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Bladder Cancer
Bladder cancer is a malignant tumor growth within the bladder. Bladder cancers usually arise from the cells lining the bladder known as transitional cells. These tumors may be classified based on their growth pattern as either papillary tumors (meaning they have a wart-like lesion attached to a stalk) or nonpapillary tumors (solid lesions with a broad base). Nonpapillary tumors are much less common (10%) but they tend to be more invasive.
Causes, incidence, and risk factors:
As with most other cancers, the exact cause is uncertain. However, several factors may contribute to the development of bladder cancer. Cigarette smoking has been shown to increase the risk of developing bladder cancer, with smokers having a four-fold increased risk when compared to non-smokers. Also, the risk of developing bladder cancer does show a gradual decline in individuals who quit smoking.
Studies show that one in four cases of bladder cancer can be attributed to industrial exposure to known carcinogens. People at increased risk due to industrial exposure include textile workers, painters, hair-dressers, and people who work with in the leather, metal, or rubber industry.
Some studies indicate that there may be a link between high doses of the artificial sweetener saccharin and transitional cell bladder cancer. Results of these studies have lead to the removal of saccharin from the market.
Women who received radiation therapy for the treatment of cervical cancer have a fourfold increased risk of developing transitional cell bladder cancer. Additionally, people who received the chemotherapy drug, cyclophosphamide (Cytoxan) may have a nine times greater risk of developing bladder cancer.
Chronic (long term) bladder infection or irritation may lead to the development of a unique type of bladder cancer known as squamous cell bladder cancer. Typically this takes years of inflammation (over 10 years) to develop into cancer.
Bladder cancer rarely occurs in people under 40 years of age. Bladder cancer occurs more frequently in the United States and England. Also, within the United States, people who live in the northern half of the country have higher rates of bladder cancer than those in the lower states.
Grade
Grade indicates the cellular aggressiveness of the tumor as defined by a pathologist. Once a tumor is biopsied, a patholgist examines the tissue assigned a standard grading system.
- G1 - low grade, well-differentiated
- G2 - moderate grade, moderately-differentiated
- G3 - high grade, poorly-differentiated
Stage
The stage of the tumor describes the location and extent of tumor involvement in the body. Typically, the TNM staging system is used. The T stands for the tumor involvement in the organ from which it developed. The N stands for lymph node involvement. The M stands for metastatsis, or spread to other organs. If bladder cancer spreads, it will typically spread to lymph nodes, the lung, liver, and bone.
- T - Tumor involvement in the bladder
- T0 - no evidence of tumor
- Ta - no-invasive tumor (mucosa surface layer only)
- Tis - carcinoma in situ (high grade cancer involving surface layer only)
- T1 - tumor involves subepithelial connective tissue layer (middle layer)
- T2 - tumor involves the muscle layer of bladder (deepest layer)
- T3 - tumor involves the fatty tissue outside bladder wall
- T4 - tumor invades local structures (prostate, vagina, pelvic wall)
- N - lymph node involvement
- N0 - no lymph node involvement
- N1 - tumor involves a single lymph node < 2cm size
- N2 - tumor involves a lymph node > 2cm or multiple lymph nodes
- M - distant organ involvement
- M0 - no evidence of distant organ involvement
- M1 - evidence of distant organ involvement
Symptoms
It is important to note that bladder cancer can exist without any of the symptoms listed below, although it is certainly more common to have one or more symptoms. Additionally, the presence of these symptoms does not necessarily indicate the presence of cancer.
- urinary urgency (precipitous need to urinate)
- urinary frequency (voiding more frequently than every 2 hours)
- painful urination
- hematuria (blood in the urine)
- bladder pain
Additional symptoms that may be associated with this disease:
- urinary incontinence (involuntary loss of bladder control)
- bone pain or tenderness
- abdominal pain
- anemia (low blood count)
- weight loss
- lethargy (tiredness)
Diagnosis
It is very important to seek medical attention if you have the signs or symptoms of bladder cancer listed above. Often, your primary doctor will refer you to a Urologist. A detailed history and physical examination will be performed, including a rectal and pelvic exam.
Diagnostic tests that may be performed include:
Office Tests:
- urinalysis - examination of urine by dipstick or by microscopic exam
- urine cytology test - microscopic exam of urine to look for cancerous cells
- blood work - to check renal function, blood count
X-ray tests
- Intravenous pyelogram (IVP) - to evaluate upper urinary tract (kidneys and ureters) for tumors or blockage
- CT scan (abdomen and pelvis) - to screen for and determine extent of disease, including involvement of bladder, lymph nodes, kidneys, and other intra-abdominal organs
- Bone scan - to determine if the cancer has spread to the bone
- Chest x-ray or Chest CT scan - to determine if cancer has spread to lungs
Hospital/Outpatient Surgical Procedures
- cystoscopy - use of lighted instrument to view inside of bladder
- bladder biopsy - usually performed during cystoscopy, which consists of taking a sample of tissue from the bladder (while the patient is asleep) to test for cancer
- transurethral resection of bladder tumor (TURBT) - this is a more extensive biopsy in which an attempt is made to remove all visible tumor from the bladder
Treatment:
The choice of an appropriate treatment is based on the grade and stage of the tumor, the severity of the symptoms, and the presence of other medical conditions. Generally, 70% or more of bladder cancers are limited to the surface (mucosa, stage Ta) or the layer just below the surface (lamina propria, T1). Treatment for these tumors is based on their likelihood of recurrence and progression.
