Bladder Cancer

What is cancer?

Cancer is uncontrolled growth of abnormal cells. It has the potential to invade normal tissue. Cancer spreads by way of blood and lymph channels. Cancer is not one disease – there are several varieties of cancer (eg carcinoma, sarcoma, leukemia, lymphoma).

What is bladder cancer?

The entire urinary tract is lined by a type of cell called transitional cell (this is referred to as urothelium), starting from the kidney right down to the urethra. The most common form of cancer in the bladder is transitional cell cancer (urologists call this TCC or urothelial cancer). There are, of course, other types of cancer like squamous cell cancer and adenocarcinoma of the bladder, but these are less common. Also, cancer from other organs can spread to the bladder or the bladder can be involved by direct invasion by cancer in adjacent organs like the uterus, cervix or rectum. In this web page the ensuing discussion pertains mainly to TCC of bladder.

What causes bladder cancer?

SMOKING – this is a well-recognized risk factor in the causation of urinary tract cancer. Both active as well as passive smoking pose increased risk. Even smoking for short periods raises the risk of getting cancer. And, urinary tract cancer can present itself several years after one has stopped smoking. It is important that one stops smoking once a diagnosis of urothelial cancer is made.

INFECTION – chronic infection can cause squamous cell cancer (SCC) in the bladder. Schistosmiasis, a parasitic infestation, is the most common cause. Chronic infection / inflammation, for example, in patients with long-term (several years) indwelling catheters can result in SCC.

OCCUPATIONAL HAZARD – exposure to certain chemicals at work can pose a serious risk for developing urothelial cancer. Workers exposed to or involved in the manufacture / handling of chemical dyes, rubber, coal gas, pest control, textile printing and hair colouring are at particular risk.

DRUGS – Phenacetin used regularly in large doses can cause urothelial cancer. Cyclophosphamide, a potent anti-cancer drug can cause bladder cancer several years following exposure. This effect can be neutralized by an agent called MESNA.

RADIATION – Although radiotherapy is used to treat certain cancers in the pelvis (eg. prostate, uterus, cervix), this has a late side effect of causing secondary cancers in the bladder or rectum.

What are the symptoms and / or signs of bladder cancer?

The most classical way of presentation is passing blood in the urine (see BLOOD IN URINE – pt guide), which is usually painless. Alternatively, blood can be found on routine testing of the urine, which may lead to the diagnosis of bladder cancer. Other symptoms like urinary frequency, urgency and burning (with or without fever) mimic urinary infection, but testing the urine for bacteria may be negative. Pain in the lower part of the abdomen, the loins, or constant pain in a bony area are late signs.

All of these symptoms may be caused by other non-cancerous conditions, but if they are present it is best to have it checked out by your urologist.

How is the diagnosis of bladder cancer made?

If you have symptoms that suggest the possibility of bladder cancer, your urologist is likely to run a few tests. Some of these are:

Urine testing for infection
Urine testing for presence of cancer cells
Routine blood tests
Ultrasound scan of your kidneys and bladder
CT or MRI scan of your abdomen
Cystoscopy (see CYSTOSCOPY – pt guide)
PET-CT scan – this is an advanced form of CT scan
Bone scan

How is bladder cancer treated?

The treatment will depend on the stage and grade of the cancer. In order to obtain this information, you will be recommended a procedure called TURBT (transurethral resection of bladder tumour). This is done under spinal or general anesthesia (seeTURBT guide).

Stage relates to how deep the cancer is invading the tissue. Clinical examination and appearances on CT or MRI scan prior to TURBT gives an idea of the stage (urologists refer to this as clinical staging). The pathologist who examines the tumour pieces taken away during TURBT then provides true estimation of stage (pathological staging).

The majority (~70%) of TCC in the bladder do not invade the muscle (Ta – involves mucosa; T1 – invades connective tissue) and this group is referred to collectively as superficial or non-muscle invasive bladder cancer (NMIBC). The rest (T2-T4) fall into the invasive bladder cancer (IBC)group.

