Bladder Cancer

Definition

Bladder cancer is a malignancy that occurs in the urinary bladder — a balloon-shaped organ in the pelvis that stores urine. Bladder cancer begins most often in the cells that line the inside of the bladder. It typically affects older adults, though it can occur at any age.

The majority of bladder cancers are diagnosed at an early stage — when it is highly treatable. However, even early-stage bladder cancer is likely to recur. For this reason, bladder cancer survivors often undergo follow-up screening tests for years after treatment.

Symptoms

Bladder cancer signs and symptoms may include:

  • Blood in urine (hematuria) — blood may appear bright red or tea- colored in the urine, or may appear in a microscopic examination of the urine. The blood often is present intermittently
  • Frequent urination
  • Painful urination
  • Urgent urination
  • Repeated urinary tract infection
  • Abdominal pain
  • Back pain

Risk Factors

  • Smoking. Bladder cancer occurs most often in cigarette smokers. Smoking increases the risk of bladder cancer by causing harmful chemicals known as carcinogens to accumulate in the urine and dwell in the bladder. These carcinogens may damage the lining of the bladder, eventually resulting in the development of cancer.
  • Chemical exposure. Kidneys play a key role in filtering harmful chemicals from the bloodstream and moving them into the urine. Because of this, it's thought that being around certain chemicals may increase the risk of bladder cancer. Chemicals linked to this form of cancer risk include arsenic and chemicals used in the manufacture of dyes, rubber, leather, textiles and paint products.
  • Chemotherapy and radiation therapy. Treatment with the anti-cancer drugs cyclophosphamide (Cytoxan) and ifosfamide (Ifex) increases risk of bladder cancer. Pelvic radiation therapy for cervical, rectal and prostate cancers is associated with an increased risk of subsequently developing bladder cancer.
  • Chronic bladder inflammation. Chronic or repeated urinary infections or inflammations (cystitis), such as may happen with long-term use of a urinary catheter, increase the risk of a squamous cell bladder cancer.
  • Personal or family history of cancer. If you have had bladder cancer once, you are likely to experience a recurrence. Cancer can recur in the kidneys, ureters, urethra or bladder. If one or more of your immediate relatives have a history of bladder cancer, you may have an increased risk of the disease, although it's rare for this form of cancer to run in families. A family history of hereditary nonpolyposis colorectal cancer (HNPCC), sometimes called Lynch syndrome, can increase your risk of cancer in your urinary system, as well as in your colon, uterus, ovaries and other organs.
  • Bladder birth defect. Rare birth defects of the bladder can increase your risk of adenocarcinoma of the bladder.
  • Age. Older adults are more likely to be diagnosed with bladder cancer. Bladder cancer diagnosis typically occurs in people 65 and older. People younger than 40 rarely get bladder cancer.
  • Race. Whites have a greater risk of bladder cancer than do people of other races.
  • Sex. Men are more likely to develop bladder cancer than women are.

Diagnostic Tests

  • Using a scope to see inside the bladder. During cystoscopy, the urologist inserts a narrow tube (cystoscope) through the urethra. The flexible cystoscope has a lens and fiber-optic lighting system, allowing the doctor to see the inside of your urethra and bladder. This examination is routinely performed in a specialized procedure room in the urologist’s office. A local/topical anesthetic is typically applied to the urethra to make the examination more comfortable.
  • Removing suspicious cells for testing. During a procedure similar to cystoscopy, the doctor removes a small tissue sample (biopsy) for testing. If a larger volume of tissue is removed, the procedure is referred to as transurethral resection of bladder tumor (TURBT). TURBT is usually performed under general anesthesia in a hospital or surgery center.
  • Testing your urine for cancer cells. A sample of urine is analyzed under a microscope by a pathologist to check for cancer cells in a procedure called urine cytology.
  • Imaging tests. Imaging tests allow non-invasive examination of the urinary tract. Intravenous pyelogram (IVP) is a type of X-ray imaging test that uses a dye to highlight the kidneys, ureters and bladder. Computerized tomography (CT) scan is a type of imaging test evaluates the urinary tract as well as the surrounding organs and tissues.

