Bladder Cancer

Introduction

Bladder cancer occurs when the cells in the bladder grow abnormally or out of control.  The exact cause of bladder cancer is unknown; however cigarette smoking and exposure to certain industrial chemicals appear to be risk factors.  The most common symptoms of bladder cancer are blood in the urine and changes in urinary habits. 

Some forms of bladder cancer are curable if detected and treated very early.  Follow up care is important for bladder cancer because it has a high risk of returning following treatment.  Most bladder cancers that return respond well to treatment.

Anatomy

Your urinary tract system consists of your kidneys, ureters, bladder, and urethra.  Your kidneys are a pair of bean shaped organs located in your lower back.  They filter waste products and extra fluids from your blood and turn them into urine.  Urine is composed mainly of water and metabolic waste products.  The urine travels through two tubes, called ureters, to your bladder.

Your bladder holds and collects urine from your kidneys.  When a certain level of urine has accumulated in your bladder, your body signals you to urinate.  The bladder has a muscular wall that allows it to change size as the volume of urine changes.  Your urethra is the tube that carries the urine from your bladder to outside of your body.  The female urethra is shorter than the male urethra.

Causes

The exact cause of bladder cancer is unknown.  Cancer occurs when cells grow abnormally and out of control, instead of dividing in an orderly manner.  Bladder cancer usually originates in the transitional cells that line the inside of the bladder. Smoking and exposure to certain industrial chemicals appear to contribute to bladder cancer.  There are different types and subtypes of bladder cancer.  They may respond to treatments in different ways.  The most common types of bladder cancer include:

Urothelial carcinoma, also called transitional cell carcinoma:  This is the most frequent type of bladder cancer.  There are several subtypes of urothelial carcinoma.  Some types of urothelial carcinoma tend to spread to other sites.

Squamous cell carcinoma:  This type of bladder cancer is not common.  Squamous cell carcinoma tends to spread to other parts of the body.

Symptoms

The most common symptoms of bladder cancer are blood in the urine and changes in bladder habits.  Blood can cause your urine to appear red, bright-red, or rust colored.  You may feel an urgent need to urinate and may urinate frequently.  You may feel the urge to urinate but not be able to do so.  You may feel pain when you urinate.  However, many people with bladder cancer just experience blood in the urine.

Other symptoms of bladder cancer are abdominal pain, weight loss, anemia, feeling tired, and bone pain or tenderness.  You may experience incontinence, urinating when you do not intend to.  The symptoms of bladder cancer are very similar to common noncancerous conditions, such as urinary tract infections or kidney stones.  If you experience any changes related to the urinary tract, a doctor should evaluate you.

Diagnosis

Any changes in your urine or voiding habits should be reported to your doctor.  Your doctor can diagnose bladder cancer by reviewing your medical history, conducting a physical examination, and with diagnostic tests.  You should tell your doctor about your risk factors and symptoms.  Your doctor will perform a rectal and pelvic exam.  You will provide a urine sample to be tested.  A urinalysis is a test that checks the color and content of the urine.  A urine cytology test determines if urine or cells from the bladder are cancerous or precancerous. 

A cystoscopy is a procedure that is commonly used to diagnose bladder cancer.  A cystoscope is a thin lighted viewing instrument that is gently inserted through the urethra to allow a doctor to view the inside of the bladder.  A biopsy can be performed with a cystoscope.  A biopsy entails removing a suspicious area of tissue from the bladder for examination by a pathologist.

Imaging tests may be ordered so your doctor can see your bladder and other organs.  Some tests include an intravenous pyelogram (IVP), X-ray, computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, ultrasound, and bone scan which can provide your doctor with more information about your bladder cancer and if it has metastasized.  Cancer that has spread from its site of origin is termed metastasized.

An IVP uses X-rays and contrast dye to check for cancer or blockages in the urinary tract.  CT scans take pictures of the organs from different angles, and MRI scans take pictures with even more detail.  An ultrasound uses sound waves to create images of structures.  A bone scan creates images that indicate if cancer is in the bones.

If you have bladder cancer, your doctor will assign your cancer a classification stage based on the results of all of your tests.  Staging describes the cancer and how it has metastasized.  Staging is helpful for treatment planning and recovery prediction.  There is more than one type of staging system for cancer, and you should make sure that you and your doctor are referring to the same one. 

In general, your doctor will classify your bladder cancer in a stage labeled from 0-4.  Lower numbers indicate a less serious cancer, and higher numbers indicate a more serious cancer.  Letters and numbers are also used to classify bladder cancer: T for degree of tumor spread in the bladder wall and nearby tissues, N for degree of lymph node spread, and M for degree of spread to distance organs.

Treatment

If you are diagnosed your doctor will refer you to an oncologist for treatment.  An oncologist is a doctor with special training in cancer and cancer treatments.  Treatment for bladder cancer depends on many factors, including the stage of the cancer and the cancer cell type.  You may opt to receive a second opinion about the best kind of cancer treatment for you.  Cancer treatments include surgery, radiation therapy, chemotherapy, intravesical immunotherapy, or a combination of therapy types.  Most people with bladder cancer receive surgery and another type of treatment.

