What is Bladder Cancer?
How do you know that you may have bladder cancer? Some people may have symptoms that suggest they have bladder cancer. Others may feel nothing at all. Some symptoms should never be ignored. You may need to talk to a urologist about your symptoms. A urologist is a doctor who focuses on problems of the urinary system and male reproductive system. Talk to one about:
People can get bladder cancer when they come into contact with tobacco or other cancer-causing agents. There also are some risks related to genes and certain types of infections. Another known risk factor is a type of radiation beam aimed at the pelvis. Patients with other cancers, such as lymphomas and leukemia, who receive treatment with the drug cyclophosphamide, may be at a higher risk for bladder cancer.
You are more likely to get bladder cancer if you smoke or breathe in tobacco smoke. Smoking tobacco may be the cause of half of all bladder tumors. If you smoke, you are more likely to get bladder cancer than those who have stopped smoking.
Some things in the workplace may put you at a greater risk for bladder cancer. Contact with chemicals used to make plastics, paints, textiles, leather and rubber may cause bladder cancer.
Your healthcare provider will first perform a full medical history and physical exam. He/she may refer you to a urologist for more tests and to form a diagnosis. If your diagnosis is bladder cancer, additional tests will find out the stage of your disease. It will also give your doctor an idea of what treatment is best for you. Some of these tests are described here.
The following tests most likely will be done:
Diagnosis of bladder cancer is confirmed when the doctor sees the tumor through a cystoscope and during transurethral resection of a bladder tumor (TURBT) described below. You will likely be put to sleep for these exams. At this time your doctor will stage your cancer and try to cut it away. They will also see whether the cancer has spread.
Imaging tests. These tests help diagnose and stage bladder cancer.
Grade and stage are two important ways to measure and describe how cancer develops. A tumor grade tells how aggressive the cancer cells are. A tumor stage tells how much the cancer has spread.
Grading is one of the ways to know if the disease will come back. It also tells us how quickly the cancer may grow and/or spread.
Tumors can be low or high grade. High-grade tumor cells are very abnormal, poorly organized and tend to be more serious. They are the most aggressive type.
The tumor stage tells how much of the tissue has the cancer. Doctors can tell the grade and stage of bladder cancer by taking a small sample of the tumor. This is called a biopsy. A pathologist in a lab examines the sample under a microscope and determines the grade and stage of the cancer.
The stages of bladder cancer are:
Bladder cancer is described by how far into the wall of the bladder the cancer has grown (which is the clinical stage). Non-muscle invasive bladder cancers are found in the inner layer cells of the bladder. These cancers do not invade the muscular wall. These tumors are staged from Ta (lowest stage) to T1 (highest stage for NMIBC).
Over half of patients with low-grade Ta cancers will have a tumor recurrence. About 6% will progress to a higher stage. High-grade T1 cancers recur at a rate of about 45% and 17% of these will probably progress to a higher stage.
Once diagnosed, the rates of survival are quite favorable for patients with NMIBC. Survival in high-grade disease ranges from about 70-85% at 10 years and a much higher rate for low-grade disease. However, it is important that the disease is diagnosed early. This helps doctors predict the course of the disease and choose the best treatment to stop it from growing.
A cancer diagnosis can be very frightening. However, your doctor and medical team are there to help you.
Talk with your healthcare team about all the available forms of treatment. They will tell you about possible risks and the side effects of treatment on your quality of life.
Your options for treatment will depend on how much your cancer has grown. Your urologist will stage and grade your cancer and assess the best way to manage your care considering your risk. Risks are classified as low, intermediate or high and suggests the likelihood of tumor recurrence and/or progression. Treatment also depends on your general health and age.
Treatments for non-muscle invasive bladder cancer include:
If these options fail to treat your cancer, your doctor may recommend removing the complete bladder.
During a tumor resection, your doctor will remove any cancer cells that can be seen at transurethral resection of bladder tumor (TURBT).
Transurethral resection of bladder tumor (TURBT) is usually done under anesthesia. The surgery is done during cystoscopy, so there is no cutting into the abdomen. You will be given general or spinal anesthesia.
A rigid cystoscope is what your doctor will use for this procedure. This scope is straight and does not bend. It has a light at the end and is bigger and allows surgical instruments to pass through it. Your doctor is able to see inside the bladder, take tumor samples and resect (cut away) the tumor.
