Bladder cancer

What is bladder cancer?

• Cancer of the bladder is a condition in which the tissues of the bladder develop malignant (cancer) cells.
• The risk of bladder cancer may be affected by smoking.
•  Bladder cancer signs and symptoms include blood in the urine and pain when urinating.
•  In order to help identify (find) and diagnose bladder cancer, tests that analyze the urine and bladder are used.
• Prognosis (chance of recovery) and treatment choices are influenced by several factors.

One of the most common cancers is bladder cancer, affecting approximately 68,000 adults per year in the United States. Bladder cancer happens more often in males than in females and typically affects older adults, although it can occur at any age.

In the cells (urothelial cells) that line the interior of your bladder, the hollow muscular organ in your lower abdomen that stores urine, bladder cancer most frequently starts. This same kind of cancer can occur in other parts of the urinary tract drainage system, but it is most common in the bladder.

When bladder cancer is highly treatable, approximately seven out of every 10 diagnosed bladder cancers start out at an early stage. In the bladder, however even early-stage bladder cancer can recur. For this reason, for years after treatment, people with bladder cancer usually need follow-up testing to check for bladder cancer that recurs or progresses to a higher level.

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Symptoms of bladder cancer

Bladder cancer signs and symptoms may include:

• Blood in urine (hematuria)
• Painful urination
• Pelvic pain

Your urine can appear bright red or cola-colored if you have hematuria. Often, urine does not look any different, but during a microscopic urine test, blood in the urine may be observed.

Bladder cancer individuals may also experience:

• Back pain
• Frequent urination

But because of something other than bladder cancer, these signs also happen.

Causes of bladder cancer

When cells in the bladder start developing abnormally, bladder cancer grows. These cells develop mutations that cause them to grow out of control and not die, rather than grow and split in an orderly way. A tumor is created by these abnormal cells.

Among the causes of bladder cancer are:

• Smoking and other tobacco use
• Exposure to chemicals, especially working in a job that requires exposure to chemicals
• Past radiation exposure
• Chronic irritation of the lining of the bladder
• Parasitic infections, especially in people who are from or have traveled to certain areas outside the United States

It’s not always clear what causes bladder cancer, and some people with bladder cancer have no obvious risk factors.

Types of bladder cancer

Different cell types may become cancerous in your bladder. The type of bladder cell in which cancer starts decides the type of cancer in the bladder. The form of bladder cancer defines which therapies are most appropriate for you.

Types of bladder cancer include:

• Urothelial carcinoma :In the cells that line the interior of the bladder, urothelial carcinoma, historically called transitional cell carcinoma, occurs. When your bladder is full, urothelial cells expand and contract when your bladder is empty. The inside of the ureters and the urethra line up these same cells, and tumors may also form in those areas. The most prevalent form of bladder cancer in the United States is urothelial carcinoma.
• Squamous cell carcinoma :Squamous cell carcinoma is associated with persistent bladder irritation attributable to an infection or long-term use of a urinary catheter, for example. It is more common in areas of the world where bladder infections are a common cause of a certain parasitic infection (schistosomiasis).
• Adenocarcinoma begins in cells that make up mucus-secreting glands in the bladder.

Risk factors of bladder cancer

Factors that may increase bladder cancer risk include:

