Bladder Cancer

1 What is Bladder Cancer?

Bladder cancer is a condition in which there is an abnormal, uncontrollable growth of cells in the inner lining of the urinary bladder, a balloon-shaped organ in your pelvic area that stores urine.

It commonly affects older adults, although it can occur at any age. A common symptom of bladder cancer is bloody urine. The great majority of bladder cancers are diagnosed at an early stage — when they are highly treatable.

Most bladder cancers arise in the innermost lining of the bladder called the urothelium or transitional epithelium. As the tumor grows and involves the other layers of the bladder wall, it becomes advanced and more difficult to treat.

Sometimes, the tumor may spread to nearby structures such as lymph nodes, bones, and muscles.

However, even early-stage bladder cancer is likely to recur. For this reason, bladder cancer survivors often undergo follow-up tests for several years after treatment to check bladder cancer recurrence.

2 Symptoms

Bladder cancer is often detected early as it causes blood to appear in the urine and other urinary symptoms.

The signs and symptoms of bladder cancer include:

  • Bright red or cola colored urine due to presence of blood in urine (hematuria) is often the first sign. Sometimes, urine may appear normal, but red blood cells may be detected in the urine only during microscopic examination.
  • Changes in urination: Frequent urination,
  • Urgency to pass urine even when your bladder is not full
  • Pain or burning sensation while urinating
  • Difficulty in passing urine or a weak urine stream

Symptoms of advanced stage bladder cancer:

  • Bladder cancers that have become large or that have spread to other parts of the body can cause other symptoms, such as:
  • Inability to pass urine
  • Low back pain on one side
  • Bone pain
  • Pelvic pain
  • Tiredness or feeling weak
  • Weight loss associated with loss of appetite
  • Swollen feet

When to see a doctor

Consult your doctor if you have signs or symptoms that worry you, such as blood in your urine.

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3 Causes

Although the exact cause is not clear bladder cancer has been linked to factors such as:

  • smoking,
  • a parasitic infection,
  • exposure to radiation and chemicals,

Bladder cancer develops when the cells in the bladder wall start dividing abnormally. These cells develop mutations that force them to grow uncontrollably without dying. These abnormal cancer cells form a tumor.

Types of bladder cancer

The type of bladder cell in which cancer begins determines the type of your bladder cancer. There are different types of cells in your bladder that can turn cancerous. The type of bladder cancer determines the treatment best suitable for you.

Types of bladder cancer include:

Transitional cell carcinoma

This type of cancer occurs in the cells lying on the inner wall of your bladder. Transitional cells expand when your bladder distends and contract when your bladder is empty. It is the most common type of bladder cancer in the United States.

Squamous cell carcinoma

Squamous cells appear in your bladder as a response to infection or irritation. Gradually, these can become cancerous. Squamous cell bladder cancer is rarely seen in the United States. It is more common in regions where a parasitic infection (schistosomiasis) is a prevalent cause of bladder infections.

Adenocarcinoma

This type of bladder cancer begins in the cells of the mucus-secreting glands in the bladder, but is very rare in the United States.

Sometimes, bladder cancersmay involve more than one type of cell.

4 Making a Diagnosis

 Making a diagnosis of bladder cancer is done by several tests.

You may initially consult your family doctor or a primary care physician if you have signs or symptoms that worry you.

Your doctor may perform some tests and procedures to investigate your condition. If your doctor suspects a bladder cancer, you may be referred to a doctor who specializes in treating diseases and conditions of the urinary tract (urologist).

Sometimes, you may be referred to other specialists, such as doctors who treat cancer (oncologists). As appointments would be brief, and often there is a lot of issues to be discussed, it is a good idea to be well-prepared.

Here is some information to help you get ready, and what to expect from your doctor.

What you can do

Know about your pre-appointment restrictions. At the time of making the appointment, you may ask if there is anything you need to do in advance, such as any dietary restrictions.

Make a list of the following information:

  • Symptoms you have, including those that may seem unrelated to the reason for your appointment.
  • Key personal information, including any major stresses or recent life changes.
  • All your regular medications, vitamins or supplements that you take.

Consider taking a family member or friend along. Sometimes, it becomes difficult to remember all the information given by your doctor during an appointment.

