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It is estimated that in 2001, 54,300 people (39,200 men and 15,100 women) will be diagnosed with, and 12,4000 people (8,300 men and 4,100 women) will die from bladder cancer in the United States. bladder cancer is the 4th most common non-cutaneous malignancy among men in the United States, and the 8th most common cancer among women. The incidence of bladder cancer increases with age among men and women. The typical age of presentation is in the 7th decade of life and can be seen in patients as early as the 3rd decade of life.
The most significant risk factor for bladder cancer is cigarette smoking. It has been estimated that cigarette smoking accounts for approximately 60% of all bladder cancer cases, and increases bladder cancer risk by 2.5-fold. Occupation exposure can also be important risk factors for bladder cancer; aniline and and other chemical dyes, combustion gases from coal and heavy metals have all been implicated. Consumption of large quantities of phenacitin-containing analgesics can lead to bladder cancer development as long as 25 years from the time of exposure. In addition prior therapy with cytoxan (cyclophosphamide) or pelvic irradiation can likewise increase one's risk of bladder cancer. Although some have suggested that coffee and artificial sweetners may increase bladder cancer risks, this has never been conclusively shown.
The vast majority of bladder cancers diagnosed in the United States are "transitional cell" cell type (transitional cell carcinoma). Multiple grading schemes have been used; most commonly tumors ae grouped into 3 grades corresponding to low, moderate and high grade. Grade is also a strong predictor of tumor aggressiveness and the risk of disease progression. "Carcinoma in situ" (CIS) is type of transitional cell carcinoma which is characterized microscopically by a pathologist as highly atypical cells confined to the bladder lining. This pre-malignant lesion is the pre-cursor lesion to a high grade invasive bladder cancer and its presence portends a worse prognosis.
Squamous cell carcinoma accounts for 5% of bladder cancers in the United States, but 80% in Egypt. Chronic infection (typically by parasites not prevalent in the US) and chronic irritation (from long term (many years) indwelling bladder catheters) may also predispose patients to development of squamous cell carcinoma. Adenocarcioma of the bladder is rare accounting for fewer than 2% of all bladder cancers. Most commonly adenocarcinoma of the bladder develops from a urachal remnant or in patients who were born with bladder exstrophy.
The most common symptom is blood in the urine ("hematuria"), either grossly (seen by the naked eye) or microscopically. Other symptoms include symptoms of bladder irritability -- burning, frequency and urgency. In many cases, the initial suspicion of a bladder tumor is made only after microscopic traces of blood are found on a routine urinalysis. Of note, the hematuria frequenctly is intermittent and a negative urinalysis does not exclude bladder cancer. All patients with hematuria should be evaluated by urologist with a urine cytology (washing of bladder cells), cystoscopy (see below), and intravenous urogram (x-ray test).
Cystoscopy (a technique performed in which urologist exams the inside of the bladder with a lighted telescope) is the primary diagnostic tool for bladder cancer, and the cystoscopic appearance of a tumor can usually provide significant clues regarding the grade and stage of the tumor. Low grade superficial tumors appear as delicate fronds while high grade invasive tumors appear like a solid mass.
Initial treatment includes transurethral resection of bladder tumor (TURBT) -- that is, resection of the suspicious lesion done through the cystoscope. This is typically done in the operating room under anesthesia.
Attempts are typically made to excise the entire suspicious lesion at this setting. Evaluation of the specimen confirms the diagnosis of bladder cancer and also helps in the grading of the cancer. Most importantly, the pathology evaluation of the specimen provides information on the stage of the cancer: the primary goal of staging is to determine if the cancer is "superficial" (stage Ta to T1) or "invasive" (stage T2 or higher).
CT examination of the abdomen and pelvis should be obtained in patients with invasive bladder cancers to evaluate the extent of the local tumor and to determine if the cancer has spread ("metastasized") to other areas of the body. Intravenous urograms should also be obtained in patients with bladder cancer in order to exclude the presence of tumor in the kidneys (renal pelvis) or ureters.
The majority of patients with superficial tumors (stage Ta or T1) can be effectively treated with transurethral resection alonge, especially those with Ta, low grade tumors. Although T1 (superficial but into "lamina propia" layers) are technically considered non-invasive, these tumors are likely to progress to "muscle invasive" (T2) disease these patients must be followed more closely than those with Ta tumors. In certain cases of superficial tumors (high grade or T1 tumors), additional therapies may inlcude installations of medicines into the bladder (intravesical therapy with agents such as BCG, Mitomycin, or Thiotepa) which ar performed to help prevent recurrences. GCG (Bacille Calmette-Guerin) is the most effective and commonly used form of intravesical therapy: a standard course of BCG consists of 6 weekly instillations. Because bladder cancers do have a high rate of recurrences, frequent surveillance cystoscopies in the ensuing months and years are required.
Patients whose cancer invades into the bladder muscle wall (stage T2 to T3) typically require surgical treatment involving the removal of the entire bladder (a radical cystectomy). A radical cystectomy should be considered a major surgery. In males, the surgery involves removal of the bladder and typically the prostate as well. In females, the surgery consists of removal of the bladder and often removal of the uterus, ovaries, fallopian tubes, and typically a partion of the vagina as well. The recurrence rate after radical cystectomy is dependant on the stage, but the overall 10-year cure rates is approximately 66%. Partial cystectomy (removal of only part of the bladder involving the tumor) is rarely performed because of high risk for local recurrence. Radiation therapy or chemotherapy for invasive cancer is not routinely performed in the United States, and is only used in certain atypical cases. Such "bladder salvage" protocols may involve an "aggressive" transurethral resectin, external beam radiation and chemotherapy individually or in combination. Outcomes with such treatments appear to be less favorable than results with radical cystectomy.
After removal, the urine is then diverted into a:
1.) urostomy (external collecting bag),
2.) catheterizable pouch (internal pouch made of intestines),
3.) a neobladder
Neobladders (also termed "orthotopic diversions") are created out of a portion of the patient's intestine, reconfigured in an attempt to create a new bladder and reconnect it to the ureters and the urethra in attempt to restone a more normal urinary function. These diversions can be performed successfully in both men and women. Furthermore, in recent years, radical cystectomy can be accomplished with preservation of the neurovascular bundles (the nerves responsible to achieving an erection) in men and the vagina in women. Such recent surgical modifications such as neobladders and nerve-sparing procedures have allowed surgeons to perform potentially curative surgery while also minimizing morbidity and thereby lessening the impact of cystectomy on quality of life: normal urniary and sexual function can be retained despite durative therapy for invasive bladder cancer. Overall, however, the type of diversion typically depends on the extent/location of the cancer and may also depend on the patient's age, physical status, mental status, and the technical ability of the operative surgeon.
When the cancer has spread outside the bladder ("metastasized"), it will often spread to adjacent lymph nodes, liver, lungs, bone or other organs. In such cases, chemotherapy is typically employed as a primary treatment. In these cases, surgery is reserved only when the patient's bladder symptoms are so severe that cystectomy become a palliative (relieve symptoms) measure.
Prevention of bladder cancer comes in the form of stopping the known causes of bladder cancer. In the United States, this is primarily in the form of cessation of smoking/tobacco use. In addition, identification of any blood in the urine, warrants further evaluation by an urologist.
- Bladder Cancer Basics for the Newly Diagnosed
- UNC Lineberger Comprehensive Cancer Center
- Bladder Cancer Advocacy Network
- The Guide to Living with Bladder Cancer
- American Cancer Society
- National Cancer Institute
- Cancer Net
- American Society of Clinical Oncology