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Bladder Cancer

Table of Contents

  1. Introduction to Bladder Cancer
  2. Signs and Symptoms
  3. Causes and Risk Factors
  4. Diagnosis
  5. Grading and Staging
  6. Treatment

Introduction to Bladder Cancer

The bladder, a part of the urinary system, is a sac-like organ. It functions to temporarily hold the urine before it leaves the body. There is a pair of tubes called ureters that transit the urine from each kidney to the bladder. As the bladder gradually fills up, the urine is finally made to leave the body via another tube called the urethra.

The bladder is made up of muscle, which is internally lined by a special layer of cells, solely found in the urinary system. This layer is known as the urothelium or transitional cell epithelium.

What is Cancer?

Cancer occurs when cells in the body grow abnormally and uncontrollably, forming a mass or lump. These masses of abnormal cells are often referred to as tumors. Some tumors grow very rapidly while others rather slowly. It is possible for someone to either have one or multiple types of tumors at a time. Not all tumors are dangerous and only those that get malignant and impose serious health issues, are called cancers.

What is Bladder Cancer?

The term bladder cancer is commonly used to describe cancers that appear in the urothelium (internal lining of the bladder), thus also called urothelial carcinomas or transitional cell carcinomas. Some other types such as squamous cell carcinoma and adenocarcinoma are also there but they are quite uncommon.

When urothelial carcinomas get aggressive, they grow very rapidly and may invade the bladder muscle (muscle-invasive bladder cancer – MIBC) or even the tissues and organs lying nearby in the pelvis. In contrast, when they are slow-growing and confined to the inner lining, they are termed as non-muscle-invasive bladder cancer (NMIBC).

Sometimes, cancer cells enter the lymph nodes resting around the bladder leading to its spread to distant organs of the body like lungs, liver, etc. This phenomenon is referred to as metastasis.

Key Statistics Regarding Bladder Cancer:

  • Bladder cancer is the 9th most common type of cancer and 13th most common cause of cancer-related deaths worldwide.1
  • Its incidence increases with age.1
  • It is the fourth most common cancer among men and affects males three times more often than females.2
  • Caucasians living in developed countries form the most affected group.1,2
  • Most of the bladder cancers are transitional cell carcinomas.2

Signs and Symptoms of Bladder Cancer

There are a variety of ways in which our body may warn us about the presence of bladder cancer. Some of them are more specific than the others and should not be ignored. However, in some cases, there may not be any symptoms at all.

The most common symptoms include:

  • Blood in urine
  • Having a frequent urge to urinate
  • Pain or burning sensation while urinating
  • Pain in the lower abdomen
  • Backache

What Should Not be Ignored

Blood in the urine is the most important sign of bladder cancer, 1 hence, requires urgent medical attention. Most of the time it is not associated with pain. It is best to talk to your doctor when you notice blood in urine, who might refer you to a urologist (someone who specializes in the diseases of the urinary system and male genital tract). There are numerous other conditions which may cause blood to appear in urine like kidney stones or urinary tract infections, it is important to exclude these conditions before a diagnosis of bladder cancer is made.

Other symptoms like painful and frequent urination are less likely to be a result of bladder cancer and mostly point towards urinary tract infections.

It is always better to talk to your doctor if you are feeling any of these symptoms to avoid any adverse outcomes.

Causes and Risk Factors

The causes of bladder cancer can be either environmental or familial, though if they exist together, the risk of bladder cancer increases substantially.3

  • Smoking

Smoking is the most important risk factor for bladder cancer.4 The duration and frequency of smoking also casts massive impact and almost half of bladder cancer patients are found to be smokers.4

  • Workplace Exposure

Exposure to certain chemicals like the ones used in rubber and plastic industries puts workers at a massive risk of getting bladder cancer in the future. Some drugs like cyclophosphamide or radiation therapies directed at the pelvis to treat some other malignancies can also augment the chances of getting bladder cancer.

  • Parasitic Infections

Studies have proven that in areas where chronic infection with Schistosoma haematobium is common, people are more likely to get bladder cancer.5

Diagnosis of Bladder Cancer

The process of establishing a diagnosis begins with a detailed medical history followed by a physical examination. If your doctor suspects something, a range of tests can be conducted to confirm the diagnosis of bladder cancer.

