Bladder Cancer

What is Bladder Cancer?

Bladder cancer is a common cancer, with more than 83,000 new cases every year in the United States. It is more common in men than women and typically affects those over 55 years of age.

Bladder cancer at an early stage of growth may not produce any noticeable signs or symptoms. Common signs of bladder cancer include hematuria (blood in the urine that looks red or rusty), which is usually painless and may appear only from time to time over a few months, a burning sensation during urination and a need to urinate often.

Symptoms

When bladder cancer causes noticeable symptoms, they are usually related to the irritation brought about by tumor growth. Patient may have symptoms of irritation, with urination that is frequent, painful, or comes with urgency.  These symptoms are more common among patients with ‘carcinoma in situ' (CIS), cancer that has not spread and is still in place. In fact, these may be the only noticeable symptom of CIS.

If a bladder tumor blocks a ureter (tubes that pass urine out of the kidneys, into the bladder), patients may experience pain in the side of the body between the ribs and the top of the hip. In some cases, tumor growth may constrict the urethra (the tube that passes urine from the bladder out of the body) and slow the flow of the urine. Bladder cancers may also shed pieces of dead tissue, fragments of other tissue and other forms of tumor-related matter that are then passed out with the urine.

If the tumor has spread beyond the bladder to the surrounding tissue, you may experience pelvic pain, bone pain at the site of new cancer, leg swelling (edema) due to the involvement of lymph nodes, loss of weight and fatigue. Anemia and high blood levels of urea and other metabolic by-products, often due to urinary tract obstruction, may be further indications of late-stage bladder cancer.

Since such symptoms are also caused by bacterial infections and kidney stones, it is essential to see your doctor for an accurate diagnosis.

Diagnosis

When you experience symptoms of bladder cancer, your doctor will conduct physical examinations in order to formulate an accurate diagnosis. These tests typically include a cystoscopy, in which a flexible camera is inserted through the urethra into the bladder, and imaging of the kidneys and ureters, which may be done with a CT scan, MRI, or ultrasound.

Treatment

Bladder cancer is treated according to how far it has grown into the bladder. The majority of bladder cancers are diagnosed in the non-muscle invasive stage. Non-muscle invasive bladder can be treated with local surgery of the bladder, as well as intravesical (in the bladder) therapies such as localized immunotherapy or chemotherapy.

Bladder cancer that has invaded into the muscle of the bladder is managed more aggressively. While this most commonly involves aggressive surgery to remove the bladder and associated organs (cystectomy), emerging therapies combine radiation, chemotherapy, and localized surgery to preserve the bladder. Patient who require removal of the bladder will require some form of reconstruction to allow passage of urine out of the body, either via an ostomy or through the urethra.

Treatments for muscle invasive bladder cancer are highly specialized and must be individualized to the patient. Your physician will speak to you about the options available to you.

Some available options include:

• Transurethral resection of the bladder tumor (TURBT): This procedure involves the insertion of a thin tube through the urethra and up into the bladder. The surgeon can then remove the tumor without the need for a large external excision. This is typically the first surgery performed for bladder tumor as it treats the cancer and provides important information for planning future care.
• Radical cystectomy: For women, a standard form of surgery is a radical cystectomy, which involves removing the entire bladder and associated tissues, with pelvic lymphadenectomy (removal of the lymph nodes within the hip cavity). Radical cystectomy in women includes removal of the uterus, fallopian tubes, ovaries, anterior vaginal wall (the front of the birth canal) and urethra.
• Radical Cystoprostatectomy: In men, a common surgical procedure is a cystoprostatectomy, which involves the removal of the bladder and prostate, with pelvic lymphadenectomy.
• Urinary diversion: Urinary diversion is a method where an alternate means of urine waste disposal is created when the bladder is removed. The most common diversion is the ileal conduit, which involves taking a piece of bowel, forming a pipe and inserting it where the bladder once was. The conduit then carries the urine from the ureters out onto the skin of the abdomen where the conduit ends in a stoma (a small opening). Urine is then emptied into a plastic bag attached to the skin, where it can be emptied at various intervals.
  Other forms of diversion involve the formation of an internal pouch made out of part of the bowel. The pouch has an inbuilt valve so that urine collects inside and does not leak through the stoma. When it needs emptying, a small plastic tube called a catheter can be passed through the stoma and the valve, allowing urine to flow out.
• Intra-vesical treatment: It involves flushing the bladder with chemotherapy or immunotherapy to eliminate any remaining cancer cells.
• Radiation therapy: Uses powerful X-rays and other high-energy rays to kill cancer cells using a machine called the linear accelerator. The cancer cells get damaged and cannot grow or multiply, resulting in the death of the cells.
• Trimodal therapy – trimodal therapy is the combination of transurethral surgery, chemotherapy, and radiation therapy to treat bladder cancer. For appropriate patients, this allows safe treatment of the cancer without need to remove the bladder.

How is your course of treatment decided?

A number of tests will be performed in order to allow doctors to determine the best course of treatment for each individual. Test including cystoscopy, transurethral resection of bladder tumor, imaging studies such as MRI, CT, or ultrasound, and tests for the urine and blood.

Complications

Possible complications of cancer surgery include:

• Transurethral bladder surgery: Mild bleeding and pain while urinating or recurrence. Rarely, bladder perforation requiring further surgery.
• Cystectomy: Infection, excess bleeding, pain, nerve damage, leakage of urine , lack of orgasm and blood clots
• Cystoprostatectomy: Lack of semen, problems with maintaining an erection
• Urinary diversion: Incontinence, stones, infections, and blockage of urine flow

Possible complications of chemotherapy include:

• Pain
• Fatigue
• Diarrhea or constipation
• Nausea and vomiting
• Hair loss
• Loss of appetite

The X-rays used during radiation therapy may damage normal body cells as well as cancer cells, although healthy cells usually recover from the damage. The incidence and severity of any side effects vary from patient to patient and may include:

• Tiredness or fatigue
• Bladder irritation, cramps or painful urination/blood in the urine
• Diarrhea and bowel cramps
• Proctitis or pain in the rectum/bleeding, vaginal discomfort

A variety of measures can be taken to alleviate these symptoms, discuss these issues with your doctor and radiation therapy team for the best advice for you.