Although T1 cancers are in the NMIBC group, they can be quite aggressive, especially if they are of a higher grade. Grade relates to the biological aggression of cancer, and again,is provided by the pathologist. Higher the grade worse is the outlook.

How is NMIBC managed?

Following TURBT, a chemotherapeutic agent called mitomycin is usually left within the bladder (intravesical chemotherapy) for an hour or so either on the same day or the following day. This reduces the recurrence rate of cancer within the bladder. This does not have any systemic side effects like balding, nausea, vomiting, etc.

Tis/ Cis – tumour in situ or carcinoma in situ – this is pre-cancerous change in the mucosa (the inner lining of the bladder). In bladder, presence of Cis means aggressive disease, and is therefore managed aggressively. Cis can present alone or along with Ta/T1/T2 disease.

Cis is usually managed by way of immunotherapy using BCG vaccine (the same vaccine that is used in the prevention of tuberculosis) that is instilled at regular intervals within the bladder. The vaccine is left inside the bladder for 1-2 hours during each session and then emptied. The bladder is inspected a few weeks following this to see if there is any remaining disease. The immune reaction caused by the BCG kills the precancerous cells. Your urologist will discuss the regime of intravesical BCG therapy that is appropriate for your situation. The side effects of BCG will be discussed in detail with you as well.

In those who do not tolerate BCG well, alternativeslike mitomycin or doxorubicin may be used.

Ta – these tumours involve only the mucosa. These can usually be cured but they have a tendency to recur. If they occur too frequently, or in several areas of the bladder and is difficult to control with TURBT or fulguration of the tumour (your urologist may call this cystodiathermy), your urologist may decide to treat this with regular intravesical chemotherapy. In the more aggressive cases it may have to be managed like IBC.

T1 – most of these are managed similar to Ta, but since they are more aggressive, they are likely to be treated with intravesical BCG therapy as well (similar to Cis). If there is more than one T1 tumour or if there is recurrence of T1 disease, your urologist is likely to consider managing this like IBC.

If NMIBC is managed endoscopically (which is the case in the majority of them), your urologist will advise repeat checks of your bladder (referred to as check cystoscopy) at regular intervals. This allows early detection and treatment of any recurrent cancer.

How is IBC managed?

The management of IBC is highly individualized and depends on several factors – age, general health and fitness, presence of metastasis (spread of cancer to other organs), etc. In general terms, it is useful to discuss the aim of treatment with your urologist:

Cure the cancer: although this is realistically achievable, in some cases they can recur a few months or years later. Hence, doctors tend to use the word remission rather than cure. This merely implies lack of any sign to indicate presence of cancer following treatment but may or may not represent cure.

Control the cancer: cure may not be possible in some instances but treatment is likely to provide long-term symptom control and therefore a better quality of life.

Ease symptoms (palliation): if cure is not possible then other treatments to control the growth of cancer can reduce bleeding and pain. In advanced cancer, pain relief and other treatments for symptom relief may be required.

Surgery

The most common operation is removal of the bladder – cystectomy. Please see BLADDER SURGERY – pt guide for details.

Radiotherapy

This uses high-energy beams of radiation that are targeted on the bladder to treat the cancerous tissue and is sometimes used instead of surgery. This is usually delivered in ‘fractions’ over several weeks and your radiation oncologist will discuss this in detail with you.

Chemotherapy

Cancer busting drugs may be given over a period of a few weeks prior to surgery or radiotherapy – this is termed neoadjuvant chemotherapy – to increase the chance of cure. If given after surgery it is called adjuvant chemotherapy.

It is quite likely that you will be managed by a team of professionals including medical / radiation oncologists, stoma therapists, specialists in pain relief, specialist nurses, etc. Your urologist is the best person to advise you on the management and prognosis (outlook) based on your specific circumstances.