Bladder cancer is the most common cancer of the urinary tract, and therefore highly treatable with options such as surgery, chemotherapy and radiation.
The bladder is an organ located in the pelvic cavity that stores and discharges urine. Urine is produced by the kidneys, carried to the bladder by the ureters, and discharged from the bladder through the urethra. Bladder cancer accounts for approximately 90% of cancers of the urinary tract (renal pelvis, ureters, bladder, urethra).
Bladder cancer often has a high rate of recurrence. Therefore surveliance programs are aggressive with urine cytology and cystoscopy are performed every 3 months for 2 years, every 6 months for the next 2 years, and then yearly.
Superficial bladder cancer has a 5-year survival rate of about 85%. Invasive bladder cancer has a less favorable prognosis. Cases of recurrent bladder cancer may indicate an aggressive tumor and a poor prognosis.
Cancer-causing agents (carcinogens) in the urine may lead to the development of bladder cancer. Cigarette smoking contributes to more than 50% of cases. Smoking cigars or pipes and exposure to second-hand smoke also increase the risk.
The primary symptom of bladder cancer is blood in the urine known as hematuria. Hematuria may be seen grossly or microscopic and is usually painless. Other symptoms include frequent urination and pain upon urination (dysuria).
Diagnosing bladder cancer often requires several steps of work-up. A complete medical history is used to identify potential risk factors (e.g., smoking, exposure to dyes).
Common laboratory tests to diagnose bladder cancer include:
- Urinalysis to detect microscopic hematuria
- Urine cytology to detect cancer cells by examining cells flushed from the bladder during urination
- Urine culture to rule out urinary tract infection
Imaging tests are performed to examine the upper tracts of the urinary system including the kidneys to rule out tumors, stones, or cysts often with a CT scan.
Cystoscopy is performed to examine the inside of the bladder to rule out bladder tumors. Local anesthesia is administered and a cystoscope (thin, telescope-like tube with a tiny camera attached) is inserted into the bladder through the urethra to allow the physician to detect abnormalities. If a tumor is seen it is then biopsied and removed under general anesthesia. Surgical removal allows the pathologist to assess the depth of invasion of the tumor into the bladder wall which is the key element in bladder cancer staging.
Treatment – Non-Surgical
Immunotherapy, also called biological therapy, is used to enhance the immune system’s ability to fight cancer. In this treatment, BCG, a vaccine derived from the bacteria that causes tuberculosis, is infused through the urethra into the bladder, once a week for 6 weeks. This vaccine stimulates the immune system to destroy cancer cells. BCG is often used for recurrent superficial bladder cancer as well as non-muscle invasive bladder cancer that harbors agressive features. BCG has been shown in randomized clinical trials to decrease the recurrence rate of bladder cancer as well and progression of bladder cancer to higher stages of disease.
Chemotherapy is the use of drugs to destroy cancer cells. It is a systemic treatment (i.e., destroys cancer cells throughout the body) and is administered orally or intravenously (through a vein). In early bladder cancer, intravesical chemotherapy (infused into the bladder through the urethra) may be recommended when BCG has failed. In patients with more aggressive disease, chemotherapy may be adjuvant (after surgery), or neoadjuvant (before surgery) therapy.
Radiation uses high-energy rays to destroy cancer cells. External beam radiation is emitted from a machine outside the body and internal radiation is emitted from radioactive “seeds” implanted into the tumor. Either type of radiation therapy may be used after surgery to destroy cancer cells that may remain. Radiation therapy is also used to ease symptoms in advanced cases of bladder cancer. Side effects include inflammation of the rectum (proctitis), incontinence, skin irritation, hematuria, and fibrosis (buildup of fibrous tissue).
Treatment – Surgical
In patients where cancer has invaded into or through the muscle of the bladder wall removal of the bladder may be indicated as the best means of cure. This procedure is known as radical cystectomy. Once the bladder is removed urinary diversion is performed to re-route the urine that was previously stored and voided through the bladder. There are several types of urinary diversion available. The specific type of diversion performed depends upon numerous factors including stage of cancer as well as the functional status and body habitus of the patient.