11
Bladder Cancer
IN THIS CHAPTER YOU’LL DISCOVER
→ Treatments for Bladder Cancer
DESPITE REPEATED ROUNDS OF antibiotics, Anna Strazzante’s urinary tract infections kept coming back. “Some women just get UTIs,” her doctor told her. But Anna wasn’t satisfied. As a physical therapist, she did have knowledge of medicine, so finally she asked her doctor if he thought she might have cancer, but he brushed her off. When she started urinating blood, she called her doctor’s office again, but the nurse was unconcerned. Finally, Anna insisted on testing, and bladder cancer was the diagnosis. Now, five years later, Anna is cancer-free. But she tells everyone she knows, “Listen to your intuition. If it seems to you that something is wrong, question it!”
What Is Bladder Cancer?
The bladder is an expandable, balloon-shaped organ that stores the urine that the kidneys excrete through tubes (one for each kidney) called ureters. Bladder cancer develops when the normal cells of the bladder’s four-layered lining begin to grow uncontrollably and form a tumor. Like other tumors, a bladder tumor can be benign, or become malignant, and spread from the bladder to other organs as well.
Statistics
There are roughly 73,000 new cases of bladder cancer diagnosed in the United States each year. The disease occurs far more often in men, who will develop an estimated 55,000 cases, compared to 18,000 in women; this translates to one in 26 men versus one in 90 women. Caucasians are diagnosed with bladder cancer almost twice as often as African-Americans, but the latter are slightly more likely to have their cancers diagnosed at a more advanced stage. Asians have the lowest rate of bladder cancer. Overall, about nine out of 10 people with bladder cancer are over the age of 55, with the average person being diagnosed at age 73.
People develop bladder cancer even if they have no predisposition to the disease, but there are several risk factors that increase the probability. Some genetic disorders can increase risk, including Lynch syndrome, or HNPCC (see chapter 8), which is primarily associated with an increased colon and endometrial cancer risk. Inheriting certain rare, specific birth defects can also increase the chances of developing bladder cancer.
Occupational exposure to carcinogens, or cancer-causing chemicals, also ups bladder cancer risk. This danger especially pertains to painters, machinists, printers, hairdressers (due to heavy exposure to hair dyes), and truck drivers, most likely because of exposure to diesel fumes.
But genetic syndromes, birth defects, or occupational chemical exposure are not the major cause of bladder cancer; smoking is. “When it comes to smoking, bladder cancer is very similar to lung cancer,” says Blaine Kristo, MD, a urologist who specializes in bladder cancer at Mercy Medical Center in Baltimore, Maryland.
Smokers are three times more likely to develop bladder cancer, and smoking is responsible for half of the bladder cancers in both men and women. This is because when you smoke, you inhale cancer-causing chemicals into your lungs, which then get into your blood and travel to the kidneys. The kidneys filter out these chemicals, and they end up concentrated in the urine, where they sit in the bladder, damaging the lining of the organ and leading to cancerous changes.
“In fact, smoking is so closely linked to bladder cancer that, even when people are diagnosed with it, they find it tough to give up the habit,” says Dr. Kristo. “Many patients are still smoking when they come to see me. I tell them they have to do everything they can to stop; this is important. In the case of many types of cancer, like lung cancer, once a patient is diagnosed and stops smoking, it may be too late. But this is not true of bladder cancer. Since most bladder cancer is superficial when it’s diagnosed, a cure is very likely.”
Outcome and Survival Rates
More than 500,000 people in the United States today are bladder cancer survivors. As with most cancers, the survival rate is dependent on how early the cancer is treated, ranging from 98 percent in those whose cancers are caught the earliest, to 63 percent for Stage II. The survival rate for Stage III bladder cancer is 46 percent, and for Stage IV is 15 percent if the bladder cancer has spread to distant organs. Again, it is important to remember that there are people today surviving bladder cancer no matter what stage their cancer was diagnosed.
Types of Bladder Cancer
Bladder cancer is divided in types according to how the cells appear. The vast majority of bladder cases are known as “transitional cell bladder cancer,” comprising 95 percent of all cases. The remaining five percent include squamous cell carcinoma, adenocarcinoma, small cell carcinoma, and sarcomas. (Sarcomas are treated differently and discussed in detail in chapter 16.)