Someone who accompanies you may remember something that you may have missed or forgotten.

Write down questions to ask your doctor

Your time with your doctor is brief, so prepare a list of questions you want to ask your doctor in advance.

For bladder cancer, some basic questions to ask your doctor include:

  • What is the stage of my cancer?
  • Will I need any additional tests?
  • What is the best available treatment option?
  • Is there a cure for my bladder cancer?
  • What are the potential risks involved with each treatment?
  • Which factors determine whether I should plan for a follow-up visit?

What to expect from your doctor

Your doctor may ask you a number of questions. Being prepared to answer these may spare you some time to cover other points you want to address.

Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Have your symptoms been continuous or occasional?
  • How severe are your symptoms?
  • Is there anything that seems to improve or worsen your symptoms?

Tests and procedures used to diagnose bladder cancer include:

Cystoscopy

During cystoscopy, your doctor passes a narrow tube called cystoscope through your urethra. The cystoscope has a lens and fiber-optic lighting system at is end, which allows your doctor to visualize and examine the inside portion of your urethra and bladder. You will be given a local anesthetic during cystoscopy to make you comfortable during the procedure.

Biopsy

During the cystoscopy procedure, your doctor may insert a special tool through the scope into your bladder in order to collect a cell sample (biopsy) for testing. This procedure is also called transurethral resection of bladder tumor (TURBT), and is used to treat bladder cancer. TURBT is performed under general anesthesia.

Urine cytology

A sample of your urine is examined under a microscope to check for cancer cells. This procedure is called urine cytology.

Imaging tests

Imaging tests allow examination of the structures of your urinary tract. Tests to highlight the urinary tract make use of a dye, which is injected into a vein before the procedure. An intravenous pyelogram is a type of X-ray imaging test that uses a dye to highlight your kidneys, ureters and bladder. A computerized tomography (CT) scan is a type of X-ray test that gives your doctor a detailed picture of your urinary tract and the surrounding tissues.

Staging of bladder cancer

Once the diagnosis of bladder cancer has been confirmed, your doctor will order certain additional tests that help to determine the extent or stage of the cancer.

Staging tests may include:

Bladder cancer stages

The stages of bladder cancer include:

Stage I

Cancer at this stage is in the bladder's inner lining but has not invaded the muscular bladder wall.

Stage II

At this stage, cancer has invaded the bladder wall but remains confined to the bladder.

Stage III

The cancer cells spread through the bladder wall into the surrounding tissues.

Stage IV

The cancer cells may have spread into the lymph nodes and other organs, such as bones, liver or lungs.

5 Treatment

The treatment options for your bladder cancer depends factors such as the type and stage of the cancer, your overall general health, and your treatment preferences.

Discuss your options with your doctor to determine what treatment is best for you.

Treatments for early-stage bladder cancer

If your tumor is very small and has not involved the bladder wall, your doctor may recommend:

Surgical removal of the tumor

Transurethral resection of bladder tumor (TURBT) is a surgical technique often used to remove bladder cancers that are confined to the inner layers of the bladder. During TURBT, your doctor inserts a small wire loop through a cystoscope, into your bladder. The loop burns away cancer cells with an electric current.

In some cases, a high-energy laser will be used instead of electric current. TURBT may result in painful or bloody urination for few days following the procedure.

Surgical removal of the tumor and a small portion of the bladder

During a segmental cystectomy, sometimes called partial cystectomy, the surgeon will resect only the portion of the bladder that contains cancer cells. Segmental cystectomy is rarely used and can be used as an option if your cancer is restricted to one area of the bladder that can easily be removed without affecting the bladder function.

Biological therapy (immunotherapy)

Biological therapy, sometimes called immunotherapy, acts by signaling the immune system pf your body to fight cancer cells. Biological therapy for bladder cancer is usually administered through your urethra and directly into the bladder (intravesical therapy). One of the biological therapy drug used to treat bladder cancer is bacille Calmette-Guerin (BCG), which is a bacterium used in tuberculosis vaccines.

Another biological therapy drug is a synthetic version of interferon, which is a protein your immune system produces to help fight against infections. The synthetic version, called interferon alfa-2b (Intron A), is sometimes used along with BCG. Side effects of biological therapy include flu-like symptoms and bladder irritation.

