Bladder Cancer

Key Points for This Section

* Bladder cancer is a disease in which malignant (cancer) cells form in the tissues of the bladder.
* Smoking, gender, and diet can affect the risk of developing bladder cancer.
* Possible signs of bladder cancer include blood in the urine or pain during urination.
* Tests that examine the urine, vagina, or rectum are used to help detect (find) and diagnose bladder cancer.
* Certain factors affect prognosis (chance of recovery) and treatment options.

Bladder cancer is a disease in which malignant (cancer) cells form in the tissues of the bladder.

The bladder is a hollow organ in the lower part of the abdomen. It is shaped like a small balloon and has a muscular wall that allows it to get larger or smaller. The bladder stores urine until it is passed out of the body. Urine is the liquid waste that is made by the kidneys when they clean the blood. The urine passes from the two kidneys into the bladder through two tubes called ureters. When the bladder is emptied during urination, the urine goes from the bladder to the outside of the body through another tube called the urethra.

There are three types of bladder cancer that begin in cells in the lining of the bladder. These cancers are named for the type of cells that become malignant (cancerous):

* Transitional cell carcinoma: Cancer that begins in cells in the innermost tissue layer of the bladder. These cells are able to stretch when the bladder is full and shrink when it is emptied. Most bladder cancers begin in the transitional cells.
* Squamous cell carcinoma: Cancer that begins in squamous cells, which are thin, flat cells that may form in the bladder after long-term infection or irritation.
* Adenocarcinoma: Cancer that begins in glandular (secretory) cells. Glandular cells in the lining of the bladder make substances such as mucus.

Cancer that is confined to the lining of the bladder is called superficial bladder cancer. Cancer that begins in the transitional cells may spread through the lining of the bladder and invade the muscle wall of the bladder or spread to nearby organs and lymph nodes; this is called invasive bladder cancer.

Refer to the following summaries for more information:

* Screening for Bladder and Other Urothelial Cancers
* Unusual Cancers of Childhood

Smoking, gender, and diet can affect the risk of developing bladder cancer.

Anything that increases your chance of getting a disease is called a risk factor. Risk factors for bladder cancer include the following:

* Smoking.
* Being exposed to certain substances at work, such as rubber, certain dyes and textiles, paint, and hairdressing supplies.
* A diet high in fried meats and fat.
* Being older, male, or white.
* Having an infection caused by a certain parasite.

Possible signs of bladder cancer include blood in the urine or pain during urination.

These and other symptoms may be caused by bladder cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

* Blood in the urine (slightly rusty to bright red in color).
* Frequent urination, or feeling the need to urinate without being able to do so.
* Pain during urination.
* Lower back pain.

Tests that examine the urine, vagina, or rectum are used to help detect (find) and diagnose bladder cancer.

The following tests and procedures may be used:

* CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerised tomography, or computerised axial tomography.
* Urinalysis: A test to check the color of urine and its contents, such as sugar, protein, blood, and bacteria.
* Internal exam: An exam of the vagina and/or rectum. The doctor inserts gloved fingers into the vagina and/or rectum to feel for lumps.
* Intravenous pyelogram (IVP): A series of x-rays of the kidneys, ureters, and bladder to find out if cancer is present in these organs. A contrast dye is injected into a vein. As the contrast dye moves through the kidneys, ureters, and bladder, x-rays are taken to see if there are any blockages.
* Cystoscopy: A procedure to look inside the bladder and urethra to check for abnormal areas. A cystoscope (a thin, lighted tube) is inserted through the urethra into the bladder. Tissue samples may be taken for biopsy.
* Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. A biopsy for bladder cancer is usually done during cystoscopy. It may be possible to remove the entire tumour during biopsy.
* Urine cytology: Examination of urine under a microscope to check for abnormal cells.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) depends on the following:

* The stage of the cancer (whether it is superficial or invasive bladder cancer, and whether it has spread to other places in the body). Bladder cancer in the early stages can often be cured.
* The type of bladder cancer cells and how they look under a microscope.
* The patient’s age and general health.

Treatment options depend on the stage of bladder cancer.

Stages of Bladder Cancer

Key Points for This Section

* After bladder cancer has been diagnosed, tests are done to find out if cancer cells have spread within the bladder or to other parts of the body.
* The following stages are used for bladder cancer:
o Stage 0
o Stage I
o Stage II
o Stage III
o Stage IV

After bladder cancer has been diagnosed, tests are done to find out if cancer cells have spread within the bladder or to other parts of the body.

The process used to find out if cancer has spread within the bladder lining and muscle or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

* Cystoscopy: A procedure to look inside the bladder and urethra to check for abnormal areas. A cystoscope (a thin, lighted tube) is inserted through the urethra into the bladder. Tissue samples may be taken for biopsy.
* CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerised tomography, or computerised axial tomography.
* MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
* Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
* Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
* Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.

The following stages are used for bladder cancer:

Stage 0

In stage 0, the cancer is found only on tissue lining the inside of the bladder. Stage 0 is divided into stage 0a and stage 0is, depending on the type of the tumour:

* Stage 0a is also called papillary carcinoma, which may look like tiny mushrooms growing from the lining of the bladder.
* Stage 0is is also called carcinoma in situ, which is a flat tumour on the tissue lining the inside of the bladder.

Stage I

In stage I, the cancer has spread to the layer below the inner lining of the bladder.

Stage II

In stage II, cancer has spread to either the inner half or outer half of the muscle wall of the bladder.

