to a pathologist for examination. Pathologists are specialists who interpret changes in body tissues caused by disease.

In addition to removing visible tumors, the doctor may remove very small samples of tissue of any suspicious-looking areas of the bladder. A pathologist also examines this tissue.

If a biopsy is taken and bladder cancer is found, the pathologist who examines the tissue will grade the tumor according to how angry the cells appear. The most widely used grading systems classify tumors into two main grades: low and high. The cells of low-grade tumors have minimal abnormalities. In high-grade tumors, the cells have become disorganized and many abnormalities are apparent. The grade indicates the tumor’s “aggression level”—how fast it is likely to grow and spread. High-grade tumors are the most aggressive and the most likely to progress into the muscle.

How is it treated?

Transurethral resection of the bladder (TURBT) is the usual treatment method for patients who, when examined with a cystoscope, are found to have abnormal growths on the urothelium. Alternative methods, such as laser therapy, compare favorably with TURBT in terms of treatment results. However, TURBT has the major advantage of providing tissue suitable for a pathologist to use in determining a tumor’s grade and stage. The tumor structure is left too distorted for this purpose after the alternative treatment methods, so biopsies of the tumor must be taken before treatment.

Following removal for non-invasive tumors, intravesical chemotherapy or intravesical immunotherapy may be used to try to prevent tumor recurrences. Intravesical means “within the bladder”. These therapeutic agents are put directly into the bladder through a catheter in the urethra (the catheter only stays in for a few minutes), are retained for one to two hours and are then urinated out.
The chief intravesical agents currently available is mitomycin C and bacillus Calmette-Guerin (BCG). Both agents have some benefits and risks. Among the benefits: Comparison studies have shown to be superior to TURBT alone for preventing tumor recurrences following TURBT. Studies have also shown both BCG and mitomycin C are superior for reducing recurrence of T1 tumors and high-grade Ta tumors. However, there is no absolute evidence that any intravesical therapy affects the rate of progression to muscle-invasive disease although some studies with BCG suggest this may be the case.

Among the risks: Irritative side effects such as painful urination and the need to urinate frequently. In addition, BCG therapy carries a 24 percent risk of flu-like symptoms and a small risk (4 percent) of systemic infections.

Recent studies have indicated a possible benefit of reducing recurrences by instilling these chemicals into the bladder immediately following resection of a bladder tumor, typically in the recovery room. BCG is not used in this way because of the risk that it might be absorbed into the bloodstream in this setting.
Once the grade and stage of the tumor has been determined, the urologist may decide to initiate a course of intravesical therapy with these agents. In general, six weekly treatments are given, in which a catheter is placed in the bladder, the medication is instilled, the catheter is removed, and the patient is instructed not to urinate for at least an hour.

Once the bladder has been assessed as free of disease at the first three month post-treatment cystoscopic inspection, many physicians consider it appropriate to apply additional treatments of these same drugs to forestall or prevent future recurrences. Whether additional treatments are given or not, periodic cystoscopies are required to detect tumor recurrence early, if it is going to develop. During the first one to two years surveillance is carried out on a quarterly basis but then can gradually be reduced to twice and eventually even once per year thereafter.

For invasive bladder cancer (muscle-invasion), the gold standard treatment is removal of the bladder (as well as prostate in men and often uterus/ovaries in women) called cystectomy. This operation can be performed both through an open incision and laparoscopically or with robotic assistance. Cystectomy also involves creating a “new” bladder to allow drainage of urine out of the body. Urinary diversion can be performed in several ways including continuous drainage via ileal conduit and continent reservoirs (neobladder).

Check here for more information regarding robotic surgery for bladder cancer

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