Bladder Cancer

Bladder Cancer

Each year about 10,000 people in the UK are diagnosed with bladder cancer. Men get bladder cancer much more commonly than women. It is rare for anyone under the age of 50 to get it but it becomes more common as people get older.

What causes bladder cancer?

Some of the possible causes or risk factors for bladder cancer are known. The following risk factors can increase the risk of developing it:

Cigarette smoking: This is the biggest risk factor for bladder cancer. The longer a person smokes for and the more cigarettes they smoke, the greater the risk. Chemicals that cause bladder cancer are present in cigarette smoke. It is thought that these chemicals get into the bloodstream and end up in the urine after being filtered by the kidneys. It may take many years for the chemicals to cause bladder cancer.

Exposure to chemicals at work: The other main cause of bladder cancer is exposure to certain chemicals at work. These include chemicals previously used in dye factories, rubber, gasworks, plastics, paints and in other chemical industries. These chemicals were banned in the UK in 1967. However, it can take up to 25 years after exposure for bladder cancers to develop.

If you think that you were exposed to certain chemicals through your work, let your cancer doctor know. You may be able to claim Industrial Injuries Disablement Benefit from the Department of Work and Pensions.

Infection: Repeated urinary infections and bladder or kidney stones (which can cause infections) have been linked with bladder cancer.

Previous treatment for cancer: Radiotherapy to the pelvis (to treat another cancer) and treatment with a chemotherapy drug called cyclophosphamide can also increase your risk.

More than 90 percent of all bladder cancers originate in the urothelium, the inner lining of the bladder. They are called transitional cell cancers, or TCC. The other types of bladder cancer are squamous cell, and adenocarcinoma.

What are the symptoms of bladder cancer?

Passing blood in the urine (haematuria) is the most common symptom. It eventually occurs in nearly all cases of bladder cancer. In the many cases, the blood is visible during urination. In some cases, it is only detected on dipstick examination of the urine or under a microscope, and is usually discovered when analysing a urine sample as part of a routine examination.

Haematuria does not by itself confirm the presence of bladder cancer. Blood in the urine has many possible causes (see below). For example, it may result from a urinary tract infection or kidney stones rather than from cancer. It is important to note that haematuria, particularly dipstick or microscopic, might be entirely normal for some individuals. A diagnostic investigation is necessary to determine whether bladder cancer or another abnormality is present.

Other symptoms of bladder cancer may include frequent urination, urinary urgency (rushing to pass urine) and pain upon urination (dysuria).

What is haematuria?

Haematuria is defined as the presence of red blood cells in the urine. It can be classified as symptomatic (ie: causes the patient to have symptoms) or asymptomatic (does not cause any symptoms), and gross (visible to the naked eye) or microscopic (visible only under the microscope) / dipstick (found only on testing the urine with a dipstick). Microscopic or dipstick haematuria is an incidental finding often discovered on urine tests as part of a routine medical evaluation, whereas gross haematuria should prompt the patient to visit his/her doctor. Haematuria can originate from any site along the urinary tract, including the kidneys, ureters, bladder, prostate and urethra.

What are the common causes of haematuria?

Blood in the urine is often not always a sign of a significant underlying problem. Studies have shown that between five and 15 percent of normal individuals can have some degree of haematuria. However, haematuria can be a sign of a serious underlying problem requiring treatment. These include urinary tract infection, bladder cancer, kidney cancer, urinary stone disease and prostate cancer.

How is haematuria investigated?

Patients who present with significant haematuria need assessment by a urologist. Significant haematuria is defined as one episode of visible haematuria or symptomatic non-visible haematuria, or persistent asymptomatic non-visible haematuria (2 out of three dipsticks positive).

Ideally, such patients should be seen as soon as possible in a one-stop clinic where the first step is a careful history and physical examination. The urine will be dipsticked to look for signs of infection or other abnormalities. If needed, it will then be sent off for a culture, to see if there are any bacteria in it. A urinary cytology is also obtained to look for abnormal cells in the urine. A blood test should also be done to measure the kidney function, and in men, after counselling, a PSA test is done.