TRANSITIONAL CELL BLADDER CANCER
The most common of all bladder cancers in the United States, transitional cell cancer arises in the urothelium, or transitional epithelium, which is the bladder wall’s innermost lining. These cells can also be present in the linings of the ureters and urethra. Transitional cells are very elastic in nature — they stretch as the bladder expands, and shrink when it’s empty; the transitional cell is also capable of changing shape. Although the transitional is the only type of cell involved in this major form of bladder cancer, it can take on various forms. Transitional cell carcinoma of the bladder is also subdivided into two types:
- • Papillary bladder cancer starts in the urothelium, but grows into the bladder cavity, remaining attached by a mushroom-like stalk. Since this type of cancer grows in toward the hollow center of the bladder, it is noninvasive to the other layers of the bladder. Papillary carcinoma has a very low malignancy rate and is easily operable. Quite often, tumors never return.
- • Nonpapillary bladder cancer is composed of flat lesions. When they occur on the urothelium, they are considered noninvasive; however, they can become invasive, or spread to the outer layers of the bladder. Nonpapillary carcinomas are also referred to as “flat carcinoma in situ.”
SUPERFICIAL BLADDER CANCER
This type makes up 75 percent of all transitional bladder cancer cases. This is a common form of bladder cancer that occurs in the lining of the bladder. Although it does not spread, it can recur after treatment.
INVASIVE BLADDER CANCER
This is the most dangerous form of the disease. It can grow into the lining of the bladder and burrow into the muscle wall.
Stages of Bladder Cancer
STAGE 0
In this earliest stage, cancerous cells are found only in the surface of the bladder’s lining. The survival rate for this earlier stage of cancer is 98 percent. This is also known as cancer in situ, or non-invasive bladder cancer.
STAGE I
Cancerous cells are found in the thin lining of the bladder, but they have not spread to the muscle of the bladder.
STAGE II
The cancer has spread to the muscle of the bladder. Most bladder cancers are diagnosed at this stage because it is when blood is most likely to show up in the urine.
STAGE III
The cancer has spread through the muscular wall to the tissue that surrounds the bladder. In men, this would be the prostate gland, and in women, the uterus or vagina.
STAGE IV
The cancer has spread to the abdominal wall or the pelvis, and possibly to nearby lymph nodes and distant organs.
Signs and Symptoms
- • Blood in the urine is the main clinical sign of bladder cancer. “The problem is denial. Many people see blood in their urine and they know that it could mean something bad so they don’t show up until several months later and by that time the cancer has spread to the muscle. So the key is getting checked out promptly. This is especially important in older people with a history of smoking, even if that habit took place 20 years ago,” Dr. Kristo notes.
- • Feeling irritation, discomfort, or pain urinating
- • Needing to urinate more frequently than usual
- • Feeling the need to empty your bladder without results
- • Needing to strain (bear down) when urinating
- • Lower back pain
- • A recurrent or treatment-resistant UTI is being recognized as a potential sign of bladder cancer. Though this cancer is more prevalent in men, women need to be especially vigilant in getting screened as chronic UTIs in females are often blamed on common causes (e. g., failure to urinate after sex, etc.).
Specific Diagnostic Tests
The following tests are specifically performed to diagnose bladder cancer. For more information on general testing for cancer, see chapter 2.
URINE CULTURE
The urine is checked to see if a bladder infection is responsible for symptoms.
CYTOSCOPY
An instrument called a cytoscope is inserted through the urethra to observe the inside surface of the bladder and collect samples of tissues that can be examined, or biopsied, to check for cancer. This is the most common bladder cancer test done. If abnormal tissue is found, a biopsy, called a transurethral resection of bladder tumor (TURBT), is performed and the specimen is examined for cancer cells.
URINE TUMOR MARKER TESTS
This test checks the urine for specific substances (markers) that bladder tumors release. Although only a few bladder cancer tumor markers are currently known, this is a hot research area.
IMAGING TESTS
Computed tomography (CT or CAT) scans and magnetic resonance imaging (MRI) are used to see if the cancer has spread. The most common imaging test, a CT urogram utilizes injected dye, then a CT scan to provide images of the urinary tract. Another test, the retrograde pyelogram, is used for those who have an allergy to X-ray dye.
Treatments
All cancer treatment depends on the stage at which it is diagnosed. “This is particularly important in bladder cancer because, although only one type of cell is involved, it can act as two different diseases, depending on its stage,” says Dr. Kristo. “Stage 0 or I, remains on the surface of the bladder and can be removed. Once bladder cancer invades the muscle, however, both surgery to retain part or all of the bladder, along with chemotherapy and/or radiation, is needed.”