Bladder Cancer Stages

If the presence of bladder has been confirmed by biopsy, additional tests might be necessary to determine the extent, or stage, of the cancer. Staging tests may include:

  • CT scan
  • Magnetic resonance imaging (MRI)
  • Bone scan
  • Chest X-ray

The stages of bladder cancer are:

  • Stage Ta. Cancer at this stage involves only the most superficial layer of the bladder's inner lining, called the mucosa.
  • CIS (carcinoma in situ): This is a superficial but high-grade variety of bladder cancer. Though initially non-invasive, CIS has a greater tendency to spread.
  • Stage T1. Cancer cells have penetrated one layer deeper into the lamina propria.
  • Stage T2. At this stage, cancer has invaded the bladder muscle wall.
  • Stage T3. The cancer cells have spread through the bladder wall to surrounding tissues.
  • Stage T4. By this stage, cancer cells have spread into other neighboring other organs, such as the prostate gland, uterus, or vagina.
  • Metastatic Disease. cancer cells have spread through the blood stream and are growing in lymph nodes, liver, lungs, etc

Bladder Cancer Treatments

Surgical Procedures

  • Transurethral resection of bladder tumor (TURBT) is the initial treatment of most bladder cancers. During TURBT, the doctor passes an endoscope through the urethra into the bladder. A specialized cutting loop is used to carefully remove the cancer cells as well a margin of underlying bladder muscle. Often, a bladder catheter is placed to keep the bladder decompressed for several days post-operatively. Following this surgery, common symptoms include painful or bloody urination for a few days.

    TURBT is the principal surgical approach for non-invasive bladder cancers (stages Ta, T1, and CIS)
  • Surgery to remove the tumor and a small portion of the bladder (Partial Cystectomy). During partial cystectomy the surgeon removes only the portion of the bladder that contains cancer cells. This might be an option if the cancer is limited to one area of the bladder that can easily be removed without harming bladder function. Partial cystectomy can be performed by an open surgical approach through an abdominal incision or by a robotic-laparoscopic approach through keyhole incisions. Surgery carries a risk of bleeding and infection. More frequent urination is common after partial cystectomy, since the operation reduces the size of urinary bladder.
  • Surgery to remove the entire bladder (Radical Cystectomy). A radical cystectomy is an operation to remove the entire bladder, as well as surrounding lymph nodes. In men, radical cystectomy typically includes removal of the prostate and seminal vesicles. In women, radical cystectomy involves removal of the uterus, ovaries and part of the vagina. Similar to partial cystectomy, radical cystectomy can be performed by an open surgical approach through an abdominal incision or by a robotic-laparoscopic approach through keyhole incisions.
  • Urinary Diversion

    Immediately after radical cystectomy, the surgeon creates a new route for urine to exit the body, known as a urinary diversion. Several options exist. Which option is best depends on the type of cancer as well as the patient’s health and preferences.

    The simplest type of urinary diversion is a urinary loop or conduit: the ureters are connected to one end of a segment of intestine; the opposite end of intestine is connected to the abdominal wall, creating a stoma, where urine drains into a synthetic pouch (urostomy bag) attached to the abdominal wall.

    A second type of urinary diversion is a cutaneous continent urinary diversion. A segment of intestine is used to create an internal reservoir to store the urine. The urine is drained several times per day by inserting a flexible catheter through a small abdominal stoma.

    The third type of urinary diversion is a continent neobladder. A segment of intestine is used to create a bladder-like reservoir. This reservoir is attached to the urethra. Many patients with neobladders can urinate fairly normally. Some other patients need to insert a catheter through the urethra to drain the urine from the neobladder bladder.

    The surgeons of Central Bucks Urology have performed hundreds of cystectomies and offer their patients all three types of urinary diversion.

Immunotherapy

Immunotherapy works by signaling your body's immune system to help fight cancer cells. Immunotherapy for bladder cancer is administered through the urethra and directly into the bladder (intravesical therapy).

The most effective immunotherapy agent is Bacillus Calmette-Guerin (BCG). BCG is a bacterium used in tuberculosis vaccines. BCG can cause bladder irritation and blood in your urine. Some people feel as if they have the flu after treatment with BCG.

An interferon is a type of cell your body uses to fight infections. A synthetic version of interferon, called interferon alfa, may be used to treat bladder cancer. Interferon alfa is sometimes used in combination with BCG. Interferon alfa can cause flu-like symptoms.

Immunotherapy can be administered beginning 2-3 weeks after TURBT to reduce the risk that cancer will recur or progress.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. Chemotherapy treatment for bladder cancer usually involves two or more chemotherapy drugs used in combination. Drugs can be given through a vein in your arm (intravenously), or they can be administered directly to your bladder by passing through your urethra (intravesical therapy).

