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Bladder Cancer

Bladder cancer is the sixth most common cancer in the United States. For the year 2014 it is estimated that more than 74,000 Americans will be diagnosed with bladder cancer and more than 15,000 will die of the disease. In recent decades there has been a steady increase in the incidence of bladder cancer. However, doctors are making progress in treatment, and survival rates are improving. But what are its symptoms? How should it be treated? The following information should help you talk to an urologist about this condition.

What happens under normal conditions?

The bladder is a hollow balloon-shaped mostly muscular organ that stores urine until ready for release. The urine is produced in the kidneys. It flows through tubes called the ureters into the bladder and is discharged through the urethra during urination. The bladder muscle aids urination by contracting (tightening) to help force out the urine.

A thin surface layer called the urothelium lines the inside of the bladder. Next is a layer of loose connective tissue called the lamina propria. Covering the lamina propria is the bladder muscle. Outside of the bladder is a layer of fat.

What causes bladder cancer?

The ways in which bladder cancers develop and progress are only partly understood.  However, a number of substances that cause the cancers to develop have been identified.  Chief among them are cancer-causing agents in cigarette smoke and various industrial chemicals. Cigarette smoking alone has been estimated to cause 50 percent of all bladder cancer cases in the United States. Long-term workplace exposure to chemical compounds such as paints and solvents has been estimated to cause another 20 to 25 percent of bladder cancer cases. Carcinogens in the blood stream are filtered out by the kidneys to eliminate them from the body. However, these carcinogens remain in the bladder for a few hours interacting with the lining of the bladder before they are removed by urination. Through this process the bladder becomes a high risk organ for cancer, particularly in smokers.

More than 90 percent of all bladder cancers originate in the urothelium, the inner lining of the bladder. The majority of diagnosed bladder tumors are confined to the urothelium or the lamina propria and have not invaded the bladder muscle.

What are the symptoms of bladder cancer?

Blood in the urine (hematuria) is the most common symptom. It eventually occurs in nearly all cases of bladder cancer and is generally described as "painless". Although the blood may be visible during urination, in most cases, it is invisible except under a microscope. In these, the blood is usually discovered when analyzing a urine sample as part of a routine examination. Blood in the urine, similar to blood in the stool or coughing up blood, is a potential warning sign of cancer, and should not be ignored.

Hematuria does not by itself indicate or confirm the presence of bladder cancer. Blood in the urine has many possible causes. For example, it may result from a urinary tract infection or kidney stones rather than from cancer. It is important to note that hematuria, particularly microscopic, might be entirely normal for some individuals. A diagnostic investigation is necessary to determine whether bladder cancer is present.

Other symptoms of bladder cancer may include frequent urination and pain upon urination (dysuria). Such "irritative" symptoms are less common. When present in the absence of a urinary infection (which may have similar or identical symptoms) exclusion of a bladder cancer as the possible cause is mandatory.

How is bladder cancer diagnosed?

The diagnostic investigation begins with a thorough medical history and a physical examination. The doctor will ask the patient about past exposure to known causes of bladder cancer, such as cigarette smoke (either through personal smoking or through "second-hand" smoke) or chemicals. Also, because hematuria can come from anywhere in the urinary tract, the doctor typically order radiological imaging of the kidneys, ureter and bladder to check for problems in these organs. In this era, this is most often accomplished by a CT Urogram (CT scan focused on the urinary tract).

Diagnostic tools to check for bladder cancer include various types of urinalysis. In one type, the urine is examined under a microscope to look for cancer cells that may have been shed into the urine from the bladder lining (urinary cytology). Urine cytology is analogous to a Pap Smear, in this case looking for cancer cells that are sloughed off in the urine. Urine can also be tested for substances known to be closely associated with cancer cells (tumor markers).

The urologist's most important diagnostic tool is cystoscopy, which is a procedure that allows direct viewing of the inside of the bladder. This is most commonly performed as an office procedure under local anesthesia or light sedation. First, a topical anesthetic gel is applied, so the patient will feel little or no discomfort. The doctor then inserts a viewing instrument called a cystoscope through the urethra and into the bladder. Looking through the cystoscope, the doctor is able to examine the bladder's inner surfaces for signs of cancer. Modern cystoscopes are soft and flexible, and this procedure is generally well tolerated.

