Cancer of the Bladder

In cancer of the bladder, certain harmful cells invade the bladder and destroy healthy cells, which cause the bladder not to function properly.

The bladder is a hollow organ that stores urine as it is filtered from the kidneys. The flexible bladder wall is made up of three layers, allowing the bladder to expand and contract as needed. Almost half of all newly diagnosed bladder cancers are found to have not spread past the epithelial lining, the innermost layer of the wall.

Bladder cancer is the fourth leading cause of new cancer cases in Canadian men, and is the 10th most common cause of new cancer among women. It is diagnosed more often in men as in women, and it is seen in Caucasians more often than in those of African descent.

Because of early diagnosis and better treatments, the mortality rates for this disease have been falling significantly over the last 25 years.

The actual cause of bladder cancer is unknown, but there are some proven risk factors. They include:

• smoking – smokers are twice as likely to develop bladder cancer than non-smokers
• chemical exposure – certain chemicals, such as those used in the following professions, can become concentrated in the urine, creating a risk factor for cancer:
• hairdressers
• painters
• textile workers
• dye, leather, and rubber workers
• race – Caucasians have a higher risk of developing this cancer than people of African descent; Asians have the lowest risk
• biological sex – men have a 4 times higher risk than women of developing bladder cancer
• age – over 90% cases of bladder cancer are diagnosed in people over the age of 55
• previous use of certain chemotherapy medications, such as cyclophosphamide* (often used in breast cancer and lymphoma treatment), can significantly increase the risk of later developing bladder cancer
• previous radiation to the pelvic area
• family or personal history of bladder cancer
• chronic irritation of the bladder (caused by long-term catheterization, or urinary tract infections)

The symptoms of bladder cancer are easily confused with those of a bladder or urinary tract infection, kidney stones, or prostate problems. They are:

• blood in the urine (most common)
• pain or burning sensation while urinating
• frequently urinating
• the feeling of not having emptied the bladder completely after urinating
• back pain
• pelvic pain

If any of these symptoms are present, it's important to get them checked by your doctor to get a diagnosis of what's causing the symptoms.

It is important to catch bladder cancer early. This increases the chance that treatment will be successful. Complications from bladder cancer occur more from the treatment (such as surgery) rather than the cancer itself. However, if the cancer is left untreated and allowed to grow, it will eventually cause even greater complications. Cancer that has spread from the bladder is more difficult to treat.

Complications from surgery depend on the type of surgery. If a partial cystectomy (removal of part of the bladder) takes place, the bladder can still collect urine, but will be quite a bit smaller. This means the person will have to urinate much more often. As well, cancer can return, and frequent checkups are necessary so that any cancerous cells can be found as early as possible.

After a radical cystectomy (removal of the entire bladder and prostate), there's no bladder to hold the urine, so another way to hold and eliminate urine must be made. In some cases, a new bladder can be created by using a small section of bowel tissue. This new bladder has to be regularly emptied manually, usually by using a tube or a catheter (a thin, flexible tube inserted into the body that permits the introduction or withdrawal of fluids).

Or, a urostomy may be necessary, in which a surgeon connects the ureters (tubes that drain the urine from the kidneys to the bladder) to the abdominal wall to create a stoma (opening). A plastic bag is externally attached to the stoma, acting like a bladder to collect urine. The bag must be emptied regularly.

Other complications from bladder cancer surgery may include infertility for women (if the uterus is removed), menopause (if the ovaries are removed), and possibly some sexual dysfunction if the vagina has been made smaller or shorter.

Men can also experience sexual dysfunction and infertility due to the removal of the prostate and the seminal vesicles (the glands that make semen).

To diagnose bladder cancer, your doctor will review your medical history, including information about past employment, possible exposure to chemicals, and lifestyle habits such as smoking. Your doctor will then do a physical exam and will probably perform a vaginal and/or rectal examination to rule out other possible causes of the symptoms.

Blood tests are done to check for kidney function, and urine is checked for blood or cancer cells. A type of test called cytology is used to evaluate the urine under a microscope, to look for cancer cells. Next, a cystoscopy is performed. A doctor inserts a thin tube called a cystoscope through the urethra (the tube that carries urine from the bladder to outside the body during urination) and into the bladder.

The cystoscope allows the doctor to look inside the bladder for any abnormalities, and to take a tiny sample of tissue (a biopsy), which will be checked for cancer cells. If you have a cystoscopy, your doctor may give you either a local or general anesthetic.

