Bladder Cancer

The bladder is a hollow organ that stores urine.

Urine is made in the kidneys and flows into the bladder through thin tubes called ureters. Urine leaves the bladder through another tube called the urethra.

In women the urethra is very short. In men it is longer since it passes through the prostate gland to the tip of the penis.

The bladderTHE URINARY SYSTEM

The wall of the bladder has several layers. Cancer begins in the lining layer and grows into the bladder wall. As the cancer grows through the layers into the wall of the bladder, it becomes harder to treat.

The inside of the bladder is lined with a layer of cells called urothelial cells. The same type of cells also lines the kidneys, the tubes connecting the kidneys to the bladder (ureters), and the urethra. Cancer can begin in the lining cells in any of these structures which are part of the urinary system.

BLADDER CANCER TYPES

Bladder cancers are categorized by cell type.. The type of bladder cancer you have is important because different types can respond differently to treatments. In addition to the cell type, it is important to know if the cancer is just on the surface (non-invasive) or if it grows into the bladder layers (invasive).

Transitional cell carcinoma: This is by far the most common type of bladder cancer. It starts in the urothelial cells and is also called urothelial carcinoma. These tumors are divided into grades based on how the cells look under the microscope. If the cells look more like normal cells, the cancer is called a low-grade cancer. When the cells look very abnormal, the cancer is high-grade. Low-grade cancers tend to grow more slowly and behave less aggressively than high-grade cancers.

Squamous cell carcinoma and Adenocarcinoma are two other cell types that are much less common. They are often invasive when found.

While there are other types of bladder cancer, they are very rare. There are also a number of bladder tumors that are benign (not cancer).

Bladder cancer is the second most common cancer of the urinary system. Bladder cancer is more common among men than women. This is a cancer of older people. Nearly 90% of people with this cancer are over the age of 55. The earlier this cancer is found and treated the better the outcome.

RISK FACTORS

The following risk factors have been linked to bladder cancer:

  • Smoking: Smoking is the greatest risk factor for bladder cancer. Smokers get bladder cancer twice as often as people who don't smoke. Certain chemicals in tobacco smoke are absorbed from the lungs into the blood. From the blood, they are filtered by the kidneys and collect in the urine. These chemicals in the urine damage the cells that line the inside of the bladder and increase the risk of cancer.
  • Work exposure: Some chemicals used in the making of dye have been linked to bladder cancer. The industries with highest risks include the makers of rubber, leather, textiles, and paint products, as well as printing companies. Workers with a higher risk of bladder cancer include painters, hairdressers, machinists, printers, and truck drivers. Smoking increases the risk among these workers.
  • Race: Whites are twice as likely to get bladder cancer as are African Americans and Hispanics. Asians have the lowest rate of bladder cancer. We do not know the reason for this.
  • Age: The risk of bladder cancer goes up with age.
  • Gender: Men get bladder cancer 4 times as often as women.
  • Chronic bladder inflammation: While urinary infections, kidney stones, and bladder stones don't cause bladder cancer, they cause ongoing inflammation and have been linked to it.
  • Personal or family history of bladder cancer: People who have had bladder cancer have a higher chance of getting another tumor. People whose family members have had bladder cancer also have a higher risk.
  • Bladder birth defects: Very rarely a connection between the belly button and the bladder doesn't go away as it should before birth and it can become cancerous. There is another, very rare, birth defect called exstrophy which can lead to bladder cancer

SIGNS AND SYMPTOMS OF BLADDER CANCER

Blood in the urine: In most cases, blood in the urine is the first sign of bladder cancer. Sometimes, there is enough blood to change the color of the urine. Or the urine may be very pale yellow-red or, less often, darker red. In other cases, the color of the urine is normal but small amounts of blood can be found by urine tests done because of other symptoms or as part of a check-up.

But blood in the urine does not mean you have bladder cancer. Much more often it is caused by other things, such as infection, benign tumors, stones in the kidney or bladder, or other causes.

Changes in bladder habits: Having to urinate more often, or feeling as if you need to go but not being able to do so can be a symptom of bladder cancer. But these problems are more often caused by something other than cancer.

