Bladder Cancer

The Urinary Bladder

The bladder is located down in the pelvis just in front of the vagina and rectum and serves as a reservoir for storage of urine. When things are working properly, the kidneys will produce urine and empty their contents through the ureters (tubes that connect the kidneys to the bladder) into the bladder where the urine is stored for several hours before emptying. The bladder plays a key role in the urinary tract in that it keeps urine flowing in the proper direction, not allowing it to flow backwards into the kidneys, and ensures that the urinary tract is emptied of waste contents periodically. When the bladder does not function properly, or if it develops infection, stones, or tumors, a Urologist is the physician who is called upon to diagnose and treat the condition.

Bladder cancer is a disease in which malignant cells form in the bladder. There are three types of bladder cancer.

  • Transitional cell carcinoma: Cancer that begins in cells that line the inside of the bladder. Most bladder cancers arise in the transitional cells.

  • Squamous cell carcinoma: Cancer that begins in squamous cells. These are thin, flat cells that normally are not in the bladder but can form due to certain infections or long term irritation of the bladder from stones or indwelling urinary catheters.

  • Adenocarcinoma: Cancer that begins in glandular (secretory) cells. Glandular cells in the lining of the bladder produce and release fluids such as mucus.

Incidence

  • The incidence of bladder cancer increases with age. People over the age of 70 develop the disease 2-3 times more often than those aged 55-69.

  • Bladder cancer is 2-3 times more common in men

  • Cigarette smokers have an increased risk of developing bladder cancer.

  • Exposure to certain chemical in the workplace also has been associated with an increased risk of developing bladder cancer.

  • Bladder cancer is the fourth most common type of cancer in men and the eighth most common type in women. Fortunately the majority of bladder cancers do not grow rapidly and can be treated without major surgery.

Different Types of Bladder Cancer

The inside or lining of the bladder is composed of a layer of cells that protect the tissues beneath them from urine. Cells of the bladder lining are always reproducing new cells. When these cells are not normal they may be cancerous. Cancers of the bladder can be categorized as low stage (superficial) or high stage (muscle invasive) and the cell types can be referred to as low grade (minimally aggressive) and high grade (highly aggressive).

  • Superficial Tumors: Bladder cancers arise on the inside lining of the bladder wall. These tumors are often have the appearance similar to a mushroom (with a larger top and a smaller stem). In the past they were sometimes called Papillomas or Bladder warts. They can be single or multiple.

  • Invasive Tumors: Cancer that begins in the transitional cells may invade through the lining of the bladder and enter the muscle wall of the bladder. These aggressive cancers can also spread to nearby organs and lymph nodes.

Symptoms

  • Blood in the urine: Bladder cancer normally shows itself because the fragile tissue often bleeds causing redness in the urine and is not usually accompanied by pain. The urine may vary from rusty to deep red, depending on the amount of blood. It may be present for some days and may disappear for weeks or months. The amount of blood is not related to the extent of the cancer. Unfortunately the bleeding often stops by itself and the urine may be clear for several weeks or months as the tumor continues to grow. It should be remembered that that there are reasons other than cancer that you may have blood in the urine, making it important to have it checked by your urologist as soon as possible so that a diagnosis can be made.

  • Frequent urination: can be a sign of bladder cancer

Diagnosis

The most common presenting symptom is blood in the urine without pain. When blood is found in your urine, several tests should be performed to find out whether a bladder cancer is present.