If tumors are present, the doctor notes their appearance, number, location and size. As removal (resection) of the tumors cannot usually be done under local anesthesia, the patient is then scheduled to return for a surgical procedure to remove the tumor under general anesthesia or spinal anesthesia. In a manner as before, the doctor inserts an instrument, called a resectoscope, into the bladder. This is a viewing instrument similar to the cystoscope, but contains a wire loop at the end for removing tissue. This procedure is done through the urethra and is called a transurethral resection of bladder tumors. The removed tissue is sent to a pathologist for examination. Pathologists are specialists who interpret changes in body tissues caused by disease.

In addition to removing visible tumors, the doctor may remove very small samples of tissue of any suspicious-looking areas of the bladder. A pathologist also examines this tissue.

If a biopsy is taken and bladder cancer is found, the pathologist who examines the tissue will grade the tumor according to how angry the cells appear. The most widely used grading systems classify tumors into two main grades: low and high. The cells of low-grade tumors have minimal abnormalities. In high-grade tumors, the cells have become disorganized and many abnormalities are apparent. The grade indicates the tumor's "aggression level"—how fast it is likely to grow and spread. High-grade tumors are the most aggressive and the most likely to progress into the muscle.

Staging of bladder cancers is based on how deeply a tumor has penetrated the bladder wall.  Table 1 lists stages of penetration using the TNM classification system.

Table 1 -- Staging of primary bladder cancer tumors (T)

Ta:

Noninvasive papillary tumor (confined to urothelium)

Tis:

CIS carcinoma (high grade "flat tumor" confined to urothelium)

T1:

Tumor invades lamina propria

T2:

Tumor invades bladder muscle

T2a:

Invades superficial bladder muscle

T2b:

Invades deep bladder muscle

T3:

Tumor invades perivesical fat

T3a:

Microscopic perivesical fat invasion

T3b:

Macroscopic perivesical fat invasion (and progressing beyond bladder)

T4:

Tumor invades prostate, uterus, vagina, pelvic wall or abdominal wall

T4a:

Invades adjacent organs (uterus, ovaries, prostate)

T4b:

Invades pelvic wall and/or abdominal wall

Stages Ta and Tis (in the urothelium) and stage T1 (in the lamina propria) are the non-muscle-invasive stages. Most Ta tumors are low grade, and most do not progress to invade the bladder muscle. Stage T1 tumors may be much more likely to become muscle invasive but many, especially if not initially deeply invasive of the connective tissue, can be managed successfully by resection and medications placed in the bladder (see below). Stage Ta tumors often recur after treatment but they tend to do so with the same stage and grade. Stage T1 tumors must be watched carefully for the possibility that they may recur at a higher and potentially lethal stage.

The Tis stage classification is reserved for a type of high-grade cancer called carcinoma in situ (CIS). CIS usually appears through the cystoscope as a flat, reddish, velvety patch on the bladder lining. It is difficult to remove and is best treated with immunotherapy or chemotherapy. If untreated, CIS will likely progress to muscle-invasive disease. CIS in the bladder is a serious finding – it is cancer not just a premalignant lesion.

How is bladder cancer treated?

Removing stage Ta and stage T1 tumors: Transurethral resection of the bladder (TURBT) is the usual treatment method for patients who, when examined with a cystoscope, are found to have abnormal growths on the urothelium (stage Ta) and/or in the lamina propria (stage T1).  

Alternative methods, such as laser therapy, compare favorably with TURBT in terms of treatment results. However, TURBT has the major advantage of providing tissue suitable for a pathologist to use in determining a tumor's grade and stage. The tumor structure is left too distorted for this purpose after the alternative treatment methods, so biopsies of the tumor must be taken before treatment.

Intravesical chemotherapy and immunotherapy:  Following removal, intravesical chemotherapy or intravesical immunotherapy may be used to try to prevent tumor recurrences. Intravesical means "within the bladder". These therapeutic agents are put directly into the bladder through a catheter in the urethra (the catheter only stays in for a few minutes), are retained for one to two hours and are then urinated out.

The chief intravesical agents currently available are thiotepa, doxorubicin, mitomycin C and bacillus Calmette-Guerin (BCG). The first three are chemotherapy drugs. The fourth, BCG, is a live but weakened vaccine strain of bovine tuberculosis. It was first used to immunize humans against tuberculosis. It is now one of the most effective agents for treating bladder cancer and especially for treating CIS.