Recurrence is when a tumor comes back in the bladder at a later date, often in another part of the bladder. Progression is recurrence of tumor with deeper involvement in the bladder wall with a more aggressive behavior. Unlike other cancers, bladder tumors have an unusual propensity to recur, likely due to the precancerous and cancerous changes that occur throughout the entire lining of the bladder.
Ta, Cis, T1 disease
Treatment of Stage Ta, Cis, or T1 disease initially consists of tumor resection (removal) through a scope. Follow-up cystoscopies (scope tests) are a mandatory part of treatment. In general, the higher the grade and higher the stage, the more likely the tumor will recur or progress. Certain medicines (BCG, interferon, thiotepa, mitomycin, adriamycin, gemzar) may be placed into the bladder and are used to decrease the likelihood of tumor recurrence and progression. The decision regarding whether to treat a patient with intravesical instillations (bladder treatments with medicine) is based on the grade, stage, number, and recurrent nature of the tumors.
When administering intravesical therapy a nurse will first check the patient's urine to make sure no infection is present. Then, medicine is administered through a catheter into the bladder. The patient holds the medicine in his or her bladder for up to 2 hours, and then voids the medicine out. The medicine reacts with the bladder to stimulate the patients own immune system to fight the cancer and cancer recurrence. Typically, these treatments are given weekly for a 4-8 week "induction" period. The induction treatments may be followed by a series of "booster" treatments which are usually given every 3 months for up to 2 years. While the specific treatment regimen and specific type of therapy will vary from physician to physician, the goal is to reduce the recurrence rate and progression of the tumor.
Side effects of these treatments include urinary frequency, urgency, and dysuria (urinary burning). In some instances, low grade fevers or flu-like symptoms may develop. These symptoms are typically self-limited and resolve within 24 to 48 hours. High fevers, chills, bloody urine, or side effects which persist for more the 48 hours should be reported to your physician. Specific instruction sheets can be obtained from the office staff at The Urology Center.
T2, T3 disease
The treatment for Stage T2 or greater tumors generally involves more aggressive therapy. These tumors have a greater capacity to grow locally and potentially spread to other areas of the body (metastasis). Treatment for Stage T2 and some T3 lesions include surgical removal of the bladder or a combination of radiation therapy and chemotherapy.
Surgical removal of the bladder (radical cystectomy) and lymph nodes (lymphadenectomy) remains the treatment of choice for patients with potentially curable disease, and who are appropriate medical candidates for the procedure. For men, this involves removal of the prostate and bladder. For women, this involves removal of the ovaries, uterus, bladder, and possibly a portion of the top part of the vagina. This is a major operation and hospital stays generally range from 4 to 6 days. In some instances, chemotherapy may be administered for several months before removal of the bladder (called neoadjuvant treatment) in order to improve long-term results.
Once the bladder is removed, the bowel is utilized to collect urine and remove it from the body. Several methods of urinary diversion have been developed. Probably the most common type is when the urine is diverted to a short piece of bowel (ileal conduit) which is brought to the skin. An appliance (plastic drainage pouch) fits over the area where the bowel meets the skin (stoma). Typically, the appliance is changed every 3 to 5 days. Alternatively, an internal pouch (continent diversion) made of bowel can be used for selected patients who would prefer not to have an external collection device. This internal pouch is also made of bowel but must be connected to the urethra or be brought to the skin. If brought to the skin, the patient can drain the bladder intermittently with a small catheter. While the procedure of continent urinary diversion is more complicated in terms of the operation and recovery, many patients find it is well worth the effort in terms of quality of life. Please see section on urinary diversion for additional information.
Chemotherapy and radiation therapy have been used with success in patients with invasive bladder cancer (Stages T2 and T3). Long term survival rates have improved and are closer to approaching that of surgery. Typically 6 to 8 weeks of radiation are combined with 2 to 4 cycles of chemotherapy. Chemotherapy regimens vary, but each cycle typically lasts 2 to 4 weeks.
T4, or any T Stage with lymph nodes involvement or spread to other organs
Advanced disease includes bladder cancer which has spread to adjacent organs, distant organs, or lymph nodes. This stage of bladder cancer is generally not curable by surgical removal. In these circumstances, chemotherapy with or without radiation is administered (if appropriate).
Chemotherapy, which is given in cycles generally lasting 2 to 4 weeks, treats bladder cancer in all areas of the body. Responses are measured by results of X-rays done after therapy and compared to those taken before the therapy. Typical chemotherapeutic agents used in the treatment of bladder cancer include methotrexate, vinblastine, doxorubicin, cisplatin, carboplatin, gemcitabine, ifosfamide, taxol, and taxotere. The most common combinations are MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) and cisplatin plus gemcitabine. Different combinations of therapy are given based on a patient's age, medical condition, and degree of tumor burden.
Support groups
The stress of illness can often be helped by joining a support group where members share common experiences and problems. Because bladder cancer is not as common as other types of cancer, it may be difficult to find local support groups specific for bladder cancer. General cancer support groups are helpful in this situation.
Prevention
Eliminating known carcinogenic agents (cigarette smoking and environmental hazards) may reduce your risk of developing bladder cancer. Since carcinogens such as smoking have a cumulative effect, it is important to stop smoking as soon as possible. This is important even after the diagnosis is made as it may impact likelihood of recurrence or progression of the disease.
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