• By allowing toxic chemicals to accumulate in the urine, smoking cigarettes, cigars or pipes may increase the risk of bladder cancer. Your body processes the chemicals in the smoke as you smoke and excretes some of them in your urine. The lining of your bladder can be harmed by these toxic chemicals, which may increase your cancer risk.
• Increasing age :As you age, bladder cancer risk rises. Bladder cancer can occur at any age, but in people younger than 40, it’s rarely identified.
• Being white :White people have a higher risk of cancer of the bladder than people of other races do.
• Being a man :Men are more likely than women to develop bladder cancer.
• Exposure to certain chemicals :In filtering toxic chemicals out of your bloodstream and transferring them into your bladder, your kidneys play a key role. It is suspected that being around these chemicals will raise the risk of bladder cancer because of this. Arsenic and chemicals used in the manufacture of dyes, rubber, leather, textiles, and paint products are chemicals linked to bladder cancer risk.
• Previous cancer treatment :The risk of bladder cancer is raised by treatment with the anti-cancer medication cyclophosphamide. People who have undergone pelvic radiation therapy for prior cancer have a high chance of developing bladder cancer.
• Chronic bladder inflammation : The risk of squamous cell bladder cancer can be increased by chronic or recurrent urinary infections or inflammation (cystitis), as may occur with long-term use of a urinary catheter. Squamous cell carcinoma in some parts of the world is related to chronic inflammation of the bladder caused by a bacterial infection known as schistosomiasis.
• Personal or family history of cancer :You are more likely to get it again if you’ve had bladder cancer. If a parent, sibling or child has a history of bladder cancer in one of your first-degree relatives, you could have an elevated risk of the illness, while running in families is rare for bladder cancer. Family history of inherited colorectal cancer without polyposis, also known as Lynch syndrome, may increase the risk of cancer of the urinary system, colon, uterus, ovaries, and other organs.

Prevention of bladder cancer

Although there’s no guaranteed way to prevent bladder cancer, you can take steps to help reduce your risk. For instance:

• Don not smoke : Not smoking means that the bladder is unable to collect cancer-causing chemicals in the smoke. Do not start if you don’t smoke. Speak to your doctor if you are smoking about a plan to help you quit. You can be encouraged to leave by support groups, drugs and other approaches.
• Take caution around chemicals :Follow all safety guidelines to prevent contamination if you deal with chemicals.
• Choose a variety of fruits and vegetables : Choose a diet rich in a variety of colorful vegetables and fruits. In fruits and vegetables, antioxidants may help reduce your cancer risk.

Diagnosing bladder cancer

Tests and procedures used to diagnose bladder cancer may include:

• Cystoscopy : Your doctor will insert a thin narrow tube (cystoscope) through the urethra to conduct the cystoscopy. The cystoscope has a lens that helps your doctor to see the inside of your urethra and bladder and to check for signs of disease in these structures.
• Your doctor can move a specific instrument through the scope and into your bladder during a cystoscopy to collect a cell sample (biopsy) for testing. This operation is also called bladder tumor transurethral resection (TURBT). In order to treat bladder cancer, TURBT may also be used.
• Urine cytology :In a technique called urine cytology, a sample of the urine is examined under a microscope to search for cancer cells.
• Imaging tests :Imaging tests, such as a computed tomography (CT) urogram or retrograde pyelogram, allow your doctor to check your urinary tract structures.

A contrast colorant injected into a vein in your hand gradually flows into your kidneys, ureters, and bladder during a CT urogram. X-ray images taken during the examination provide your urinary tract with a clear view and help the doctor locate any areas that might be cancerous.

An X-ray test used to get a thorough look at the upper urinary tract is a retrograde pyelogram. Your doctor will thread a thin tube (catheter) through the urethra and through your bladder during this procedure to inject contrast dye into your ureters. While X-ray images are captured, the dye then flows into the kidneys.

Determining the extent of the cancer

Your doctor may recommend additional tests to decide if your cancer has spread to your lymph nodes or to other areas of your body after confirming that you have bladder cancer.

Tests may include:

• CT scan
• Magnetic resonance imaging (MRI)
• Bone scan
• Chest X-ray

To allocate a stage for your cancer, your doctor uses details from these procedures. Roman numerals ranging from 0 to IV reflect the stages of bladder cancer. A cancer that is limited to the inner layers of the bladder and that has not developed to affect the muscular bladder wall is indicated in the lowest phases. The highest stage, stage IV, suggests that in distant areas of the body, cancer has spread to lymph nodes or organs.

As doctors develop cancer diagnosis and care, the cancer staging system continues to evolve and is becoming more difficult. Your doctor uses the stage of your cancer to choose which therapies are right for you.