There are several types of surgery for bladder cancer.  The type that you receive depends on the stage of your cancer.  Transurethral surgery and cystectomy (bladder removal) surgery are the most common surgeries for bladder cancer.

Transurethral surgery uses a cystoscope to remove the cancer cells.  This treatment is most frequently used for early stage bladder cancer.  A cystectomy is used to treat higher stages of bladder cancer.  A partial cystectomy removes only part of the bladder.  A radical cystectomy removes the entire bladder.

If your entire bladder is removed, reconstructive surgery will create another way for your body to store and remove urine.  A urostomy involves attaching tissue from your small intestines to the ureters and using a bag worn on the outside of the body to collect the urine.  Continent diversion is another option.  Continent diversion entails creating a sac from the small intestines and attaching it to the ureters.  With this option, urine can be removed by placing a tube in the diversion or by surgically creating a route for the urine to travel to the urethra to be removed by urination.

Radiation therapy uses high-energy beams to destroy cancer cells. Chemotherapy uses cancer-fighting drugs to destroy cancer cells.  Intravesical immunotherapy involves placing a treatment inside of the bladder to trigger your immune system to fight the cancer cells.  There are several different types of radiation therapies, chemotherapies, and intravesical immunotherapies.

Even with treatment, it is common for bladder cancer to return.  This is termed “recurrent bladder cancer”.  The cancer may come back in your bladder or in other parts of the body.  Your doctor can explain your risk for recurrent bladder cancer and possible additional treatments if it does recur.

The experience of cancer and cancer treatments can be an emotional process for people with cancer and their loved ones.  It is important that you receive support from a positive source.  Some people find comfort in their family, friends, counselors, co-workers, and faith.  Cancer support groups are another good option.  They can be a good source of information and support from people who understand what you are experiencing.  Ask your doctor for cancer support group locations in your area.

Prevention

Am I at Risk

Risk factors for bladder cancer:

_____ Smoking cigarettes or using tobacco products, such as chew, is the greatest risk factor for bladder cancer.  Chemicals from tobacco collect in the lining of the bladder and increase the risk of cancer.  According to the American Cancer Society, people that smoke develop bladder cancer twice as often as those who do not smoke.
_____ Exposure to certain chemicals used at work or industrial manufacturing is linked to bladder cancer.  Chemicals used in making dye, arylamines, or aromatic amines used in making rubber, leather, printing materials, textiles, pesticides, and paint products are associated with bladder cancer.  Painters, hairdressers, machinists, rubber workers, aluminum workers, leather workers, pesticide applicators, printers, and truck drivers are at risk if they do not follow good safety practices.  People that smoke and are exposed to the chemicals have even a greater risk of developing bladder cancer.
_____ Arsenic in drinking water increases the risk for bladder cancer.
_____ The risk for bladder cancer is higher with increasing age.
_____ Men get bladder cancer more often than women.
_____ Caucasians develop bladder cancer more often than people of other races.  Asians have the lowest incidence of bladder cancer.
_____ People that have had bladder cancer are at risk for experiencing it again.
_____ A family history of bladder cancer puts you at a higher risk for developing it.
_____ Urinary infections, kidney stones, and bladder stones do not cause bladder cancer, but they have been linked in research to an increased risk of bladder cancer.
_____ People that consume small amounts of liquids each day have an increased risk for bladder cancer.
_____ Some medications and radiation therapy to treat other cancers can increase the risk for bladder cancer.
_____ In rare cases, certain birth defects involving the bladder contribute to an increased risk for bladder cancer.
_____ A parasite found in developing third world countries, schistosomiasis, is linked to the development of bladder cancer.

Complications

Metastasis can be a complication of bladder cancer.  This means that the cancer has spread from the bladder to distant organs.  Common sites for bladder metastasis include the lymph nodes, rectum, colon, liver, lungs, and pelvic bones.  Bladder cancer is associated with other medical conditions, such as anemia, swelling of the ureters, urinary incontinence, and urethral narrowing.

Bladder cancer that has been treated has a high risk of returning.  Most bladder cancers that return respond well to treatment.  You should make and attend all follow up appointments with your doctor so that recurrent bladder cancer can be identified and treated early.

Advancements

Researchers have a good understanding of how normal cells in the bladder turn into cancer cells.  They are using DNA studies to determine methods to prevent, detect, treat, and predict the course of bladder cancer.  They continue to study the effects of second hand smoke and industrial chemicals in efforts to prevent bladder cancer.  Researchers are studying medications and vitamins that they hope will prevent recurrent bladder cancer.

The Food and Drug Administration (FDA) has recently approved tumor marker tests and several are being studied.  Tumor marker tests identify protein or enzymes from cancer cells in the urine. 

Fluorescence in situ hybridization (FISH) is a screening test for recurrent bladder cancer that has recently been approved by the FDA.  Researchers hope to increase the sensitivity of these studies and use them for early detection of bladder cancer or recurrent bladder cancer.

Researchers are studying new treatment methods for bladder cancer.  Photodynamic therapy (PDT) uses chemicals and a laser to kill early superficial bladder cancer cells.  Researchers are also conducting clinical trials for new medications, immunotoxins, and gene therapies to kill bladder cancer cells.