Stage III

In stage III, cancer has spread from the bladder to the fatty layer of tissue surrounding it, and may have spread to the reproductive organs (prostate, uterus, vagina).

Stage IV

In stage IV, cancer has spread from the bladder to the wall of the abdomen or pelvis. Cancer may have spread to one or more lymph nodes or to other parts of the body.

Recurrent Bladder Cancer

Recurrent bladder cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the bladder or in other parts of the body.

Treatment Option Overview

Key Points for This Section

* There are different types of treatment for patients with bladder cancer.
* Four types of standard treatment are used:
o Surgery
o Radiation therapy
o Chemotherapy
o Biologic therapy
* New types of treatment are being tested in clinical trials. These include the following:
o Chemoprevention
o Photodynamic therapy

There are different types of treatment for patients with bladder cancer.

Different types of treatment are available for patients with bladder cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Four types of standard treatment are used:

Surgery

One of the following types of surgery may be done:

* Transurethral resection (TUR) with fulguration: Surgery in which a cystoscope (a thin lighted tube) is inserted into the bladder through the urethra. A tool with a small wire loop on the end is then used to remove the cancer or to burn the tumour away with high-energy electricity. This is known as fulguration.
* Radical cystectomy: Surgery to remove the bladder and any lymph nodes and nearby organs that contain cancer. This surgery may be done when the bladder cancer invades the muscle wall, or when superficial cancer involves a large part of the bladder. In men, the nearby organs that are removed are the prostate and the seminal vesicles. In women, the uterus, the ovaries, and part of the vagina are removed. Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, surgery to remove only the bladder may be done to reduce urinary symptoms caused by the cancer. When the bladder must be removed, the surgeon creates another way for urine to leave the body.
* Segmental cystectomy: Surgery to remove part of the bladder. This surgery may be done for patients who have a low-grade tumour that has invaded the wall of the bladder but is limited to one area of the bladder. Because only a part of the bladder is removed, patients are able to urinate normally after recovering from this surgery.
* Urinary diversion: Surgery to make a new way for the body to store and pass urine.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy after surgery to kill any cancer cells that are left. Treatment given after surgery, to increase the chances of a cure, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Bladder cancer may be treated with intravesical (into the bladder through a tube inserted into the urethra) chemotherapy. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

New types of treatment are being tested in clinical trials. These include the following:

Chemoprevention

Chemoprevention is the use of drugs, vitamins, or other substances to reduce the risk of developing cancer or to reduce the risk that cancer will recur (come back).

Photodynamic therapy

Photodynamic therapy (PDT) is a cancer treatment that uses a drug and a certain type of laser light to kill cancer cells. A drug that is not active until it is exposed to light is injected into a vein. The drug collects more in cancer cells than in normal cells. Fiberoptic tubes are then used to deliver the laser light to the cancer cells, where the drug becomes active and kills the cells. Photodynamic therapy causes little damage to healthy tissue.

Treatment Options by Stage

Stage 0 Bladder Cancer (Carcinoma in Situ)

Treatment of stage 0 bladder cancer may include the following:

* Transurethral resection with fulguration.
* Transurethral resection with fulguration followed by intravesical biologic therapy or chemotherapy.
* Segmental cystectomy.
* Radical cystectomy.
* A clinical trial of photodynamic therapy.
* A clinical trial of biologic therapy.
* A clinical trial of chemoprevention therapy given after treatment to stop cancer from recurring (coming back).

Stage I Bladder Cancer

Treatment of stage I bladder cancer may include the following:

* Transurethral resection with fulguration.
* Transurethral resection with fulguration followed by intravesical biologic therapy or chemotherapy.
* Segmental or radical cystectomy.
* Radiation implants with or without external radiation therapy.
* A clinical trial of chemoprevention therapy given after treatment to stop cancer from recurring (coming back).
* A clinical trial of intravesical therapy.

Stage II Bladder Cancer

Treatment of stage II bladder cancer may include the following:

* Radical cystectomy with or without surgery to remove pelvic lymph nodes.
* Combination chemotherapy followed by radical cystectomy.
* External radiation therapy combined with chemotherapy.
* Radiation implants before or after external radiation therapy.
* Transurethral resection with fulguration.
* Segmental cystectomy.

Stage III Bladder Cancer

Treatment of stage III bladder cancer may include the following:

* Radical cystectomy with or without surgery to remove pelvic lymph nodes.
* Combination chemotherapy followed by radical cystectomy.
* External radiation therapy combined with chemotherapy.
* External radiation therapy with radiation implants.
* Segmental cystectomy.

Stage IV Bladder Cancer

Treatment of stage IV bladder cancer may include the following:

* Radical cystectomy with surgery to remove pelvic lymph nodes.
* External radiation therapy (may be as palliative therapy to relieve symptoms and improve quality of life).
* Urinary diversion as palliative therapy to relieve symptoms and improve quality of life.
* Cystectomy as palliative therapy to relieve symptoms and improve quality of life.
* Chemotherapy alone or after local treatment (surgery or radiation therapy).
* A clinical trial of chemotherapy.

Treatment Options for Recurrent Bladder Cancer

Treatment of recurrent bladder cancer depends on previous treatment and where the cancer has recurred. Treatment for recurrent bladder cancer may include the following:

* Surgery.
* Chemotherapy.
* Radiation therapy.
* A clinical trial of chemotherapy.