Bladder cancer grade

Bladder cancer tumors are further categorized based on how, when viewed through a microscope, the cancer cells look. This is known as tumor grade, and bladder cancer can be identified by your doctor as either low or high grade:

• Low-grade bladder tumor :This type of tumor has cells which are similar to normal cells in appearance and organization (well-differentiated). A low-grade tumor typically grows slower and is less likely than a high-grade tumor to penetrate the muscular wall of the bladder.
• High-grade bladder tumor : This form of tumor has abnormal-looking cells that do not resemble normal-appearing tissues (poorly differentiated). A high-grade tumor appears to grow more rapidly than a low-grade tumor and may be more likely to spread to the bladder muscle wall and to other tissues and organs.

Treatment of bladder cancer

Bladder cancer care choices rely on a variety of variables that are taken into account along with your general health and your treatment preferences, including the type of cancer, the degree of cancer and the stage of the cancer.

Treatment for bladder cancer can involve:

• Surgery to remove cancerous tissue
• Chemotherapy in the bladder (intravesical chemotherapy), to treat tumors that are confined to the lining of the bladder but have a high risk of recurrence or progression to a higher stage
• Reconstruction to create a new way for urine to exit the body after bladder removal
• Chemotherapy for the whole body (systemic chemotherapy), to increase the chance for a cure in a person having surgery to remove the bladder, or as a primary treatment in cases where surgery isn’t an option
• Radiation therapy to destroy cancer cells, often as a primary treatment in cases where surgery isn’t an option or isn’t desired
• Immunotherapy to trigger the body’s immune system to fight cancer cells, either in the bladder or throughout the body

Your physician and members of your care team may prescribe a variety of treatment approaches.

Bladder cancer surgery

Approaches to bladder cancer surgery might include:

• Transurethral resection of bladder tumor (TURBT) :TURBT is a technique to eliminate bladder cancers that are also not muscle-invasive cancers, limited to the inner layers of the bladder. A surgeon passes a short wire loop through a cystoscope and into the bladder during the operation. Using an electric current, the wire loop burns away cancer cells. Alternatively, cancer cells can be killed using a high-energy laser.TURBT is done under regional anesthesia where either the lower part of the body is given medication numbs or general anesthesia where medication puts you to sleep during the procedure. You would not have any cuts (incisions) in your abdomen because physicians conduct the operation through the urethra.

  As part of the TURBT treatment, your doctor may prescribe a one-time injection of cancer-killing medication (chemotherapy) into your bladder to eliminate any remaining cancer cells and to prevent a tumor from coming back. For up to an hour, the drug stays in your bladder and then is drained.

• Cystectomy is surgery to remove all or part of the bladder. During a partial cystectomy, your surgeon removes only the portion of the bladder that contains a single cancerous tumor. Partial cystectomy may only be an option if cancer is limited to one area of the bladder that can easily be removed without harming bladder function.

An operation to remove the whole bladder, part of the ureters and surrounding lymph nodes is a radical cystectomy. In men, the removal of the prostate and seminal vesicles usually requires radical cystectomy. In women, the removal of the uterus, ovaries and part of the vagina is also involved in radical cystectomy.

Check : Cost of bladder cancer surgery in India

Radical cystectomy can be done using robotic surgery with a single incision on the lower part of the belly or through several small incisions. The surgeon sits on a nearby console during robotic surgery and uses hand controls to precisely move robotic surgical instruments.

A cystectomy carries a risk of bleeding and infection. In males, erectile dysfunction can be caused by prostate and seminal vesicle removal. Your surgeon may, however, be able to save the nerves required for an erection. In women, ovarian removal causes premature menopause and infertility.