Further tests include an ultrasound of the kidneys and bladder, or a CT scan of the abdomen and pelvis . A CT scan is the preferred method of evaluating kidney masses and is the best modality for the evaluation of urinary stones.

A flexible cystoscopy is also likely to be required. This is a look into the bladder with a small flexible telescope, which is inserted via the urethra under local anaesthetic. Looking through the cystoscope your urologist can examine the inner lining of the bladder and urethra for abnormalities.

It is usually in this way that bladder cancer is diagnosed.

What happens once the diagnosis of bladder cancer is made?

Bladder cancer is usually seen as a growth in the bladder at the time of a flexible cystoscopy. The growth then needs to be biopsied, or resected. This is usually called a transurethral resection of a bladder tumour. Under anaesthetic a telescope is inserted into the bladder, and tissue removed using a wire loop. The removed tissue is sent to a pathologist for examination, who can then look at the tissue under a microscope and describe how aggressive the tumour looks (the grade), and how far into the lining of the bladder it has gone (the stage). Thus the tissue is removed, usually in its entirety, and at the same time tissue can be examined by the pathologist to establish the diagnosis.

Bladder tumours are graded according to how abnormal the cells look under the microscope, from Grade 1 (least abnormal) to grade 3 (most abnormal). The tumours are staged according to the TNM staging system.

bladder-TNM

The T stage for bladder cancer indicated how far the cancer has spread locally. The N stage indicates if it has spread to lymph nodes, and the M stage describes whether it has developed distant spread or metastases.

Bladder cancer is described a superficial if it is Ta or T1, and muscle invasive if it is T2 or greater. These two types of cancer behave and are treated differently. Most Ta tumors are low grade, and most do not progress to invade the bladder muscle. Stage T1 tumors are much more likely to become muscle invasive. Stage Ta tumors often recur after treatment but they tend to recur with the same stage and grade.

The Tis stage classification is reserved for a type of high-grade cancer called carcinoma in situ (CIS). This is a very aggressive but superficial growth in the bladder, which can progress to become muscle invasive. It is often treated with BCG instillation into the bladder (intravesical treatment with BCG).

How is bladder cancer treated?

For superficial bladder cancers, the initial resection, followed by instillation of intravesical mitomycin C (a chemotherapy solution that is placed into the bladder after the operation) is usually all the treatment that is required (see below). Regular inspections of the bladder (flexible cystoscopy) will be required to ensure that the growth has not returned, and the first of these will usually be at 3 months.

For muscle invasive disease, cystectomy, surgical removal of the bladder, may be recommended. This operation may also be used for patients with CIS or high-grade T1 cancers that have persisted or recurred after initial intravesical treatment. There is a significant risk that the cancer may become muscle invasive in such cases, and some patients may want to consider cystectomy as a first choice of treatment. During a cystectomy, the bladder is removed, and then the urine is usually drained into a small segment of bowel and then bought out to drain onto the anterior abdominal wall (ileal conduit). In some cases, a new bladder can be formed out of small bowel, so that the patient can pass urine again normally.

What is intravesical chemotherapy?

Following removal of your bladder tumour, intravesical chemotherapy or intravesical immunotherapy may be used to try to prevent tumour recurrences. Intravesical means “within the bladder”. These therapeutic agents are put directly into the bladder through a catheter in the urethra, are retained for one hour and are then urinated out.

The chief intravesical agents currently used are mitomycin C and bacillus Calmette-Guérin (BCG). BCG is a live, but weakened, vaccine strain of bovine tuberculosis and it is now one of the most effective agents for treating bladder cancer and especially for treating CIS.

They are used because we know that they help to prevent tumour recurrence, and while mitomycin C (MMC) does not prevent the rate of progression (the chance of the tumour becoming more invasive), there is some evidence that BCG may.

Each agents produces irritative side effects such as frequent urination (up to 40 % for MMC, 60% for BCG), painful urination (70% and 30%). In addition, BCG therapy carries a 20% percent risk of flu-like symptoms and a small risk (4 percent) of generalised infection. There is a chance of skin rash with MMC (up to 15%).

Further information on bladder cancer can be obtained by clicking the links below:

Macmillan: more information on treatment for bladder cancer 

Cancer Research UK: Bladder Cancer

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