Most bladder cancer involves abnormal cell growth in the innermost lining (urothelium) of the bladder wall. About 90 percent of all urothelial tumors are diagnosed as transitional cell carcinomas. In transitional cell carcinoma, normal lining cells undergo changes that lead to their uncontrolled growth. Most bladder cancers begin this way. Unless treated, these can form tumors and eventually spread and cause cancer in other parts of the body.
Cancer confined to the lining is called superficial bladder cancer. Low-grade, superficial bladder cancers have minimal risk of progression to death. Most patients with superficial cancers can be cured using a procedure to remove cancerous cells, called transurethral resection, either with or without chemotherapy. Between 70 and 80 percent of all newly diagnosed bladder cancers are first diagnosed with this form of the disease.
However, high-grade non–muscle-invasive cancers frequently progress and muscle-invasive cancers are often lethal. These include squamous cell carcinoma and adenocarcinoma. Sqaumous cell carcinoma is unregulated growth of squamous cells, thin, flat cells that can form in the bladder after long-term infection and irritation. Adenocarcinoma begins in the glandular cells and can also form with long-term infection and irritation.
Those with deeply invasive cancer can sometimes be cured by surgery, radiation therapy, or a combination of these and chemotherapy. Some patients with distant metastases have achieved long-term complete response following treatment with combination chemotherapy regimens, and there are clinical trials for patients with all stages of bladder cancer.
Nonetheless, a majority of patients with deeply invasive tumors, or regional or distant metastases cannot be cured. In the U.S., the standard treatment for patients with invasive bladder cancers is radical cystectomy and urinary diversion. Other treatment approaches include transurethral resection (TUR) and segmental resection with or without radiation therapy, combined chemotherapy-radiation therapy, or either followed by salvage cystectomy, when needed, for local failure.
By far, cigarette smoking is the single biggest risk factor in development of bladder cancer. Other risks include a family history of the disease, being a Caucasian, being a male over age 65, exposure to workplace substances like paint, dyes, hairdressing products, textiles and rubber; eating a high-fat diet, especially fried meats; being an older Caucasian male; having a long-term parasitic infection; and chemotherapy or radiation to treat other cancers.
In the early stages, individuals with bladder cancer often have no symptoms and the first sign of trouble is blood in the urine, a condition called hematuria. Urine may appear rusty or red, but more often the amount of blood is so small that it cannot be seen without a microscope.
Other symptoms include:
- Frequent urination, or feeling the need to urinate without being able to do so.
- Painful urination.
- Lower back pain.
- A slow or intermittent urine stream
- Pelvic pain
Because these are also symptoms of other disorders, including prostate cancer and BHP, it is very important to have a full urological examination as soon as they appear.
The first step in an evaluation for bladder cancer is a thorough physical exam, including urinalysis and urine flow testing, together with a complete family and individual medical and work history. If there are any signs or symptoms of bladder problems, additional tests may be necessary. These include:
- An examination of urine under the microscope for signs of blood (urine cytology)
- Using special x-rays and a special dye to examine the kidneys, bladder and connecting tubes (intravenous pyelogram (IVP) or CT urography).
- Inserting a thin, flexible and lighted tube through the urethra to examine the bladder (cystoscopy). A biopsy may be taken of any abnormal growths are detected.
- Several tests are available that can look for two proteins in the urine that have been linked to cancer.
- Another a urine test called fluorescence in situ hybridization, or FISH, can identify some chromosomal abnormalities indicating early transitional cell cancer.
There are four stages of bladder cancer. The first stage is cancer that is confined to the bladder lining. This is the most common type and represents between 60 and 70 percent of all cases diagnosed. The second stage is when cancer has spread to the muscle wall, the third to tissue around the bladder, and the fourth indicate that it has spread to other organs in the body.
Many factors must be taken into consideration when it comes to selecting the most appropriate treatment for bladder cancer. Among these are a patient’s age and gender, cancer type, tumor type, grade, and stage. Surgical treatment is often recommended for bladder cancer patients, together with radiation, chemotherapy or immunotherapy, and depends on the degree of the grade and stage of the disease, as well as other factors. These procedures include:
- Transurethral resection (TUR) is used to diagnose bladder cancer and remove any cancerous tissue. It is performed under general or spinal anesthesia. A thin, flexible tool called a cystoscope is passed through the urethra into the bladder to inspect the cancerous area while another tool, called a resectoscope, is used to remove the cancer for biopsy and burn away remaining cancer cells.
- Segmental partial cystectomy involves removing only the affected portion of the bladder and is indicated for patients with a normally functioning bladder and a solitary tumor that has not spread to the bladder muscle. Because only the affected area is removed, most of the bladder is preserved.
- Radical or simple cystectomy involves removal of the entire bladder when cancer has spread into the wall of the bladder (stage 2 & 3). This procedure often can be performed using smaller incisions and an operating robot. Under general anesthesia, an incision is made into the lower abdomen, blood vessels leading to and from the bladder are tied off, and the bladder is divided from the urethra, ureters, and other tissues holding it in place. The bladder is then removed. Often other pelvic organs and structures are also removed to prevent bladder cancer from spreading to nearby tissues. Surgeons often build an alternative bladder, using part of the intestine, or create a conduit to carry urine into an special bag that rests close to the body.
- Radiation therapy usually involves delivering a precise amount of radiation targeted directly at cancerous cells and affected tissue. This is often used with chemotherapy to treat invasive bladder cancer.
- Chemotherapy involves the use of one or several drugs that kill cancer cells. These are delivered by injected either into the urethra and bladder, or into a vein. Intravenous chemotherapy is typically used before surgery or for cancer that has spread.
- Immunotherapy involves injecting a live bacterium into the bladder once per week for about six weeks. The body’s natural immune system response attacks both the bacteria and cancer cells. The technique can often prevent recurrence of superficial cancer that has been removed or successfully treated.
- The depth of a cancer’s invasion into the bladder wall, and the degree of differentiation of the tumor, are the most significant determinants of patient outcomes. Most superficial tumors are well differentiated, but in those with tumors that are less differentiated, those with large, multiple, or tumors associated with carcinoma in other areas of the bladder mucosa are at greatest risk for recurrence and the development of invasive cancer.
- Patients who respond to immunotherapy have a 20 percent risk of recurrence within five years.
- Involvement of multiple cell lines is associated with poor outcomes, as is certain genetic abnormalities and expression of certain antigens.
- Complications after radical cystectomy may be as high as 25–35 percent, while partial cystectomy has a complication rate ranging from 11–29 percent. Recurrence rates after partial cystectomy are between 40-80 percent, according to some estimates.
- Transurethral surgery, intravesical medications, and cystectomy are each associated with 5-year survival in 55-80 percent of patients.
- Invasive tumors confined to the bladder muscle after radical cystectomy are associated with approximately a 75 percent 5-year progression-free survival.
- Patients with more deeply invasive tumors have 5-year survival rates of 30-50 percent after radical cystectomy.
- If a locally extensive cancer has spread to adjacent pelvic organs or to the lymph nodes or other distant sites, 5-year survival is uncommon.
Our bladder cancer rehabilitation therapists can help patients improve strength and endurance, regain independence, reduce stress and maintain energy to fully participate in activities. If the bladder has been removed, patients also learn how to care for their external bladder device, as well as how to cope with the challenges they will face as they recover.