Bladder Cancer
Contents:
General
Bladder cancer affects the inner lining of the bladder. The bladder is a hollow, balloon like organ lying in the pelvis, which collects urine from the kidneys. The bladder stores urine until it is full enough to empty through the urethra.
Most bladder cancers are superficial and look like tiny sea anemones growing on the inside lining of the bladder. They are sometimes known as papillary tumours. More rarely bladder cancer can be invasive and grows deeper into the bladder wall, extending into the muscle layer or its surrounding tissues. This happens in only a small percentage of patients by the time it is diagnosed.
Bladder cancer is the most frequently occurring tumour of the urinary system and is more common in men than women. Few cases occur under the age of 50. Bladder cancer develops very slowly and as it grows may spread to other organs near the bladder.
Risk factors
Age
The risk of developing bladder cancer increases with age. Half of all cases occur in people over 70.
Gender
Bladder cancer affects more men than women.
Smoking
Smoking increases the risk of bladder cancer. The chemicals in cigarette smoke concentrate in the urine. People who smoke 20 cigarettes a day for 10 years have double the risk of developing bladder cancer compared with non smokers.
Diet and drinking habits
At the moment there is no evidence to suggest that diet and drinking habits affect bladder cancer. However excessive consumption of coffee is thought to be a possible contributing factor.
Chemicals
Certain chemicals can cause bladder cancer. In the past these chemicals were used in the following industries; painting and decorating, leather-working, dyeing, papermaking, dry cleaning, rubber and plastic, and mechanics. Even though these chemicals have been banned in the UK for up to 40 years, they still cause new cases of bladder cancer today because of the long time the cancer takes to develop.
Bladder stones and repeated infections
Repeated or chronic bladder infections, or bladder stones, slightly increase the risk of developing bladder cancer.
Endemic schistosomiasis
This is an often chronic illness that results from infection of the blood with a parasitic flatworm. It causes debilitation and can cause liver and intestinal damage. Endemic schistosomiasis occurs in parts of Africa and Middle East and can increase the risk of contracting bladder cancer.
Previous bladder cancer
Having bladder cancer in the past increases the risk of developing it again.
Prevention
Smoking
Giving up smoking can help to reduce the risk of bladder cancer.
Screening
There is currently no reliable screening test available for bladder cancer. Recent research has developed a possible urine test that on first trials appears to be effective in picking up bladder cancer. The test has yet to be trialled in larger numbers of people.
Symptoms
Symptoms of bladder cancer include:
- blood in the urine known as haematuria. This may appear suddenly with no apparent cause and without pain. The urine may vary from rusty brown to deep red, depending on the amount of blood.
- experiencing pain when passing urine
- the need to pass urine very often or very urgently
Diagnosis
Urine sample and internal examination
Initially a doctor will carry out an examination and a urine test to look for blood and infection. They may also carry out an internal examination of the rectum (back passage) and birth canal (vagina) in women. If anything abnormal is detected a bladder specialist (urologist) will carry out further tests.
Cytoscopy
Cystoscopy is a telescopic examination that allows the urologist to inspect the inside of the bladder. A tube with optic fibres is inserted into the bladder through the urethras so the specialist can look for any abnormalities. Any suspicious growth maybe removed to analyse in more detail.
Blood tests
Blood tests give an indication of general health and how well the kidneys are working.
Intravenous Urogram or Pyelogram (IVU or IVP)
This is an X-ray examination that looks at the kidneys, ureters and bladder. A dye is injected so the doctor can see any abnormalities on the X-ray film.
Cystogram
A Cystogram is a type of x-ray that gives a very accurate picture of the inside of the bladder. The process involves inserting a catheter into the bladder and instilling a dye.
CT or CAT scan
The CT scan is a type of X-ray where a three dimensional picture of the affected tissues and organs can be built up. A special oral dye can help outline the organs that are being examined and improve the quality of the pictures.
Radioactive bone scans
Bone scans can check if any cancer has spread from the bladder to the bones. A tiny amount of radioactive liquid is injected into a vein. Any areas of the bone that are abnormal pick up the dye, these areas can then be X-rayed to give more detail.
Ultrasound scans
Ultrasound scans produce a picture of the inside of the bladder by using sound waves.
Treatment
Treatment of superficial tumours
Superficial tumours can be removed completely by cutting them off. A probe is passed up the cystoscope and the bladder wall is cauterised to prevent bleeding. The tumours are then removed through the cystoscope. Small tumours are destroyed completely however the bladder may develop other tumours with time. It is important to have regular cystoscopies every few months to check that the bladder remains tumour free.
Chemotherapy
Intravesical (in to the bladder) chemotherapy may be given after the removal of the tumour. Studies have shown that in some patients the likelihood of developing more tumours may be lessened by washing out the bladder regularly with one of several drugs. This treatment is usually given on a weekly basis for 6-8 weeks. The drug is put into the bladder through a small tube (catheter) and is monitored in the outpatient department of the hospital.
Radiotherapy treats the cancer with high energy x-rays, with minimum damage to surrounding healthy cells. It may be given before, after or instead of surgery. The treatment is usually given daily (Monday to Friday) and takes four to six weeks if radiotherapy is used alone, but may be only one week if given before cystectomy.
