Bladder Cancer

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Download AUA Bladder Cancer Treatment Guidelines

Bladder cancer is one of the most common cancers, affecting approximately 68,000 adults in the United States each year.

Bladder cancer occurs in men more frequently than it does in women and usually affects older adults, though it can happen at any age.

Bladder cancer most often begins in the cells (urothelial cells) that line the inside of your bladder — the hollow, muscular organ in your lower abdomen that stores urine. Although it's most common in the bladder, this same type of cancer can occur in other parts of the urinary tract drainage system.

About seven out of every 10 bladder cancers diagnosed start out at an early stage — when bladder cancer is highly treatable. However, even early-stage bladder cancer may recur in the bladder. For this reason, people with bladder cancer typically need follow-up tests for years after treatment to look for bladder cancer that recurs or advances to a higher stage.

Bladder cancer care at Fairbanks Urology

Symptoms

Bladder cancer signs and symptoms may include:

If you have hematuria, your urine may appear bright red or cola colored. Sometimes, urine may not look any different, but blood in urine may be detected during a microscopic exam of the urine.

People with bladder cancer might also experience:

But, these symptoms often occur because of something other than bladder cancer.

Causes

Bladder cancer develops when cells in the bladder begin to grow abnormally. Rather than grow and divide in an orderly way, these cells develop mutations that cause them to grow out of control and not die. These abnormal cells form a tumor.

Causes of bladder cancer include:

  • 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 types of cells in your bladder can become cancerous. The type of bladder cell where cancer begins determines the type of bladder cancer. The type of bladder cancer determines which treatments may work best for you.

Types of bladder cancer include:

  • Urothelial carcinoma. Urothelial carcinoma, previously called transitional cell carcinoma, occurs in the cells that line the inside of the bladder. Urothelial cells expand when your bladder is full and contract when your bladder is empty. These same cells line the inside of the ureters and the urethra, and tumors can form in those places as well. Urothelial carcinoma is the most common type of bladder cancer in the United States.

  • Squamous cell carcinoma. Squamous cell carcinoma is associated with chronic irritation of the bladder, for instance from an infection or from long-term use of a urinary catheter. Squamous cell bladder cancer is rare in the United States. It's more common in parts of the world where a certain parasitic infection (schistosomiasis) is a common cause of bladder infections.

  • Adenocarcinoma. Adenocarcinoma begins in cells that make up mucus-secreting glands in the bladder. Adenocarcinoma of the bladder is rare in the United States.

Some bladder cancers include more than one type of cell.

Risk factors

Factors that may increase bladder cancer risk include:

  • Smoking. Smoking cigarettes, cigars or pipes may increase the risk of bladder cancer by causing harmful chemicals to accumulate in the urine. When you smoke, your body processes the chemicals in the smoke and excretes some of them in your urine. These harmful chemicals may damage the lining of your bladder, which can increase your risk of cancer.

  • Increasing age. Bladder cancer risk increases as you age. Bladder cancer can occur at any age, but it's rarely found in people younger than 40.

  • Being white. White people have a greater risk of bladder cancer than do people of other races.

  • Being a man. Men are more likely to develop bladder cancer than women are.

  • Exposure to certain chemicals. Your kidneys play a key role in filtering harmful chemicals from your bloodstream and moving them into your bladder. Because of this, it's thought that being around certain chemicals may increase the risk of bladder cancer. Chemicals linked to bladder cancer risk include arsenic and chemicals used in the manufacture of dyes, rubber, leather, textiles and paint products.

  • Previous cancer treatment. Treatment with the anti-cancer drug cyclophosphamide increases the risk of bladder cancer. People who received radiation treatments aimed at the pelvis for a previous cancer have an elevated risk of developing bladder cancer.

  • Chronic bladder inflammation. Chronic or repeated urinary infections or inflammations (cystitis), such as might happen with long-term use of a urinary catheter, may increase the risk of a squamous cell bladder cancer. In some areas of the world, squamous cell carcinoma is linked to chronic bladder inflammation caused by the parasitic infection known as schistosomiasis.

  • Personal or family history of cancer. If you've had bladder cancer, you're more likely to get it again. If one of your first-degree relatives — a parent, sibling or child — has a history of bladder cancer, you may have an increased risk of the disease, although it's rare for bladder cancer to run in families.