Your doctor may order any of the following tests:

  • Urinalysis:  It is conducted to check the appearance, concentration, and contents of the urine.
  • Urine cytology: This test looks for the presence of abnormal cells in the urine by observing the sample under a microscope.6
  • Blood Tests: These include tests like complete blood count (CBC), enzyme markers, kidney, and liver function tests.
  • CT Scan:  This is an imaging test, which can show any mass residing locally in the bladder, its invasion of the surrounding tissues and distant metastases.7
  • Flexible Cystoscopy: In this, a narrow tube is inserted inside your bladder through the urethra, which has a light source and camera attached to its far end (cystoscope). It allows the doctor to look inside your bladder for any gross pathology. The tube is flexible and the test is performed under local anesthesia to avoid any discomfort to the patient. 6
  • Rigid Cystoscopy:  In this case, the cystoscope used is non-flexible and much more advanced. It allows surgical instruments to pass through it thus your doctor may also perform a few procedures using this tool e.g. transurethral resection of bladder tumors (TURBT).

This procedure is confirmatory to diagnose bladder cancer, 8 and is also used to assess its stage and spread.

  • Retrograde Pyelogram:  it is an X-ray based test. The doctor injects a dye in your bladder through a catheter that goes in via urethra so that they can observe the internal lining of the bladder. Any tumors if present might show up in the X-ray image.

Grading and Staging of the Bladder Cancer

Grading and staging often go hand in hand when it comes to diagnosing how aggressive the tumor is.

Grading of the Cancer:

When the tumor sample (biopsy), taken via TURBT, is sent to the lab to confirm the diagnosis, the cells are viewed under the microscope to identify exactly how abnormal they are. The more abnormal and aberrant the cells are, the more likely it is for the tumor to grow more and spread to distant sites. This is called grading the tumor. Tumors can be high-grade, which means they are aggressive and can recur or low-grade meaning they are benign and not that serious.

Staging of the Cancer:

Staging primarily gives an idea about the spread of the tumor, whether it is confined to the urothelium or has penetrated through underlying muscles and into the surrounding structures. 

The stages of bladder cancer are:

  • Ta: Tumor is restricted to the urothelium.
  • Tis: Tumor is high-grade but confined to the urothelium.
  • T1: Tumor has spread beyond urothelium but has not reached the muscle layer yet.
  • T2: Tumor has invaded the bladder muscle.
  • T3: Tumor has penetrated through bladder muscle, invading surrounding tissues, usually fat.
  • T4: Tumor has invaded surrounding organs in the pelvis like the prostate in men and vagina in females.

Treatment of Bladder Cancer

Various treatment modalities are available to treat bladder cancer. Factors like the spread of cancer, patient age, grade, and stage of tumor often determine the treatment of choice.

An increasingly high number of patients now wants to avoid long hospital stays and to get back to their routine as soon as possible. In some cases, it is possible due to the presence of Ambulatory Surgical Centers. Outpatient surgery is performed at these centers, which means there is no need for hospital admission prior to surgery or even after it. Patients are discharged on the same day, which helps avoid the unnecessary hassle of staying at the hospital and the expenses also drop significantly, making the surgery more pocket friendly.

Although not all surgeries can be performed this way and only your surgeon can tell, if you are eligible for one.