TESTS TO FIND BLADDER CANCER

  • Medical history and physical exam: Your doctor will ask you about your medical history to check for risk factors and symptoms. At your visit, the doctor can look at the urine sample to see if blood cells can be seen.
  • Urine culture: A sample of your urine is sent to the lab to see if you might have an infection. An infection can sometimes cause symptoms that look like bladder cancer. It may take 2 or 3 days to get the results of this test.
  • Bladder tumor marker studies: These tests look for certain substances released by cancer cells into the urine.
  • Urine cytology: In this test, urine or cells "washed" from the bladder are sent to the lab to see if cancer cells (or pre-cancer cells) are present. This is often done at the same time as the cystoscopy. Not finding cancer on this test doesn't mean you are cancer-free.
  • Cystoscopy: A cystoscope is a soft, flexible scope with a lens and a light. The doctor places it into the bladder through the urethra. The area is first numbed with lidocaine gel so it will be comfortable. Through the cystoscope the doctor can see the inside of the bladder. If there is anything that doesn't look normal, a small piece of tissue can be removed as a biopsy.
  • Biopsy: When a piece of tissue is removed to see if it contains cancer cells, the test is called a biopsy. This test can tell if cancer is present, what type of bladder cancer it is, and how deep it has gone into the bladder wall. Bladder biopsy samples are most often taken during cystoscopy.

IMAGING TESTS

If you have bladder cancer, your doctor may order some of these tests to see the upper parts of the urinary tract. These imaging tests can also determine if the cancer has spread to tissues near the bladder, nearby lymph nodes, or to distant organs.

  • Intravenous pyelogram (IVP): An IVP is an x-ray of the urinary system taken after putting a special dye into a vein. The dye passes into the ureters and bladder. This more clearly outlines these organs on x-rays and helps find tumors.
  • Retrograde pyelography: For this test, a thin, flexible tube called a catheter is placed into the bladder or into a ureter. Then, a dye is put through the catheter to make the lining of the bladder, ureters, and kidneys easier to see on x-rays. Like IVP, this test can be used to find tumors in the upper part of the urinary tract.
  • Chest x-ray: A chest x-ray may be done to look for a tumor or a spot on the lungs that might have spread from the bladder cancer.
  • Computed tomography (CT): The CT scan is a special kind of x-ray that takes detailed images of your kidneys and bladder as well as other organs. It can help find enlarged lymph nodes that might contain cancer.
  • Magnetic resonance imaging (MRI): This test is like a CT scan, but it uses powerful magnets and radio waves instead of x-rays to make pictures. For some scans, a contrast material may be put into your vein to help see some structures better. MRI scans take longer than CT scans. Also, for most MRI scans you will be inside a tight tube-like machine. This can upset people with fear of enclosed spaces. If you are worried about this, talk to your doctor about it before getting an MRI.
  • Ultrasound: Ultrasound uses sound waves to make images so there is no radiation exposure. It is useful to image the kidneys and can help show the size of a bladder cancer and whether it has spread beyond the bladder.
  • Bone scan: For this test, a small amount of a radioactive substance is put into a vein. This substance builds up in areas of bone that contain cancer. A scanner can spot these areas that may be spread of the cancer cells.

TREATMENT

The main types of treatment for bladder cancer are surgery, radiation therapy, immunotherapy, and chemotherapy. Surgery, alone or along with other treatments, is used in more than 9 out of 10 cases.

SURGERY

There are several kinds of surgery for bladder cancer. Some involve removing the entire bladder and others do not. The type of surgery depends on the stage of the cancer. The most common types of surgery are explained below.

  • Transurethral surgery: This operation is used most often for early stage bladder cancer. It is done with a scope placed into the bladder through the urethra (same approach as the cystoscopy) so no incisions are made. Through this scope the tumor is removed and the bladder wall sampled to be sure no cancer remains. The side effects of this surgery are usually mild and do not usually last long. There may be some bleeding or mild pain right after surgery. You can usually go home the same day. Some patients will need a catheter for a few days after surgery but many do not. In less than 1 to 2 weeks you should be able to go back to your normal activities.