Prevention

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

  • Don't smoke. Not smoking means that cancer-causing chemicals in smoke can't collect in your bladder. If you don't smoke, don't start. If you smoke, talk to your doctor about a plan to help you stop. Support groups, medications and other methods may help you quit.

  • Take caution around chemicals. If you work with chemicals, follow all safety instructions to avoid exposure.

  • Choose a variety of fruits and vegetables. Choose a diet rich in a variety of colorful fruits and vegetables. The antioxidants in fruits and vegetables may help reduce your risk of cancer.

Diagnosis

Tests and procedures used to diagnose bladder cancer may include:

Cystoscopy
  • Cystoscopy. To perform cystoscopy, your doctor inserts a small, narrow tube (cystoscope) through the urethra. The cystoscope has a lens that allows your doctor to see the inside of your urethra and bladder, to examine these structures for signs of disease.

  • Biopsy. During cystoscopy, your doctor may pass a special tool through the scope and into your bladder to collect a cell sample (biopsy) for testing. This procedure is sometimes called transurethral resection of bladder tumor (TURBT). TURBT can also be used to treat bladder cancer.

  • Urine cytology. A sample of your urine is analyzed under a microscope to check for cancer cells in a procedure called urine cytology.

  • Imaging tests. Imaging tests, such as computerized tomography (CT) urogram or retrograde pyelogram, allow your doctor to examine the structures of your urinary tract.

     

Determining the extent of the cancer

After confirming that you have bladder cancer, your doctor may recommend additional tests to determine whether your cancer has spread to your lymph nodes or to other areas of your body.

Tests may include:

  • CT scan

  • Magnetic resonance imaging (MRI)

  • Bone scan

  • Chest X-ray

Dr. Nimeh uses information from these procedures to assign your cancer a stage. The stages of bladder cancer are indicated by Roman numerals ranging from 0 to IV. The lowest stages indicate a cancer that's confined to the inner layers of the bladder and that hasn't grown to affect the muscular bladder wall. The highest stage — stage IV — indicates cancer has spread to lymph nodes or organs in distant areas of the body.

The cancer staging system continues to evolve and is becoming more complex as doctors improve cancer diagnosis and treatment. Your doctor uses your cancer stage to select the treatments that are right for you.

Bladder cancer grade

Bladder cancer tumors are further classified based on how the cancer cells appear when viewed through a microscope. This is known as tumor grade, and your doctor may describe bladder cancer as either low grade or high grade:

  • Low-grade bladder tumor. This type of tumor has cells that are closer in appearance and organization to normal cells (well-differentiated). A low-grade tumor usually grows more slowly and is less likely to invade the muscular wall of the bladder than is a high-grade tumor.

  • High-grade bladder tumor. This type of tumor has cells that are abnormal-looking and that lack any resemblance to normal-appearing tissues (poorly differentiated). A high-grade tumor tends to grow more aggressively than a low-grade tumor and may be more likely to spread to the muscular wall of the bladder and other tissues and organs.

Treatment

Treatment options for bladder cancer depend on a number of factors, including the type of cancer, grade of the cancer and stage of the cancer, which are taken into consideration along with your overall health and your treatment preferences.

Bladder cancer treatment may include:

  • 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

A combination of treatment approaches may be recommended by your doctor and members of your care team.

Bladder cancer surgery

Approaches to bladder cancer surgery might include:

  • Transurethral resection of bladder tumor (TURBT). TURBT is a procedure to remove bladder cancers confined to the inner layers of the bladder, those which aren't yet muscle-invasive cancers. During the procedure, a surgeon passes a small wire loop through a cystoscope and into the bladder. The wire loop burns away cancer cells using an electric current. Alternatively, a high-energy laser may be used to destroy the cancer cells.

    TURBT is performed under regional anesthesia — where medication given numbs only the lower part of your body — or general anesthesia — where medication puts you to sleep during the surgery. Because doctors perform the procedure through the urethra, you won't have any cuts (incisions) in your abdomen.

    As part of the TURBT procedure, your doctor may recommend a one-time injection of cancer-killing medication (chemotherapy) into your bladder to destroy any remaining cancer cells and to prevent a tumor from coming back. The medication remains in your bladder for up to an hour and then is drained.