If the cancer is on the superficial level, the urologist can treat it. But once it spreads to the muscular wall of the bladder, you need to see a urological oncologist who specializes in treating bladder cancer, or a urologist with a great deal of expertise in the disease. “A lot of urologists and urologic oncologists specialize in prostate cancer, so you need to find an expert at a hospital where a lot of bladder cancers are treated. The outcomes are better at a hospital that treats 100 cases a year versus just three,” says Dr. Kristo.
Surgical Treatments
Bladder cancer is always treated with some form of surgery although the extent depends on the stage of the cancer.
TRANSURETHRAL SURGERY
Transurethral surgery is the most common form of treatment for bladder cancer and is the only treatment required for superficial bladder cancer, which is unlikely to spread. For this procedure, a wire-tipped tube called a resectoscope is passed into the bladder through the urethra, so no abdominal incision is needed. Cancerous cells are removed, and a laser is used to burn away any other suspicious tissue. This procedure can also be used to confirm a bladder cancer diagnosis as well as to stage the cancer.
CYSTECTOMY
This is the surgical procedure used for bladder cancers that are larger and have invaded the bladder wall. There are three types of cystectomies:
Partial Cystectomy
This surgery involves the removal of part of the bladder. It is a good choice if the cancer has entered the bladder wall, but is still small and confined to a single area. In this procedure, the tumor is removed, along with part of the bladder wall. The hole in the bladder wall is then closed. This procedure is appropriate only for small cancers that are not far advanced.
Simple Cystectomy
This procedure is used to remove the entire bladder.
Radical Cystectomy
This procedure involves the removal of the entire bladder, along with nearby lymph nodes, part of the urethra and any nearby organs that may contain cancer cells. In men, this would be the prostate, the seminal vesicles, and part of the vas deferens (the main duct through which the sperm travels). In women, the cervix, the uterus, the ovaries, the fallopian tubes, and part of the vagina are removed.
BLADDER RECONSTRUCTION
When the bladder is removed, another way to store and remove urine from the body is needed. This requires reconstructive surgery, and many types are available. One option calls for the removal of short piece of the intestine, which is connected to the ureters, and then to the outside of the body. This option requires the use of a stoma (surgical opening). A small bag is connected to the stoma, which is emptied when it is full.
An alternative procedure is called a continent diversion. For this, a valve is created from a piece of intestine, which allows for urine to be stored in an internal pouch. It is drained several times each day by using a catheter.
There is also a newer method, called a neobladder, in which a sort of artificial bladder is created in the form of a urinary reservoir made of a piece of intestine. This option allows for normal urination. But although this may sound preferable, sometimes complications can occur, so it sometimes is better to go with the use of a stoma.
One of the key reasons why early stage superficial bladder cancer and later stage bladder cancer are treated so differently centers on the issue of removal of the bladder. In early stage bladder cancer, the superficial cancer can be removed and the bladder left in place. But when all or part of the bladder is removed, sometimes along with other organs like a man’s prostate or a woman’s reproductive organs, this can result in major problems like incontinence or sexual dysfunction.
“This is a big surgery, and it’s a life-changing one, so it’s critically important for patients to be plugged into a center that can provide not only excellent care, but also support for caregivers and patient support groups as well,” says Dr. Kristo.
IMMUNOTHERAPY
This type of biological therapy uses the body’s own immune system to fight cancer. Bladder cancer patients who undergo transurethral resection for superficial bladder cancer may be candidates for a biological treatment called bacillus Calmette-Guérin (BCG), which helps prevent the cancer from recurring. For this, a live, weakened bacterial organism, BCG, is inserted into the bladder via catheter. The bacteria causes inflammation, stimulating the immune system to attack it and kill any remaining cancer cells.
CHEMOTHERAPY
Chemotherapy is often used either before or after surgery. And like BCG, it is often used following transurethral surgery to wipe out any remaining microscopic cancer cells, but it can also be used beforehand, even in cases of advanced bladder cancer, to improve results after surgery.
“Previously, doctors have been reluctant to use chemotherapy in such cases, fearing the patient might be weakened too much and less able to withstand surgery, but research shows that this is a powerful strategy that can improve or extend survival, so it should be discussed,” notes Dr. Kristo.
RADIATION
This common treatment uses high-energy radiation to kill cancer cells. It can be used as part of the treatment for early stage bladder cancer, as the main treatment for people with advanced bladder cancer who for various reasons aren’t candidates for surgery, or to help prevent or treat symptoms caused by advanced bladder surgery. It can also be used to enhance the effects of chemotherapy.