• Neobladder reconstruction :Your surgeon must establish a new way for your urine to leave your body after a radical cystectomy (urinary diversion). Neobladder reconstruction is one method for urinary diversion. Out of a slice of your gut, your surgeon builds a sphere-shaped reservoir. Sometimes called a neobladder, this reservoir sits within your body and is attached to your urethra. The neobladder helps you to urinate normally, in most cases. A small number of individuals with a neobladder have trouble emptying the neobladder and will need to regularly use a catheter to remove all the urine from the neobladder.
• Ileal conduit :Your surgeon builds a tube (ileal conduit) using a section of your intestine for this kind of urinary diversion. The tube runs from your kidney draining ureters to the outside of your body where the urine is emptied into a pouch (urostomy bag) that you’re carrying on your stomach.
• Continent urinary reservoir :Your surgeon uses a part of the intestine to create a small pouch (reservoir) to carry urine located within your body during this form of urinary diversion procedure. Through using a catheter a few times per day, you remove urine from the tank through an opening in your abdomen.

Immunotherapy in bladder cancer

Immunotherapy, also called biological therapy, aims to help combat cancer cells by signaling the body’s immune system.

Bladder cancer immunotherapy is often delivered through the urethra and straight into the bladder (intravesical therapy). Bacillus Calmette-Guerin (BCG), which is a vaccine used to protect against tuberculosis, is one such immunotherapy drug used for treating bladder cancer. A synthetic form of interferon, which is a protein that your immune system produces to help combat diseases, is another immunotherapy medicine. In conjunction with BCG, a synthetic variant, called interferon alfa-2b (Intron A), is also used.

Atezolizumab (Tecentriq) is a new immunotherapy alternative for locally advanced or metastatic cancer of the bladder that after chemotherapy, has not responded or has worsened. The medicine, an intravenous (IV) drug, works by activating the immune system of the body to attack the cancerous tumor.

Atezolizumab is also being studied as a possible first line therapy for people with bladder cancer who aren’t eligible for chemotherapy.

Bladder preservation

The bladder can be maintained in some forms of muscle-invasive disease by using a three-prong treatment strategy. Identified as trimodality therapy, TURBT, chemotherapy and radiation therapy are part of the treatment strategy.

Next a TURBT operation is performed by your surgeon to extract as much cancerous tissue from your bladder as possible, while preserving bladder function. You undergo a chemotherapy regimen along with radiation therapy after TURBT, all of which take place within the first few weeks after surgery.

If not all the cancer has disappeared or you have a recurrence of muscle-invasive cancer after attempting trimodality therapy, your surgeon can prescribe a radical cystectomy.

Upper urinary tract disease

In the upper urinary tract, the same kind of cancer (urothelial cancer) that causes the majority of bladder cancers can also occur, affecting:

• The thin tubes that drain urine from your kidneys to your bladder (ureters)
• The area within your kidney where urine collects before emptying into a ureter (renal pelvis)
• Other urinary tract structures deep within the kidney where the process of producing urine begins

Treatment of upper urinary tract cancer, similar to treatment for bladder cancer, depends on several factors such as the size of the tumor, the position of the tumor, the general health and your desires.

Upper urinary tract cancer normally requires surgery to remove the cancer in order to destroy any residual cancer cells and to avoid recurrence, along with chemotherapy or radiation therapy as follow-up treatments.

If one of your kidneys needs to be removed, surgery could leave you with only one working kidney. If this occurs, it is possible that your doctor will prescribe routine kidney function tests to monitor how well your remaining kidney is doing.

After bladder cancer treatment

Cancer of the bladder can recur. Because of this, for years after successful treatment, individuals with bladder cancer require follow-up monitoring. What tests are you going to have and how often, among other things, depends on the form of bladder cancer and how it has been treated.

Ask your doctor to build for you a follow-up plan. In general, for the first few years after treatment for bladder cancer, physicians prescribe a procedure to examine the inside of the urethra and bladder (cystoscopy) every three to six months. You may need a cystoscopy test only once per year after a few years of surveillance without detecting cancer recurrence. At regular intervals, your doctor can prescribe other tests as well.

More frequent monitoring can be carried out on people with aggressive cancers. Those with cancers that are less aggressive can undergo testing less often.