After radiotherapy regular cystoscopy examinations of the bladder are important. If the tumour comes back again it may be treated by local surgery but cystectomy (removal of the total bladder) may be necessary.
Side effects of radiotherapy
Radiotherapy can cause side effects such as tiredness, tender skin, diarrhoea and an irritated bladder.
Treatment of invasive tumours
Surgery, radiotherapy and chemotherapy can be used alone or in combination to treat invasive bladder cancer. The treatment depends on the type and size of tumour, if it has spread and the general health of the patient.
If the cancer is in its early stages, the specialist may be able to remove it during cytoscopy. Advanced bladder cancer may require surgery through the abdomen.
Partial Cystectomy or Transurethral resection of tumour
If the tumour is confined to the bladder wall it may be possible to remove the tumour and just the section of the bladder involved. This can be done either as a telescopic procedure (cystoscopic resection) or as an operation cutting through the abdomen (partial cystectomy). Urine can be passed normally after the operation.
Total or radical cystectomy
If the tumour is larger it may be necessary to remove the bladder completely (complete or radical cystectomy). Cystectomy is a very extensive operation and removes most of the structures in the pelvis. This is done to give the best chance of cure and make the risk of cancer recurrence as low as possible.
In women a radical cystectomy operation involves the removal of the whole bladder, the urethra, the lower end of the ureters, the front wall of the vagina, the womb (hysterectomy), fallopian tubes and ovaries. In younger women the ovaries may be preserved. As a result the vagina will be shorter and narrower following the operation.
In men radical cystectomy involves the removal of the whole of the bladder, the prostate gland, the lower ends of the ureters and sometimes the urethra is removed. Damage may occur to the nerves in the pelvis making some men unable to achieve an erection. Sometimes inability to obtain an erection can be helped by an injection or an operation.
Sexual feeling and orgasm may be impossible for both men and women after the operation.
Replacing the bladder
Urostomy
If the bladder has been completely removed, a new water tank for the urine will have to be created. The most common method is by making a urostomy. A small section of the bowel is used to join the ureters from the kidney to the skin of the abdominal wall. The remaining bowel is joined together again. The opening or urostomy drains the urine into a flat, changeable, bag which is attached to the side of the abdomen (like a colostomy bag). This fills up in the same way as the bladder did and will need to be emptied regularly by a small tap on the bag.
Bladder Reconstruction
Sometimes the bladder can be replaced inside the abdomen by using bowel made into a balloon-shaped sack stitched to the top of the urethra. It may be possible to empty the bladder normally, but a small tube (catheter) may be needed to drain the urine several times a day.
Continent Pouch
If the urethra has to be removed a continent pouch can be formed using a piece of bowel. Although urine is not passed out through the urethra a bag does not need to be worn. Instead the urine is drained by passing a small catheter into the new bladder every three hours through the umbilicus or navel.
Stoma care nurses
Stoma care nurses advise and help before and after bladder surgery and teach patients how to deal with urostomy, bladder or pouch instillation.
Chemotherapy
Chemotherapy uses anti-cancer or cytotoxic drugs to kill cancer cells. For invasive bladder cancer it is injected into a vein in the arm and will travel to bladder cancer cells anywhere in the body, not just in the bladder.
Chemotherapy is normally given in addition to some form of surgery or radiotherapy. Some chemotherapy is given via a drip (intravenous infusion), and some directly in to the bladder.
Side effects of chemotherapy
The drugs travel throughout the body so side effects are not restricted to the bladder. Modern anti- sickness drugs help to prevent vomiting although nausea and loss of appetite can still occur. Sense of taste may also change.
Some hair loss may occur with the condition changing and becoming thinner. Total hair loss is unusual. Other side effects such as mouth ulcers, tiredness, irritability, loss of libido (sex drive) and a greater susceptibility to infection are all possible.
All side effects should stop after treatment finishes.
Immune therapy
BCG (the TB vaccine) can be instilled in to the bladder and has been shown to slow down recurrence of superficial bladder tumours.
Statistics
Worldwide
- Worldwide an estimated 336,000 new cases occur each year
- It is the 9th most frequent cancer in the world.
- Bladder cancer is more common in men than women, with a worldwide male:female ratio of 3:1
- Highest incidences are generally found in industrially developed countries, particularly in North America and Western Europe and in areas associated with endemic schistosomiasis (an illness caused by a blood infection).
- Parts of Africa and the Middle East have very high incidence rates of bladder cancer due to endemic schistosomiasis.
- India and China have very low rates of bladder cancer.
Europe
- Across Europe rates of bladder cancer are fairly consistent.
- Italy has the highest rate of male bladder cancer in Europe, followed by France.
- Denmark has the highest rate of female bladder cancer in Europe followed by the UK.
UK
- Bladder cancer is the 4th most common cancer in men
- Bladder cancer is the 8th most common cancer in woman
Trends
In general incidence of bladder cancer has risen during the 20th century in developed countries. It now appears to be decreasing slightly.
Socio-economic
There is a slightly higher incidence and mortality in more deprived areas of developed countries.
Survival
Survival rates have increased from over 40% in the early 70s to 58%-67% in the early 90s. | 