  • Cystectomy. 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.

    A radical cystectomy is an operation to remove the entire bladder, part of the ureters and surrounding lymph nodes. In men, radical cystectomy typically includes removal of the prostate and seminal vesicles. In women, radical cystectomy also involves removal of the uterus, ovaries and part of the vagina.

    Radical cystectomy can be performed through a single incision on the lower portion of the belly or with multiple small incisions using robotic surgery. During robotic surgery, the surgeon sits at a nearby console and uses hand controls to precisely move robotic surgical instruments.

    Cystectomy carries a risk of infection and bleeding. In men, removal of the prostate and seminal vesicles may cause erectile dysfunction. But, your surgeon may be able to spare the nerves necessary for an erection. In women, removal of the ovaries causes infertility and premature menopause.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. Chemotherapy treatment for bladder cancer usually involves two or more chemotherapy drugs used in combination.

Chemotherapy drugs can be given:

  • Through a vein in your arm (intravenously)

  • Via a tube passed through your urethra directly to your bladder (intravesical therapy)

Chemotherapy is frequently used before bladder removal surgery to increase the chances of curing the cancer. Chemotherapy may also be used to kill cancer cells that might remain after surgery. Chemotherapy is sometimes combined with radiation therapy in very select cases as an alternative to surgery.

Intravesical chemotherapy may be the primary treatment for superficial bladder cancer, where the cancer cells affect only the lining of the bladder and not the deeper muscle tissue. Or sometimes immunotherapy may be administered as intravesical therapy for superficial bladder cancer.

Radiation therapy

Radiation therapy uses high-energy beams aimed at your cancer to destroy the cancer cells. Radiation therapy for bladder cancer usually is delivered from a machine that moves around your body, directing the energy beams to precise points.

In select cases, radiation therapy is sometimes combined with chemotherapy as an alternative to surgery or when surgery isn't an option.

Immunotherapy

Immunotherapy, also called biological therapy, works by signaling your body's immune system to help fight cancer cells.

Immunotherapy for bladder cancer often is administered through the urethra and directly into the bladder (intravesical therapy). One such immunotherapy drug used to treat bladder cancer is Bacillus Calmette-Guerin (BCG), which is a vaccine used to protect against tuberculosis. Another immunotherapy drug is a synthetic version of interferon, which is a protein your immune system makes to help fight infections. The synthetic version, called interferon alfa-2b (Intron A), is sometimes used in combination with BCG.

Bladder preservation

Using a three-prong treatment approach may preserve the bladder in certain cases of muscle-invasive disease. Known as trimodality therapy, the treatment approach includes TURBT, chemotherapy and radiation therapy.

First, your surgeon performs a TURBT procedure to remove as much cancerous tissue as possible from your bladder, while maintaining bladder function. After TURBT, you undergo a regimen of chemotherapy along with radiation therapy, which both take place during the first several weeks after surgery.

If, after trying trimodality therapy, not all of the cancer is gone or you have a recurrence of muscle-invasive cancer, your surgeon may recommend a radical cystectomy.

Upper urinary tract disease

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

Similar to treatment for bladder cancer, treatment of upper urinary tract cancer depends on a lot of factors, such as tumor size, tumor location, your overall health and your preferences.

Upper urinary tract cancer generally involves surgery to remove the cancer, along with chemotherapy or radiation therapy as follow-up treatments to kill any remaining cancer cells and to prevent recurrence.

Surgery might leave you with only one functioning kidney, if one of your kidneys needs to be removed. If that happens, your doctor will likely recommend regular testing of your kidney function to monitor how well your remaining kidney is doing.

After bladder cancer treatment

Bladder cancer may recur. Because of this, people with bladder cancer need follow-up testing for years after successful treatment. What tests you'll have and how often depends on your type of bladder cancer and how it was treated, among other factors.

Ask your doctor to create a follow-up plan for you. In general, doctors recommend a test to examine the inside of your urethra and bladder (cystoscopy) every three to six months for the first few years after bladder cancer treatment. After a few years of surveillance without detecting cancer recurrence, you may need a cystoscopy exam only once a year. Your doctor may recommend other tests at regular intervals as well.

People with aggressive cancers may undergo more-frequent testing. Those with less aggressive cancers may undergo testing less often.


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