Bladder cancer (transitional cell carcinoma of the bladder) is the second most common urological cancer in adults.
Condition – Bladder Cancer
It occurs more commonly in men and is often associated with cigarette smoking. Other risk factors include exposure to certain industrial chemicals, namely aromatic amines, often used in the printing and rubber industry.
Symptoms and signs
Haematuria (blood in the urine) is the most common presenting symptom in patients with bladder cancer. The bleeding may be seen with the naked eye or only found when the urine is examined under the microscope. Irritative voiding symptoms such as burning, frequent and urgent urination can also result from bladder cancer.
If you complain of any of these symptoms your doctor may ask you to have a number of investigations to determine a cause for the symptoms. Such tests may include:
- Urine microscopy and culture – to confirm the presence of blood and to exclude an underlying urinary tract infection
- Urine cytology – this involves the microscopic evaluation of the urine looking specifically for any cancer cells
- Intravenous pyelogram (IVP) – this is a dye study, that is very good at looking at the inside of the kidneys, at the tubes that drain urine from the kidney to the bladder (called the ureters), and at the bladder itself
- Cystoscopy – this involves a very small fibre-optic scope being passed through the urethra into the bladder. This very simple test can be done as an outpatient using a local anaesthetic gel injected into the urethra. This test is essential in any patient with blood in the urine in order to thoroughly evaluate the bladder
- Bladder biopsy – if any abnormality is seen in the bladder a small piece of tissue can be taken and sent to the pathologist for examination
- Transurethral resection (TUR) – if the urologist sees a tumour on cystoscopy it can be removed via the cystoscope. Usually, this can only be done under a general anaesthetic. Once again the tissue is sent to the pathologist. For many patients this is the only treatment their cancer will need.
Once the diagnosis of bladder cancer is made, your doctor will order a number of investigations to ensure that the cancer has not spread to anywhere else in the body. These may include a CT scan of the abdomen and pelvis, a chest Xray or CT scan of the chest, liver function tests and rarely an MRI scan.
TNM Classification of Bladder Cancer
The TNM staging system classifies bladder cancers based on 3 key pieces of information:
- The letter T is followed by numbers and/or letters to describe how far the main (primary) tumorhas grown through the bladder wall and whether it has grown into nearby tissues. Higher T numbers mean more extensive growth.
- The letter N is followed by a number from 0 to 3 to indicate any cancer spread to lymph nodesnear the bladder. Lymph nodes are bean-sized collections of immune system cells, to which cancers often spread first.
- The letter M is followed by 0 or 1 to indicate whether or not the cancer has spread (metastasized) to distant sites, such as other organs or lymph nodes that are not near the bladder.
Once the T, N, and M categories have been determined, this information is combined to find the overall cancer stage. Bladder cancer stages are defined using 0 and the Roman numerals I to IV (1 to 4). Stage 0 is the earliest stage, while stage IV is the most advanced.
Treatment – Bladder Cancer
Treatment options for superficial bladder cancer:
- Cystoscopy and diathermy of the tumour
- Transurethral resection of the bladder tumour (TURBT)
- Intravesical therapy
Treatment options for advanced bladder cancer:
Small tumours can easily be destroyed by heat delivered by either an electro-cautery device or laser fibre, similar to many superficial skin cancers. These instruments are passed into the bladder through a tiny channel within the cystoscope.
Larger tumours are usually completely resected using a curved endoscopic loop passed through the cystoscope. The tissue is removed from the bladder and sent to the pathologist for diagnosis. Often a urethral catheter is placed into the bladder for a time, to ensure there is no significant bleeding.
Certain drugs can be placed into the bladder via a catheter to coat the lining of the bladder and help reduce the risk of recurrence of the tumour and its progression. The most commonly used drugs include Bacille Calmette-Guerin (BCG) and Mitomycin C. The drugs delivered this way are not associated with the side effects commonly seen with chemotherapy.
Unfortunately, for those patients who have had one bladder cancer, up to 70% of them will develop a recurrent tumour. Therefore, it is imperative that these patients are diligently followed-up with regular check cystoscopies. These can be done under local anaesthetic and are usually performed at 3 monthly intervals in the first year, 4 monthly intervals in the second year, 6 monthly for the third and once a year thereafter.
A surgeon passes a telescopic instrument into the bladder via the urethra. The bladder wall and openings to the ureters can then be examined through a scope while filling the bladder with water. Any bladder cancer detected can then be removed surgically by the surgeon.
Treatment option for superficial Bladder Cancer.
With intravesical therapy, the doctor puts the drug directly into the bladder (through a catheter) rather than giving it by mouth or injecting it into a vein. This may be either immunotherapy, which causes the body’s own immune system to attack the cancer cells, or chemotherapy.
Medicines given this way mainly affect the cells lining the bladder, with little to no effect on cells elsewhere. This means that any cancer cells outside of the bladder lining, including those that have grown deeply into the bladder wall, are not treated. Drugs put into the bladder also can’t reach cancer cells in the kidneys, ureters, and urethra, or those that have spread to other organs.
Cystectomy involves the complete removal of the bladder and in the male patient removal of the prostate and seminal vesicles as well. In the female the uterus and tubes are also removed. Obviously once the bladder is removed, the drainage of urine needs to be addressed. Reconstructive techniques used include:
- Ileal conduit
- Continent cutaneous reservoir
- Orthotopic bladder substitution
Essentially, in these operations a segment of bowel is harvested and isolated from the intetsine. The ureters are connected to one end and the other drains to the skin (stoma) and empties into a bag, in the case of an ileal conduit, into a reservoir of bowel with a stoma that is catheterizable, in the case of the continent cutaneous reservoir and finally into a new bladder fashioned out of the bowel and is connected to the patients own urethra allowing normal micturition in the case of bladder substitution.
Radiation therapy can be used to treat muscle invasive bladder cancer as well, either in isolation or more commonly nowadays in combination with chemotherapy. Multiple chemotherapeutic agents are used together with the radiation therapy. This prolonged treatment course can give results approaching those of surgery in terms of curing the cancer.
Treatment options for advanced Bladder Cancer.
Chemotherapy is the use of drugs to kill or slow the growth of cancer cells. Chemotherapy drugs are also called cytotoxics, which means poisonous (toxic) to cells (cyto). Many of these drugs are obtained from natural sources such as plants, while others are completely developed in the laboratory. There are many types of chemotherapy drugs, which are often used in different combinations and at different strengths.
All treatment options are associated with differing risks and benefits. Patients with bladder cancer are best served when managed in units where multidisciplinary clinics are available so as to offer each individual patient the best treatment option for both their cancer and themselves.