Surgery for invasive bladder cancer

If your cancer has invaded into the deeper layers of the bladder wall, following treatment options may be considered:

Surgical removal of the entire bladder

A radical cystectomy is a procedure that involves removal of the entire bladder along with the surrounding lymph nodes. In men, radical cystectomy includes removal of the prostate and seminal vesicles. In women, radical cystectomy involves removal of the uterus, ovaries, and a part of the vagina. Nowadays, radical cystectomy is increasingly performed using robotic surgery technique.

In robotic surgery, the surgeon sits near the surgical console and uses hand controls to precisely move the surgical instruments. Cystectomy involves a risk of infection and bleeding. In men, removal of the prostate and seminal vesicles may result in erectile dysfunction. But in selective cases, your surgeon may try to spare the nerves required for an erection. In women, removal of the ovaries results in infertility and premature menopause.

Surgery to create a new path for urine to be excreted

Immediately following the radical cystectomy procedure, your surgeon will work towards creation of a new way for urine to be expelled from your body. There are several options. The best option for you depends on your situation and your preferences.

Your surgeon may create a tube (urinary conduit) from a piece taken from your intestine. This tube runs from your ureters, which drain your kidneys, to the outside of your body, where your urine empties into a pouch (urostomy bag) that you can wear on your abdomen. In another procedure, your surgeon will use a portion of your intestine to create a small reservoir to collect urine inside your body (cutaneous continent urinary diversion). You will need to empty the urine from the reservoir through a hole made in your abdomen using a catheter a few times each day.

In some cases, your surgeon may create a bladder-like reservoir from a piece of your intestine (neobladder). This reservoir remains inside your body, and is attached to your urethra, so that you can urinate normally. You may need a catheter to drain all the urine from your neobladder.

Chemotherapy

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

Chemotherapy is used to kill the cancer cells that persist after surgery. It can also be used before surgery. In this case, chemotherapy helps to shrink a tumor so that the surgeon can perform a less invasive surgery. Chemotherapy can sometimes be combined with radiation therapy in selective cases where surgery is not an option.

Radiation therapy

Radiation therapy involves the use of high-energy beams targeted at your tumor to destroy the cancerous cells. For bladder cancer, radiation therapy is delivered from a machine that goes around your body, directing the energy beams to precise regions of your body. This can be used after the surgery to get rid of any remaining cancer cells.

In some cases, radiation therapy is sometimes combined with chemotherapy when surgery is not an option, though this is generally considered as a last resort.

6 Prevention

You can take some steps to reduce your risk of bladder cancer, although there is no sure way to prevent bladder cancer.

Some risk factors such as

  • age,
  • gender,
  • race,
  • family history

are under your control. But here are some things you can do to lower your risk:

Stop smoking

Quitting smoking avoids collection of cancer-causing chemicals in your bladder, and thus prevents bladder cancer. Support groups, medications, and other methods are available to help you quit.

Limit exposure or take caution around chemicals

If you work in industries that use certain organic chemicals, follow all the safety practices in order to avoid exposure.

Drink plenty of water throughout the day

Drinking a lot of liquids, especially water, helps in diluting the toxic chemicals that may be concentrated in your urine and flushes them out of your bladder more quickly.

Eat lots of fruits and vegetables

A diet high in a variety of colorful fruits and vegetables helps in protecting against bladder cancer. The antioxidants present in these fruits and vegetables help in reducing your risk of cancer.

7 Lifestyle and Coping

Lifestyle modifications are necessary in order to cope with bladder cancer.

Living with a concern that your bladder cancer can recur any time leaves you with a feeling that you have very little control over your own future.

However, as there are no ways to ensure that your bladder cancer does not recur, you can just take simple steps to manage your stress. Over time, you can see what works best for you, but until then, you might have to schedule follow-up tests and go to each appointment. Once you complete your bladder cancer treatment, ask your doctor to create a personalized schedule of follow-up tests.

Before every follow-up cystoscopy exam, you may have some anxiety. You may fear whether your cancer has come back or worry about the discomfort that occurs during the exam, let this anxiety not prevent you from attending your appointment.