Check : Cost of bladder cancer chemotherapy in India

Intravesical Chemotherapy for Non-Muscle-Invasive Bladder Cancer

Intravesical therapies inject a drug through a catheter inserted in the urethra (the duct through which urine exits the body) directly into the bladder instead of through the mouth or through a vein. For one to two hours, the medication remains in the bladder. It is then drained into the catheter or into the urine. We can offer intravesical chemotherapy after transurethral resection for early-stage non-muscle-invasive) bladder cancer to decrease the risk that the cancer will return. For intravesical chemotherapy, we usually use the medication mitomycin (Mitosol®).

Chemotherapy before Surgery for Muscle-Invasive Bladder Cancer

Our physicians may prescribe chemotherapy prior to surgery for muscle-invasive bladder cancer. This approach to treatment is called neoadjuvant chemotherapy. Large clinical trials have shown that for people with muscle-invasive bladder cancer, this method improves cure rates and long-term survival. For neoadjuvant chemotherapy, we usually use the medications gemcitabine (Gemzar®) and cisplatin.

Chemotherapy after Surgery for Muscle-Invasive Bladder Cancer

Without neoadjuvant chemotherapy, some individuals will have surgery. In this situation, any remaining cancer cells can be destroyed by chemotherapy after surgery (adjuvant chemotherapy) and the chances of these cancer cells developing new tumors can be decreased. We use the same medications, gemcitabine and cisplatin, for adjuvant chemotherapy that are used for neoadjuvant chemotherapy.

Chemotherapy for bladder cancer that has spread

Conventional chemotherapy regimens and immunotherapy therapies as well as methods that are being studied in clinical trials include our standard treatments for bladder cancer that has spread. Such strategies are intended to suppress tumors and alleviate symptoms while preserving the quality of life.

Side effects of chemotherapy

With chemotherapy in your bladder, you have less side effects than you would have with chemotherapy in a vein. This is because it appears to linger in your bladder because of the medication. And it gets very little into your bloodstream.

Any of the adverse reactions can include:

Irritation of the bladder 

Chemotherapy can irritate your bladder. You may feel as if you have a bad urine infection (cystitis). This can make you :

• pass urine very often
• pass urine with urgency
• feel uncomfortable
• feel some pain

Blood in your urine

You may have a small amount of bleeding. Contact the hospital immediately if:

• the bleeding is getting worse
• there are blood clots in your urine
• you have severe pain when passing urine
• you can’t pass urine and have severe pain

Skin rash and itching

After having this therapy, you may get a rash on your hands or feet for a short time. Some rashes on the skin may become red, sore, and swollen. Some individuals get severe itching. If you get any of these signs, call your physician.

Infection

Your risk of having an infection can increase with some chemotherapy. You also have an increased risk of infection from a catheter being put in. Contact your doctor if you usually feel unwell, have extreme pain, foul smelling urine or discharge, or if you have a fever.

Allergic reaction

There is a possibility that there will be an allergic chemotherapy reaction. But it’s rare. The nurse gives you drugs to control the reaction if it happens. If you are feeling unwell at any time, inform the doctor or nurse.

Radiotherapy in bladder cancer treatment

When is radiation therapy used?

Radiation therapy can be used:

• As part of the treatment for some early-stage bladder cancers , after surgery that doesn’t remove the whole bladder (such as TURBT)
• As the main treatment for people with earlier-stage cancers who can’t have surgery or chemotherapy
• To try to avoid cystectomy (surgery to take out the bladder)
• As part of treatment for advanced bladder cancer (cancer that has spread beyond the bladder)
• To help prevent or treat symptoms caused by advanced bladder cancer

Radiation therapy is often given along with chemotherapy to help the radiation work better. This is called chemoradiation.

In the hospital radiotherapy department, you have radiotherapy treatment. You usually have it from Monday to Friday, and on weekends, you have a break.

Radiotherapy care can be very extensive to attempt to cure bladder cancer. It could take 4 to 7 weeks. Your doctor will tell you how many doses you need for radiotherapy.