Once a diagnosis of cancer is made, the stage of the cancer (how far it has advanced) is determined. Some of the following tests might be done :

• CT or CAT scans (computed tomography) show any tumours or abnormalities in the urinary tract area (this includes the bladder, kidneys, urethra, and ureters).
• MRIs (magnetic resonance imaging), more sophisticated than CT scans, show any irregularities in the bladder or urinary tract area.
• IVP (intravenous pyelogram or intravenous pyelography) involves injection of dye into the bloodstream (which becomes concentrated in the urine), at which point X-rays are taken. The X-rays follow the urinary path and show any obstructions or abnormalities.
• Ultrasounds can be performed on the abdominal or pelvic regions to determine whether the bladder cancer has spread to any organs within these areas (e.g., the kidneys).
• Bone scans determine if the cancer has spread to the bones.
• Chest X-rays show if the cancer has spread to the lungs.

Like most cancers, bladder cancer can be treated by surgery, radiotherapy, chemotherapy, or a combination of therapies. The choice of treatment depends on the location and the staging of the cancer.

Surgery

When bladder cancer is caught early, a transurethral resection of all visible bladder tumour (TURBT) can be done. Using a cystoscope, the doctor uses a special tool to burn away the cancerous cells inside the bladder. The advantage of this treatment is that the bladder stays intact and people can still urinate normally after the procedure.

Surgery to remove the bladder is called a cystectomy. If the cancer has invaded through the bladder wall, or if it covers a large portion of the bladder, surgeons generally choose this surgery over TUR.

In women, removing the bladder usually involves also removing the uterus (hysterectomy), fallopian tubes, ovaries, and part of the vagina. If the woman is young, the ovaries might be left intact so that she won't have early menopause. For men, the prostate and the seminal vesicles (the glands that produce semen) must usually be removed along with the bladder.

Occasionally, an operation called a segmental cystectomy may be performed if the cancer is limited to a small part of the bladder wall. This surgery doesn't remove the entire bladder, so people can still urinate normally afterward.

Radiotherapy

There are two types of radiotherapy used to treat bladder cancer: internal and external.

External radiotherapy aims radiation directly at the cancer cells in the bladder. It may be done prior to surgery to shrink the size of the tumour, or after the surgery along with chemotherapy.

Internal radiotherapy is another type of radiotherapy that is less commonly performed for treating bladder cancer, but may remain an option for some individuals. This is done by inserting radiation implants directly into the bladder, and usually requires a hospital stay. Visitors might not be allowed – this is to avoid exposing them to the radiation coming from the person being treated. Once the implants are removed, no more radiation is released and the person can return home from the hospital.

The side effects of radiotherapy are usually temporary, and they include:

• fatigue
• red, dry skin at the radiation site
• nausea
• decreased appetite
• diarrhea
• vaginal dryness
• erectile difficulty

Chemotherapy

Chemotherapy can be used alone or in combination with surgery and/or radiotherapy. It's available as a general treatment (usually given intravenously) or a local one.

Local chemotherapy or immunotherapy (intravesical therapy) involves putting chemotherapy or certain other medications directly into the bladder for several hours at a time. The greatest advantage to intravesical treatment is that there are fewer side effects since the medications are not given systemically (throughout the body). This approach is usually reserved for superficial tumours removed during a cystoscopy, both to treat tiny amounts of tumour left behind or to prevent recurrence after successful removal.

General, or systemic, chemotherapy circulates throughout the body, so more of the body systems are affected by the treatment. This approach is used if the cancer has spread and can't be reached by the local (intravesical) approach.

Side effects from chemotherapy include:

• nausea and vomiting
• hair loss
• fatigue
• diarrhea
• mouth sores
• increased risk of infection

The prognosis (outlook) for bladder cancer is good. The sooner the cancer is discovered, the better the chances of survival. The five-year survival rate can be as high as 96% if the cancer has not spread beyond the inner layer of the bladder wall. However, this drops dramatically once the cancer has spread to other areas of the body.

If bladder cancer does return, it most often happens within the first year or two after treatment, so good follow-up is essential. This involves cystoscopies and urine tests at least every three months for a couple of years, then less frequent ongoing monitoring.

While some of the risk factors for bladder cancer can't be avoided (age and sex, for example), there are some precautions that can be taken to help avoid developing it. For those who work with high-risk chemicals, it's important to have urine tests as part of general annual physical examinations. Any unusual bladder symptoms should be checked by a doctor immediately.

Since smoking is a known risk factor for getting bladder cancer, smokers should try to quit or ask their doctor about ways to quit.

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