Instead, you can adopt certain measures to cope with your concerns:

  • Write your thoughts or feelings in a journal or discuss them with your friend.
  • Take good care of yourself so that you are well prepared to fight cancer if it comes back. Take care of yourself by modifying your diet to include lots of fruits, vegetables, and whole grains.
  • Do some exercises for at least half an hour most days of the week.
  • Get proper sleep so that you wake up fresh.
  • Talk with other bladder cancer survivors. Connect with bladder cancer survivors who may be experiencing the same fears. Contact your local chapter of the American Cancer Society to know about support groups in your area.

8 Risk and Complications

Factors that pose a risk of developing bladder cancer include:

Smoking

Smoking causes almost half of all the bladder cancers that occur in both men and women. Smoking cigarettes, cigars or pipes can make you more susceptible to bladder cancer by causing harmful chemicals to accumulate in your urine. Our body processes the chemicals in the smoke and excretes some of them in urine. These harmful chemicals damage the lining of your bladder, and increase your risk of cancer.

Advancing age

Your risk of bladder cancer increases with age. Bladder cancer can occur at any age, but it is rare among people younger than 40. Almost 9 out of 10 people with bladder cancer are above 55 years of age.
Race and ethnicity: Whites have a greater risk and are about twice more likely to develop bladder cancer than do people of other races.

Gender

Men are more likely to develop bladder cancer than women.

Exposure to certain chemicals at workplace

Your kidneys play an important role in filtering out harmful chemicals from your bloodstream and moving them into your bladder. Because of this, it is believed that exposure to certain industrial chemicals may increase your risk of bladder cancer. Chemicals linked to bladder cancer risk include

  • arsenic,
  • chemicals used in the dye industry,
  • rubber,
  • leather,
  • textiles,
  • paint products.

Previous cancer treatment

Treatment with the chemotherapy drug cyclophosphamide for a long term irritates the bladder and increases your risk of bladder cancer. People who have received radiation treatments targeted to the pelvis for a previous cancer are at an elevated risk of developing bladder cancer.

Taking a certain diabetes medication

According to the US Food and Drug Administration (FDA), people who take the diabetes medication pioglitazone (Actos) for more than a year have an increased risk of bladder cancer. Other diabetes medications that contain pioglitazone – pioglitazone and metformin (Actoplus Met) and pioglitazone and glimepiride (Duetact).

Chronic bladder irritation and inflammation

Chronic or repeated urinary infections or inflammations (cystitis), such as might happen due to long-term use of a bladder catheter, kidney and bladder stones and other causes for bladder irritation may increase your risk of a squamous cell bladder cancer.

In some parts of the world, mainly in Africa and the Middle East, squamous cell carcinoma is linked to chronic bladder inflammation caused by a parasitic worm infection called schistosomiasis.

 Personal or family history of cancer

If you have had bladder cancer in the past, you are more likely to get it again. People with one or more of your immediate relatives having a history of bladder cancer may have a higher risk of the disease, though bladder cancer rarely runs in families. A family history of hereditary nonpolyposis colorectal cancer, also called Lynch syndrome is linked to increased risk of cancer in your urinary system, as well as in your colon, uterus, ovaries, and other organs.

Some people may inherit a gene syndrome that enhances their risk of bladder cancer. For example, a mutation in the retinoblastoma (RB1) gene can cause eye cancer in infants, and also increase the risk of bladder cancer.

Not drinking adequate fluids

People who do not drink lot of fluids, especially water are at a greater risk of developing bladder cancer.

Congenital defects in the bladder

Birth defects such as urachus increase the risk of developing adenocarcinoma of the bladder, which is quite rare.
Bladder cancer often has the tendency to recur. Therefore, bladder cancer survivors must undergo follow-up testing for several years even after successful treatment. The type of tests and their frequency depends on the type of bladder cancer and your treatment, among other factors. Ask your doctor to develop a follow-up plan for you. In general, doctors order a test to examine the inside of your urethra and bladder (cystoscopy) that is performed every three to six months for the first few years after bladder cancer treatment. Then, you may undergo cystoscopy once in a year. People with aggressive cancers may require more frequent testing, and those with less aggressive cancers undergo testing less often.

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