You usually have outpatient radiotherapy, so you don’t need to stay in the hospital. Each time you have surgery, you will have to drive to the hospital. If you have a long way to go, several hospitals have rooms nearby where you can stay.

If you remain in the hospital, you go from your ward to the radiotherapy department (inpatient).

You’ll need to clear your bladder and intestines before each radiotherapy session. You’re going to have an enema (medicine) to inject into your bottom. When you have had this, it is a good idea to stick close to a bathroom as you will need to use the toilet very soon afterwards.

Radiation therapy uses precisely focused high-energy beams to kill cancer cells. Our doctors deliver radiation therapy in a variety of forms. The form we recommend depends on the type of cancer, the location of the tumor, and whether it has spread.

Check : Cost of bladder cancer radiotherapy in India

As part of your treatment for bladder cancer, you may receive radiation therapy before, during, or after surgery. This can shrink the tumors or destroy any remaining cancer cells. For some people, we may use radiation, often combined with a low dose of chemotherapy, in place of surgery altogether.

Our radiation oncologists use advanced techniques to target areas at risk while reducing radiation exposure to normal tissue.

Intraoperative Radiation Therapy during Bladder Cancer Surgery

Intraoperative radiation therapy is a therapy offered to reduce the chance of cancer returning during bladder cancer surgery. This method provides powerful radiation that is put directly on the tissue via thin tubes called catheters. This may destroy cancer cells that may remain after the removal of the tumor. If the cancer has extended into the bladder, it is most generally prescribed.

It is safe to use a higher-than-usual dose of radiation since this medication happens during surgery and can be administered to a specifically specified region. Normal tissue, especially the intestine, may be temporarily moved away from the area of treatment or protected with shielding devices during the delivery of radiation.

During the surgical process, intraoperative radiation therapy normally takes only a few minutes. All radiation-related materials are removed until the radiation dose is given, and the process continues.

External-Beam Radiation Therapy for Bladder Cancer

The most prevalent method of radiation treatment is external-beam radiation therapy. It is delivered by a computer from outside the body. And frequently, the radiation is in the form of X-rays. The charged particles referred to as protons or other energy forms are also used. As an alternative to cystectomy, our physicians can prescribe external beam radiation therapy coupled with low-dose chemotherapy (removal of the bladder). This means that the tumor is killed, but the bladder is left intact.

Image-Guided Radiation Therapy for Bladder Cancer

We use a type of external-beam radiation therapy called image-guided radiation therapy to check the location of the tumor and the position of the bladder before and during the delivery of radiation treatment. One difficulty in supplying bladder cancer radiation therapy is that the bladder moves as it empties and fills with urine. We implant gold markers to indicate the exact location of the tumor and monitor the motion of the bladder from day to day in order to precisely target tumors over several radiation treatments.

We often use CT scanners attached to the radiation delivering devices. The scanners allow us to visualize the bladder, such as the bowel and rectum, as well as normal surrounding tissue. We will achieve high cure rates and improve the chances of maintaining a healthy bladder with the use of these advanced techniques.

Intensity-Modulated Radiation Therapy for Bladder Cancer

When preparing treatment, the specific imaging methods we use allow us to use intensity-modulated radiation therapy safely and efficiently. This approach utilizes computer programs to measure and administer differing doses of radiation from various angles directly to the tumor. Our radiation oncologists played a leading role in creating this form of radiation therapy, in close collaboration with the medical physics team.

Side effects of radiation therapy

Bladder cancer radiation therapy can cause temporary side effects, including urinating more often and more urgently, burning when urinating, nausea, loss of appetite, diarrhoea, and pain around the anus. During care, symptoms appear to build up and usually continue to improve within a number of weeks after treatment ends.

Less generally, the intestine or bladder can be damaged permanently by radiation therapy. Bowel movements can be more regular and looser and may cause blood in the urine to damage the lining of the bladder (radiation cystitis). Radiation therapy can also induce weak erections and for some months after treatment, make ejaculation painful.