All four agents have some benefits and risks. Among the benefits:  Comparison studies have shown each of the four to be superior to TURBT alone for preventing tumor recurrences following TURBT. Studies have also shown both BCG and mitomycin C to be superior to doxorubicin or thiotepa for reducing recurrence of T1 tumors and high-grade Ta tumors. However, there is no absolute evidence that any intravesical therapy affects the rate of progression to muscle-invasive disease although some studies with BCG suggest this may be the case.

Among the risks:  Each of the four agents produces irritative side effects such as painful urination and the need to urinate frequently. In addition, BCG therapy carries a 24 percent risk of flu-like symptoms and a small risk (4 percent) of systemic infections. Thiotepa has a 13 percent risk of suppressing bone marrow activity — causing a reduction in white blood cells and platelets. The main side effects for each intravesical agent are shown in Table 2, along with estimated probabilities of occurrence.

Table 2: Side effects of treatment and estimated probabilities of occurrence

Intravesical Agent

Side Effects

BCG

Mitomycin C

Thiotepa

Doxorubicin

Frequent urination

63%

42%

11%

27%

Painful urination

75%

35%

30%

20%

Flu-like symptoms

24%

20%

11%

7%

Fever or chills

27%

3%

4%

4%

Systemic infections

4%

Not available

0.3%

Not available

Skin rash

6%

13%

2%

2%

Suppression of bone marrow activity

1%

2%

13%

0.8%

Recent studies have indicated a possible benefit of reducing recurrences by instilling these chemicals into the bladder immediately following resection of a bladder tumor, typically in the recovery room. BCG is not used in this way because of the risk that it might be absorbed into the bloodstream in this setting.

Once the grade and stage of the tumor has been determined, the urologist may decide to initiate a course of intravesical therapy with these agents. Generally, BCG is chosen if either stage T1 or carcinoma in situ is present. These patients are at highest risk of recurrence and progression and BCG is the most effective agent for preventing these adverse events. In general, Mitomycin is used for stage Ta tumors. Indications for these treatments are based upon the number of tumors that were present, their size, their appearance, the grade of tumor, and whether or not they penetrated the wall of the bladder (but not including the muscle layer). In general, six weekly treatments are given, in which a catheter is placed in the bladder, the medication is instilled, the catheter is removed, and the patient is instructed not to urinate for at least an hour.

Once the bladder has been assessed as free of disease at the first three month post-treatment cystoscopic inspection, many physicians consider it appropriate to apply additional treatments of these same drugs to forestall or prevent future recurrences.  While recent studies demonstrate this concept of  "maintenance therapy" is useful for some patients receiving BCG, it is of less certain benefit for those receiving the other three chemotherapeutic drugs. Whether additional treatments are given or not, periodic cystoscopies are required to detect tumor recurrence early, if it is going to develop. During the first one to two years surveillance is carried out on a quarterly basis but then can gradually be reduced to twice and eventually even once per year thereafter.

Cystectomy:  Surgical removal of the bladder may be an option for patients with CIS or high-grade T1 cancers that have persisted or recurred after initial intravesical treatment. There is a substantial risk of progression to muscle-invasive cancer in such cases, and some patients may want to consider cystectomy as a first choice of treatment. If so, they should ask their doctor for information about both the risks of cystectomy and the methods of urinary reconstruction ("urinary diversion").

An alternative is to repeat intravesical therapy. There is some evidence that patients may respond to repeat therapy. However, the evidence is too weak to draw firm conclusions about whether any amount or type of intravesical therapy, in any combination, can affect progression of high-grade disease. Patients with high risk disease, such as high grade TA or T1 cancer or CIS, who fail BCG are at particularly high risk and should strongly consider radical cystectomy.

Frequently asked questions:

Do bladder tumors occur in children?

Fortunately, bladder tumors are rare in children.

What are some risk factors for bladder cancer?

Smokers develop bladder cancer at two to three times the rate of non-smokers. People who work with dyes, metal, paints, leather, textile and organic chemicals may be at a higher risk. People who have chronic bladder infections may also be at higher risk.

Is there a screening test for early detection of bladder cancer?

Not at this time, although periodic check of the urine for microscopic blood may promote earlier detection.

 

Where can I go for more information?

Urology Care Foundation: Bladder Cancer Patient Guide

AUA Guidelines Patient Guides: The Management of Bladder Cancer



Reviewed: January 2011

Last updated: April 2014

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Bladder Cancer Glossary
  • abdominal: in the abdomen, the cavity of this part of the body containing the stomach, intestines and bladder.