Options for Treatment

  • TURBT – This method uses a rigid cystoscope so no incision is made. The patient is kept under general anesthesia and the doctor resects the tumor using surgical instruments that are passed through the scope. Tumor resection can be done completely and any other areas of urothelium that the surgeon finds abnormal could also be removed. You are left with a Foley’s catheter in your bladder after the surgery that spares time for your bladder to heal. You may need more than one session of TURBT to get rid of all the tumors. It is one of those surgeries that can be performed at an ambulatory surgery center.
  • Intravesical Chemotherapy – The term “intravesical” means inside the bladder. Drugs that can kill cancer cells are placed directly inside the bladder, which helps avoid the systemic side effects associated with their injection in the bloodstream. The drug stays in there for a few hours before the patient passes them out in the urine. This option is only recommended if the tumor is restricted to the urothelium. It may also be given after surgery in order to decrease the risk of recurrence.9
  • Intravesical Immunotherapy – This treatment option revolves around increasing the inherent ability of the immune system to fight the cancer cells. Bacillus Calmette-Guerin (BCG), originally a vaccine preparation against tuberculosis, is used in this method. It is inserted inside the bladder through a catheter. It has been found to be very helpful in treating bladder cancers. 9 Some patients may need more than one course while the effect of every course lasts for six weeks. This procedure also does not require a hospital setting.
  • Cystectomy – If the intravesical immunotherapy does not work or if the chances of the spread of cancer are high, 9 the surgeon may decide to remove a part of your bladder or even complete bladder if a large area is involved. Some surrounding organs e.g. prostate in men and uterus in females may also be removed.
  • When only a part of the bladder is removed, the rest is sewn up and you are left with a smaller bladder and the need to urinate more often. This procedure is called partial cystectomy.
    • Radical cystectomy is the removal of the whole bladder.

Urinary Diversion After Radical Cystectomy:

When a radical cystectomy is done, you will require some other way of voiding urine, which is known as urinary diversion.

  • Ileal Conduit:

This is usually done by removing a part of your small intestines that is then attached to both of your ureters. The other end of the intestine is connected to an opening (stoma) made on the surface of your abdomen, allowing continuous passage of urine into a bag attached to that opening. This bag has to be manually cleaned by the patient. This is the simplest and widely used method called Incontinent diversion by an ileal conduit.

  • Continent Diversion:

In other cases, a pouch is made using a part of your intestine that has the ability to hold the urine for some time that you can remove by putting a catheter inside an opening in your abdomen. No bag is attached to the body.

  • Neobladder:

For some patients, a new bladder (neobladder) is made, again using a part of the intestines. The patient can void normally through a urethra, though the urge to urinate is lost. This problem can be solved by making timed visits to the restroom.

It should be remembered that certain side effects may be associated with these treatment modalities. Especially with radical cystectomy, the sexual and reproductive life of the patient may be greatly affected. Removal of surrounding organs like prostate in men and uterus or ovaries in females can make the survivors lose their reproductive potential.

Your surgeon will help you decide the type of surgery that best suits your condition, and also about all the potential adverse effects and positive outcomes that could help you lead a better.

References:

  1. Sanli, O., Dobruch, J., Knowles, M. A., Burger, M., Alemozaffar, M., Nielsen, M. E., & Lotan, Y. (2017). Bladder cancer. Nature reviews Disease primers3(1), 1-19.
  2. 2.   Kaufman, D. S., Shipley, W. U., & Feldman, A. S. (2009). Bladder cancer. The Lancet374(9685), 239-249.
  3. Kantor, A. F., Hartge, P., Hoover, R. N., & Fraumeni Jr, J. F. (1985). Familial and environmental interactions in bladder cancer risk. International journal of cancer35(6), 703-706.
  4. Burger, M., Catto, J. W., Dalbagni, G., Grossman, H. B., Herr, H., Karakiewicz, P., … & Lotan, Y. (2013). Epidemiology and risk factors of urothelial bladder cancer. European urology63(2), 234-241.
  5. Antoni, S., Ferlay, J., Soerjomataram, I., Znaor, A., Jemal, A., & Bray, F. (2017). Bladder cancer incidence and mortality: a global overview and recent trends. European urology71(1), 96-108.
  6. Pashos, C. L., Botteman, M. F., Laskin, B. L., & Redaelli, A. (2002). Bladder cancer: epidemiology, diagnosis, and management. Cancer practice10(6), 311-322.
  7. Totaro, A., Pinto, F., Brescia, A., Racioppi, M., Cappa, E., D’Agostino, D., … & Bassi, P. (2010). Imaging in bladder cancer: present role and future perspectives. Urologia internationalis85(4), 373-380.
  8. Richterstetter, M., Wullich, B., Amann, K., Haeberle, L., Engehausen, D. G., Goebell, P. J., & Krause, F. S. (2012). The value of extended transurethral resection of bladder tumour (TURBT) in the treatment of bladder cancer. BJU international110(2b), E76-E79.
  9. Amling, C. L. (2001). Diagnosis and management of superficial bladder cancer. Current problems in cancer, 25(4), IN1-278.