Intravesical chemotherapy is used to treat non-invasive bladder cancers.

Systemic chemotherapy is used to treat muscle-invasive or metastatic bladder cancers. Chemotherapy may be used to kill cancer cells that might remain after an operation. It may also be used before surgery. In this case, chemotherapy may shrink a tumor enough to allow the surgeon to perform a less invasive surgery. Chemotherapy is sometimes combined with radiation therapy.

Radiation therapy

Radiation therapy uses high-energy beams aimed at your cancer to destroy the cancer cells. Radiation therapy can come from a machine outside your body (external beam radiation) or it can come from a device placed inside your bladder (brachytherapy).

Radiation therapy may be used before surgery to shrink a tumor so that it can more easily be removed with surgery. Radiation therapy can also be used after surgery to kill cancer cells that might remain. Radiation therapy is sometimes combined with chemotherapy.

Surveillance

Bladder cancer often recurs. Because of this, bladder cancer survivors undergo follow-up testing for years after successful treatment.

What types of tests are used to screen for bladder cancer recurrence?

Cystoscopy, cytology, bladder biopsy and urine-DNA tests are the principal tools used in bladder cancer surveillance.

How often should you undergo screening for bladder cancer recurrence?
In general, doctors recommend cystoscopy screening every three months for the first year, every four months during the second year and every six months during the third year after initial diagnosis and treatment. Patients with aggressive cancers may undergo more frequent screening. Those with less aggressive cancers may undergo screening tests less often.

How can you prevent a bladder cancer recurrence?

Doctors don't yet know a reliable way to prevent bladder cancer recurrence. Talk to your doctor about ways to reduce your risk, such as:

  • Stopping smoking. Ask your doctor about strategies to help you quit smoking. Support programs and medications can help.
  • Increasing your intake of antioxidant vitamins. Some studies suggest that large amounts of certain vitamins may reduce the risk of recurrent bladder cancer in some people. But not enough study has been done to recommend taking big doses of antioxidants in pill form. In fact, large doses of vitamin supplements could be harmful. A safe way to increase your antioxidant intake is to increase fruits and vegetables in your diet. Talk to your doctor about other ways to get more vitamins.

Although there's no guaranteed way to prevent bladder cancer, you can take steps to help reduce your risk. For instance:

  • Don't smoke. Not smoking means that cancer-causing chemicals in smoke can't collect in your bladder. If you don't smoke, don't start. If you smoke, talk to your doctor about a plan to help you quit. Support groups, medications and other methods may help you quit.
  • Take caution with chemicals. If you work with chemicals, follow all safety instructions to avoid exposure.
  • Have your well tested for arsenic. If you have your own well, consider having it tested for high levels of arsenic in the water.
  • Drink plenty of fluids. Drinking liquids, especially water, dilutes toxic substances that may be concentrated in your urine and flushes them out of your bladder more quickly.
  • Eat your fruits and vegetables. Choose a diet rich in a variety of colorful fruits and vegetables. The antioxidants in fruits and vegetables may help reduce your risk of cancer.

Alternative Medicine

  • No complementary or alternative bladder cancer treatments have been found to cure bladder cancer. But doctors are studying ways to prevent it, including some complementary and alternative approaches. If you're worried about your risk of bladder cancer or that your cancer could recur, you may be interested in trying complementary and alternative treatments. Talk to your doctor about your options.
  • Vitamins
    Fruits and vegetables are the safest way to get your vitamins. Some research suggests larger doses of certain vitamins, such as vitamin E, in pill form may help reduce the risk of bladder cancer. But other studies haven't found this.
  • More study is needed to understand what dose is safest and most effective. Until then, focus on eating a wide variety of fruits and vegetables that are rich in vitamins. If you're interested in vitamin supplements, ask your doctor about what doses may be reasonable.
  • Green tea
    Drinking green tea has been linked to many health benefits. But whether it can reduce the risk of bladder cancer isn't clear. Animal studies have shown promise, but studies in humans have been mixed. For example, one study showed that people who drink the most green tea have a reduced risk of bladder cancer, while another study found that drinking green tea over many years increased the risk of bladder cancer. More study is needed to understand whether green tea is helpful or harmful when it comes to preventing this form of cancer.

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