  • anesthesia: Loss of sensation in any part of the body induced by a numbing or paralyzing agent. Often used during surgery to put a person to sleep.

  • anesthetic: A substance that causes lack of feeling or awareness.

  • biopsies: Tiny pieces of body parts are removed with a needle or during surgery and examined under a microscope to determine if cancer or other abnormal cells are present.

  • biopsy: A procedure in which a tiny piece of a body part (tissue sample), such as the kidney or bladder, is removed (with a needle or during surgery) for examination under a microscope; to determine if cancer or other abnormal cells are present.

  • bladder: The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.

  • bladder infection: Also known as cystitis. Urinary tract infection involving the bladder. Typical symptoms include burning with urination, frequency, urgency and wetting.

  • bone marrow: A soft, reddish substance inside some bones that is involved in the production of blood cells.

  • bovine tuberculosis: Contagious disease caused by an infection in the lymph nodes which spreads to other organs like the lungs.

  • cancer: An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.

  • carcinogen: Any substance that produces cancer.

  • carcinoma: Cancer that begins in the skin or in tissues that line or cover body organs.

  • carcinoma in situ: Also known as CIS. The stage of high-grade cancer that appears as a flat, reddish, velvety patch on the bladder lining.

  • catheter: A thin tube that is inserted through the urethra into the bladder to allow urine to drain or for performance of a procedure or test, such as insertion of a substance during a bladder X-ray.

  • chemotherapy: Treatment with medications that kill cancer cells or stop them from spreading.

  • chronic: Lasting a long time. Chronic diseases develop slowly. Chronic renal (kidney) failure may develop over many years and lead to end-stage renal (kidney) disease.

  • CIS: Also known as carcinoma in situ. The stage of high-grade cancer that appears as a flat, reddish, velvety patch on the bladder lining.

  • contract: To shrink or become smaller.

  • CT scan: Also known as computerized tomography, computerized axial tomography or CT scan. A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce cross-sectional images of the body. Shows detailed images of any part of the body, including bones, muscles, fat and organs. CT scans are more detailed than general X-rays.

  • cyst: An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.

  • cystectomy: Surgical removal of the bladder.

  • cystoscope: A narrow, tube-like instrument fitted with lenses and a light passed through the urethra to look inside the bladder. The procedure is called cystoscopy (sis-TAW-skuh-pee).

  • cystoscopic: Viewing the bladder with a narrow, tube-like instrument passed through the urethra.

  • cystoscopy: Also known as cystourethroscopy. An examination with a narrow, flexible tube-like instrument passed through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.

  • cytology: The examination of cells obtained from the body tissue or fluids, especially to establish if they are cancerous.

  • cytology: Examination of cells obtained from the body tissue or fluids, especially to determine if they are cancerous.

  • dysuria: Painful or difficult urination, most frequently caused by infection or inflammation but it can also be caused by certain drugs.

  • gene: The basic unit capable of transmitting characteristics from one generation to the next.

  • general anesthesia: Person is put to sleep with muscle relaxation and no pain sensation over the entire body.

  • hematuria: Blood in the urine, which can be a sign of a kidney stone or other urinary problem. Gross hematuria is blood that is visible to the naked eye. Microscopic hematuria cannot be seen but is detected on a urine test.

  • immunotherapy: Treatment to stimulate or restore the ability of the immune system to fight infection and disease.

  • infection: A condition resulting from the presence of bacteria or other microorganisms.

  • intravesical: Inside the bladder.

  • intravesical chemotherapy: Chemotherapy administered within the bladder.

  • intravesical immunotherapy: Treatment of disease by administering antibodies inside the bladder.

  • invasive: Not just on the surface; with regard to bladder cancer, a tumor that has grown into the bladder wall.

  • invasive: Having or showing a tendency to spread from the point of origin to adjacent tissue, as some cancers do. Involving cutting or puncturing the skin or inserting instruments into the body.

  • ions: Electrically charged atoms.

  • kidney: One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.

  • kidney stone: A stone that develops from crystals that form in urine and build up on the inner surfaces of the kidney, in the renal pelvis or in the ureters. (Also see nephrolithiasis.)

  • kidneys: One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.

  • lamina propria: In the bladder, a layer of loose connective tissue between the urothelium and bladder muscle (separated by a membrane from the urothelium).

  • laser: Device that utilizes the ability of certain substances to absorb electromagnetic energy and re-radiates as a highly focused beam of synchronized single wave-length radiation.