  • Cystectomy: When bladder cancer is invasive more aggressive treatment is needed so all or part of the bladder may need to be removed. This operation is called a cystectomy. In the past, the surgeon had to cut through the abdomen to get to the bladder, but now many of these operations can be performed with minimally invasive techniques using the laparoscope and robotic systems. For either operation, you will be asleep.

    When only part of the bladder is removed, it is called a partial cystectomy. If the entire bladder is removed it is a radical cystectomy. (If the entire bladder is removed, a reconstruction will be done. See below). Nearby lymph nodes are also taken out. In men, the prostate is removed. In women, the uterus, ovaries, fallopian tubes, and a small part of the vagina are often removed. You will need to stay in the hospital for about 7 to 10 days. After about 4 to 6 weeks you should be able to go back to your normal activities.

  • Reconstructive surgery: If the whole bladder is removed, the body needs another way to store and remove urine. There are several ways to do this. One option is a urostomy. In this approach, tissue taken from the small intestine (bowel) is attached to the ureters and connected to the skin of your belly though a small opening (called a stoma). A bag sticks to your belly around this opening to catch the urine.

    A second method is called a continent diversion. This does not require a bag outside the body. Instead, the surgeon creates a sac from a small piece of intestine and attaches the ureters to it. Urine is emptied when a drainage tube (catheter) is placed into the hole (stoma) of the diversion.

    A third option is a neobladder. The surgeon builds a replacement "bladder" using a segment of intestine and connects the neobladder to the urethra so you can urinate through you natural orifice. When possible, this is the preferred reconstruction.

INTRAVESICAL THERAPY

Intravesical treatment is placed right into the bladder rather than being given by mouth or put into a vein. The most common form of this type of treatment for bladder cancer is immunotherapy. This treatment causes the body's own natural defenses (immune system) to attack the cancer.

BCG is an example of immunotherapy that is useful for treating bladder cancer. BCG is a type of bacteria that is sometimes used to vaccinate people against TB (tuberculosis). When used to treat bladder cancer, BCG is given right into the bladder through a thin, flexible tube called a catheter. The body's immune system responds to the BCG. Immune system cells are drawn to the bladder and attack the cancer. BCG is usually given once a week for 6 weeks.

Another form of intravesical immunotherapy is interferon, a substance normally made by the body. Interferon is often combined with BCG for treating certain bladder cancers.

In contrast, intravesical chemotherapy involves anti-cancer drugs put into the bladder through a catheter. Drugs given this way reach cancer cells in the bladder lining directly. Because it mainly affects the cells lining the bladder, intravesical chemotherapy doesn't make you feel ill or cause your hair to fall out like some intravenous treatments can cause. The main side effects of intravesical chemo are irritation and a burning feeling in the bladder.

CHEMOTHERAPY

Chemotherapy (often called simply "chemo") is the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they spread throughout the body. Chemo is useful in treating cancer that has spread beyond the bladder to lymph nodes and other organs.

Chemo might be used to shrink a large tumor so it is easier to remove during surgery. When used this way it is called neoadjuvant chemo (giving the drugs before the local treatment). It can also be given after surgery to prevent the growth of stray cancer cells still in the body. This is called adjuvant chemo.

Sometimes chemo is given with radiation in order to help the radiation work better. This is sometimes done as an alternative to surgery for more frail patients.

Side effects of chemo

While chemo drugs kill cancer cells, they also damage some normal cells and this can lead to side effects. These side effects depend on the type of drugs used, the amount taken, and the length of treatment. Short-term side effects might include:

  • nausea and vomiting
  • not feeling hungry
  • hair loss
  • mouth sores
  • greater chance of infection (from a shortage of white blood cells)
  • bleeding or bruising after minor cuts or injuries (from a shortage of blood platelets)
  • tiredness (from low red blood cell counts, called anemia)

RADIATION THERAPY

Radiation therapy is treatment with high-energy rays (such as x-rays) to kill cancer cells and shrink tumors. The radiation may come from outside the body or from radioactive materials placed directly in the tumor. After surgery, radiation can kill small deposits of cancer cells that may be too small to see.


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