  1. Urinalysis to check the color of urine and its contents.
  2. Internal exam of the vagina and or rectum.
  3. IVP (Intravenous pyelogram). The patient is injected with a special "contrast solution" which passes quickly into the urine. The x-rays are taken as the dye moves through the urinary tract. It allows the urologist to see images of the kidneys, ureters and bladder.
  4. Cystoscopy: a procedure to look inside the bladder and urethra to check for abnormal areas. In Cystoscopy, a pencil thin telescope instrument with a light source and magnifying lenses is inserted gently into the urethra and passed into the bladder to examine its lining. The scope also permits the Urologist to remove a tissue sample for biopsy if needed.
  5. Ultrasound: using ultrasound the bladder and kidneys can be seen very well by way of ultrasonic sound waves. The appearance of the kidneys as well as the size of the bladder and the quality of emptying can be measured while stones and large tumors can be visualized.
  6. If bladder cancer is suspected, a biopsy is performed. If the tissue is positive, the cancer is staged using tumor, node, metastases (TNM) system.
  7. Urine cytology is also important in detecting bladder cancer. For this test, urine is examined under a microscope to search for cancer cells that may not be visible to the naked eye.
  8. Bladderchek® (NMP-22) to detect elevated levels of tumor markers in the urine.

Further Tests May Include

  • CT or CAT SCAN: This test takes a large number of x-rays and creates cross sectional pictures of your body. It also has the ability to create a three dimensional image of the organs inside.

  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

  • Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.

  • Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

Treatment

The treatment for bladder cancer depends on the type of cancer, how deeply the tumor has grown into the bladder, the patient's age and overall health. Options include surgery, chemotherapy, radiation and immunotherapy. Treatments are often combined.

Surgery

  • Superficial Bladder Cancer: The type of surgery will depend on the stage of the disease. If the cancer is superficial (confined to the bladder lining) and has not grown into the bladder wall the physician may elect to remove the tumor using a scope passed into the bladder through the urethra called a resectoscope (transurethral resection). At the same time the Urologist may elect to biopsy other areas in the bladder lining to be sure that it is free of cancer cells. Small tumors are often destroyed completely by this treatment but unfortunately the bladder may develop other tumors with time.

  • Four out of every five bladder tumors are superficial and do not need additional treatment. Because tumors can return, if you are diagnosed with a bladder cancer it is important for the urologist to look into your bladder with a Cystoscope on a regular basis and to inspect cells from your urine with a microscope.

  • If the doctor believes that you are likely to develop new tumors, you may be advised to undergo additional treatments by having medications inserted into the bladder. A catheter is placed into the bladder and is partially filled with BCG. After instilling the solution, the patient is instructed to keep that solution in the bladder for one to two hours before urinating. BCG, a vaccine derived from the bacteria that causes tuberculosis, is used to enhance the immune system's ability to fight cancer. BCG has been shown to dramatically reduce the chances of certain bladder cancers from recurring. Sometimes the BCG is used with interferon. These treatments are usually given on a weekly basis for 6-8 weeks. If one drug is not completely effective, other drugs may be successful and will be recommended.

  • Invasive Bladder Cancer: When the bladder cancer is found to be invasive, (grown through the bladder lining and into the bladder muscle) removal of the bladder (partial or radical cystectomy) is performed along with removal of the nearby lymph nodes. If the bladder is removed a new passage will be made for the urine to leave the body. The most common method is by the formation of an Ileal conduit or urostomy. In this technique a small section of the bowel is removed and used to join the ureters from the kidney to the skin of the abdominal wall and the remaining bowel is joined together again. In men, the prostate gland is also removed. These operations are all very complex procedures. If your urologist feels that the best course of treatment for your bladder cancer is surgery, he/she will discuss these in detail with you.

  • Metastatic Bladder Cancer: Sometimes, the bladder tumor has grown into the bladder wall and may also have shed some cancer cells into the lymph system and bloodstream. Once in the lymph system or blood stream the tumor cells may spread to the bones or lungs. The Bladder is usually not removed when this is the case and generally this advanced disease requires chemotherapy. If the patient requires Chemotherapy, they may be referred to an Oncologist. If Radiation is required they will be referred to a Radiation Oncologist. If you are diagnosed with bladder cancer your urologist will be able to discuss with you how often you will need to come to the office for follow up testing.

  • Treatment Options for recurrent bladder cancer: Treatment for recurrent bladder cancer depends on previous treatments and where the cancer has recurred. Bladder cancer has a high rate of recurrence.