  • lesion: A zone of tissue with impaired function as a result of damage by disease or wounding. Examples are scars, abscesses, tumors and ulcers.

  • local anesthesia: Loss of sensation only in one part of the body induced by application of an anesthetic agent.

  • malignant: A cancerous growth that is likely to grow and spread which can cause serious disablement or death.

  • ovaries: Female reproductive organs that produce eggs and also produce the sex hormones estrogen and progesterone.

  • papillary tumor: Tumor with nipple-like, stalk-like or finger-like appearance.

  • pathologist: A physician who interprets and diagnoses the changes caused by disease in tissues and body fluids.

  • pelvic: Relating to, involving or located in or near the pelvis.

  • perivesical: Around the bladder.

  • prostate: A walnut-shaped gland in men that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.

  • radical: Complete removal.

  • radiologic: X-ray.

  • radiological imaging: Obtaining images of internal body parts with the use of X-rays and radioactive dyes.

  • resection: The surgical removal of a portion of a body part.

  • resectoscope: A tube-shaped instrument used by the urologist to scoop a tumor from the bladder lining.

  • sedation: State of calm relaxation induced in one or more body systems by administration of medical agents (sedatives).

  • Side effects: An action or effect of a drug other than that desired. Commonly it is an undesirable effect (e.g., nausea, headache, insomnia, acute toxic reaction or drug interaction).

  • spinal anesthesia: Anesthesia injected into the lower back which results in a loss of sensation in that part of the body.

  • stage: Classification of the progress of a disease.

  • stone: Small hard mass of mineral material formed in an organ.

  • stool: Waste material (feces) discharged from the body.

  • superficial: On the surface.

  • systemic: Affecting the whole body.

  • tissue: Group of cells in an organism that are similar in form and function.

  • topical: Describes medication applied directly to the surface of the part of the body being treated.

  • torted: Twisted.

  • transurethral: Through the urethra. Several transurethral procedures are used for treatment of BPH. (See TUIP, TUMT, TUNA or TURP.)

  • transurethral resection: Surgery performed with a special instrument inserted through the urethra.

  • tuberculosis: An infectious disease that causes small, round swellings to form on mucous membranes.

  • tumor: An abnormal mass of tissue or growth of cells.

  • tumor marker: A substance in the blood, urine or body tissues that can be elevated in cancer, among other tissue types.

  • TURBT: Also referred to as transurethral resection of the bladder. Surgical procedure performed where a lighted tube is inserted through the urethra into the bladder. It serves as a diagnostic and therapeutic role in the treatment of bladder cancer.

  • ureter: One of two tubes that carry urine from the kidneys to the bladder.

  • ureters: Pair of tubes that carry urine from each kidney to the bladder.

  • ureters: Tubes that carry urine from the kidneys to the bladder.

  • urethra: A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.

  • urethral: Relating to the urethra, the tube tha carries urine from the bladder to outside the body.

  • urinal: A portable device that is used as a receptacle for urine.

  • urinalysis: A test of a urine sample that can reveal many problems of the urinary system and other body systems. The sample may be observed for physical characteristics, chemistry, the presence of drugs or germs or other signs of disease.

  • urinary: Relating to urine.

  • urinary cytology: Inspection under a microscope of cells found in the urine.

  • urinary diversion: A term used when the bladder is removed or the normal structures are being bypassed and an opening is made in the urinary system to divert urine. The flow of urine is diverted through an opening in the abdominal wall.

  • urinary tract: The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.

  • urinary tract infection: Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.

  • urinate: To release urine from the bladder to the outside. Also referred to as void.

  • urination: The passing of urine.

  • urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.

  • urologist: A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)

  • urology: Branch of medicine concerned with the urinary tract in males and females and with the genital tract and reproductive system of males.

  • urothelium: Mucus lining in organs of the urinary tract, consisting in the bladder of three to seven cell layers.

  • uterus: A hallow, muscular organ in the pelvis cavity of females in which the embryo is nourished and develops before birth.

  • vagina: The tube in a woman's body that runs beside the urethra and connects the uterus (womb)to the outside of the body. Sometimes called the birth canal. Sexual intercourse, the outflow of blood during menstruation and the birth of a baby all take place through the vagina.

  • vas: Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.

Bladder Cancer Anatomical Drawings

click images for a larger view
 

 

 

 

 

 

 

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