Bladder Cancer

OverviewSymptomsDiagnosisTreatment Metastatic DiseasePreventionOther ResourcesPatient Stories

Overview

  • In the United States, more than 74,000 people will be diagnosed with bladder cancer in 2014, and in the same year, 15,580 will die from it.
  • Rates for new bladder cancer cases have been falling by about 0.6% each year over the last decade.
  • Death rates have been stable over the past 10 years, with survival at 5 years approximately 77% (with rates dependent on disease stage)
  • There are several subtypes of bladder cancer and each behaves differently, but the most common subtype of bladder cancer is “urothelial” cancer. An older term is “transitional cell” cancer.
  • The risk 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 largest risk factor for bladder cancer is cigarette smoking, and accounts for approximately 60% of all bladder cancer cases.
  • Other risks of bladder cancer include certain occupations such as those with exposure to aniline, chemical dyes, and combustion gases from coal and heavy metal.
  • Prior therapy with cytoxan (cyclophosphamide) or pelvic irradiation (which may be used for other types of cancers) can also increase one's risk of bladder cancer. 

Symptoms

  • Blood in the urine can be a symptom of bladder cancer (among other problems)
    • Visible blood (“gross hematuria”) should prompt a visit to a urologist for evaluation
    • Blood the doctor finds on urine testing (“microscopic hematuria”) should also be evaluated by the treating physician, and in some cases requires evaluation by a urologist
  • Pelvic pain
  • Weight loss
  • Pain from sites where bladder cancer has spread

Diagnosis

  • The majority of bladder cancer cases are diagnosed when patients are discovered to have blood in their urine.
  • Cystoscopy, a procedure in which a small camera is inserted into the bladder, is used to diagnose bladder cancer through visual inspection.
  • Biopsy of bladder cancer is performed as an outpatient procedure (in which the patient goes home the same day). The tumor can have many different appearances, but often will appear as a lump of tissue that extends out from the interior bladder wall (as pictured below). 

Bladder cysto

  • The urologist removes the tumor from the bladder by scraping it out, with the intention of removing the entire tumor at one time. This tumor is sent to a pathologist who can determine the specific type of bladder cancer which then helps determine further treatment.
  • CT scan (and in some cases MRI) are commonly used to evaluate whether bladder cancer has spread.  This shows great detail of the kidneys as well as lymph nodes, lung, liver, and bone (organs in which bladder cancer may spread).
  • Chest x-ray can show spread of bladder cancer to the lungs, and is often used at initial diagnosis and for follow-up appointments.
  • Intravenous pyelograms, CT urograms, or retrograde pyelograms are procedures that are performed to determine whether cancer is present in the kidneys or kidney tubes (ureters).
  • Bone scans and PET scans are x-rays that are only used in very specific situations.

Treatment

  • Bladder cancer treatment is determined by how far the tumor extends into the bladder wall and the tumor type
  • Bladder cancer is divided into superficial and invasive disease
  • Treatment is determined based on whether the tumor is superficial or invasive, and whether it is low grade or high grade
  • Below is a picture of how we determine the depth of tumor invasion into the bladder
    • Ta: Tumor only is within the superficial lining of the bladder wall
    • T1: Tumor is into the connective tissue layer (between the superficial lining and the muscle)
    • T2: Tumor extends into the muscle layer of the bladder
    • T3: Tumor extends into the fat layer of the bladder (beyond the muscle)
    • T4: Tumor extends into organs near the bladder (such as the prostate, vagina, or seminal vesicles)

      Superficial Disease (Ta, T1)

  • The majority of patients with superficial tumors (Stage Ta or T1) can be effectively treated with transurethral resection alone, especially those with Ta, low grade tumors. 
  • Once treatment is complete, cystoscopies must be performed at varying intervals in the ensuing years since bladder cancer has a high rate of recurrence
  • Further treatment is determined based on whether the tumor is considered low grade or high grade
    • Low grade tumors may recur, but are unlikely to spread
    • High grade tumors may also recur, but also may spread
    • High grade Ta or T1 tumors are likely to progress to "muscle invasive" (T2) disease and must be followed more closely than low grade tumors
      • Additional therapies may include medication placed into the bladder
      • These medications include BCG, Mitomycin C, or Thiotepa, and are given to help prevent recurrences
      • BCG (Bacille Calmette-Guerin) is the most effective and commonly used form of intravesical therapy:
        • A standard course of BCG consists of 6 weekly instillations. 
        • Some patients will receive BCG for maintenance over the next 3 years
        • Because bladder cancers do have a high rate of recurrences, frequent surveillance cystoscopies in the ensuing months and years are required

      Invasive Disease (T2, T3, T4)

  • Invasive disease means that the bladder cancer has spread to the bladder muscle wall
  • Treatment typically requires chemotherapy followed by surgery that removes 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 portion of the vagina as well. 
    • All patients must undergo a “urinary diversion” in which urine is diverted to a reservoir that is created from a piece of bowel.

  • Urinary diversions include:
    1. Urostomy or ileal conduit (external collecting bag in which urine freely flows into a bag without need for a catheter to drain it)
    2. Catheterizable pouch (internal pouch made of intestines in which the patient uses a catheter to drain the reservoir)
    3. Neobladder (“orthotopic diversion”) (internal pouch that is connected to the urethra in which patients can urinate, to offer more “normal” urinary function)

Metastatic Disease

  • Cancer that has spread outside the bladder is known as “metastatic” disease
  • Bladder cancer spreads most often to lymph nodes, liver, lungs, bone or other organs. 
  • The best therapy for metastatic disease is typically chemotherapy. In these cases, surgery is only used to relieve symptoms when the patient’s bladder symptoms are severe.

Prevention

  • The best prevention for bladder cancer is to stop smoking or any use of tobacco (in those who use these substances)
  • It is important that any blood in the urine be evaluated by a urologist, even if it is only noticed once

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