If a tumor is clearly seen, the doctor will attempt to remove it all. The doctor may also remove very small samples of other areas of the bladder that may look abnormal. These samples will also be checked for grade and stage. You may be left with a Foley catheter in your bladder after this procedure to allow your bladder to heal.
You may need to have your tumor resectioned more than once. During your follow-up examinations your doctor will check to make sure all the cancer is removed.
Intravesical ("within the bladder") therapy, is when a treatment drug is put directly into your bladder. The drug is put into the bladder with the help of a catheter (a thin tube that is placed through the urethra). You will hold the drug in your bladder for one to two hours and then pass it out. Intravesical chemotherapy is usually given immediately after surgery.
Immunotherapy is a treatment that boosts the ability of your immune system to fight the cancer. Bacillus Calmette-Guerin (BCG) is the immunotherapy drug that is used for bladder cancer. BCG also has been used as a tuberculosis vaccine.
Your BCG therapy will probably last about six weeks for the first course. It is usually done in your doctor's office, not in the hospital or operating room. You may get BCG treatment more than once.
The BCG drug is inserted into the bladder through a catheter. The therapy triggers the immune system to attack bladder cancer cells. It is one of the most effective treatments for bladder cancer, especially carcinoma in situ (CIS). It is not recommended if you have a weak immune system or certain symptoms. Side effects can include:
Intravesical chemotherapy is usually given immediately after surgery. With intravesical chemotherapy, drugs that are known to kill cancer cells are placed directly into the bladder, not in the bloodstream. As a result, many common side effects of chemotherapy - like hair loss - can be avoided. Because the drugs only reach the bladder lining, this type of treatment is only recommended for NMIBC.
Mitomycin C is the most common chemotherapy drug used for intravesical therapy. It is usually given after the initial TURBT. It helps stop cancer cells from going to another place and growing. It also reduces the recurrence rates. It can also be given as a six-week induction course similar to BCG. Common side effects include:
Some patients may respond to repeat therapy if the cancer returns. If you have high-grade Ta or T1 cancer or CIS, or you tried BCG and it did not work, you may need something else to control the cancer. In this case, you should talk to your doctor about surgery to remove the bladder.
After the bladder is free of disease, your doctor may suggest more treatment with the same drugs to keep the tumor from coming back. This may happen at the first three-month appointment after treatment.
Maintenance therapy is a good choice for people who have had BCG, less so for those who have had chemotherapy drugs. It is given for up to three years after treatment, and generally about every six months for three weeks at a time.
Your doctor will talk to you about whether you are a candidate for maintenance therapy. He/she will also talk about whether intravesical chemotherapy or BCG are good options for you.
If you have NMIBC, you may have to remove your bladder if intravesical BCG therapy fails. You may also need to remove it if you are at a greater risk of getting the cancer again or of it spreading. Cystectomy is being recommended more and more for tumors that are high-grade T1, T1+CIS (carcinoma in situ) and T1+LVI (lymphovascular invasion)
Partial cystectomy is a good choice for some patients if the tumor is located in a specific part of the bladder and does not involve more than one spot in the bladder. The surgeon removes the tumor, the part of the bladder containing the tumor, and nearby lymph nodes. After part of the bladder is removed, you may not be able to hold as much urine in your bladder as before surgery. You may need to empty your bladder more often.
For NMIBC, radical cystectomy is usually done if other therapies fail. The surgeon removes the entire bladder, nearby lymph nodes, and part of the urethra. In men, he/she may remove the prostate as well. In women, the surgeon may remove the uterus, ovaries, fallopian tubes, and part of the vagina. Other nearby tissues may also be removed.
When your bladder is removed or partly removed, your urine will be stored and made to leave your body by a different route. This is called urinary diversion. If you have a radical cystectomy, you will need to know about urinary diversion options.
Because the surgeon uses tissue from your intestines for bladder reconstruction, you must have sufficient bowel tissue for them to create your urinary diversion method. Before this is done, your surgeon will explain the procedure to you so that you can understand what will be done and the adjustments you will need to make. Here are some of the urinary diversion options your surgeon may offer:
Talk with your doctor about your options for a urinary diversion. Having a urinary diversion will greatly impact your quality of life. For more information on urinary diversion visit our Urinary Diversion article.
You may hear about possible clinical trials for your bladder cancer. Clinical trials are research studies that involve people. They test if a new treatment or procedure is safe and effective.
Through clinical trials, doctors find new ways to improve treatments and the quality of life for people with disease. Although clinical trials may or not be effective for your particular problem, they present an option to think about. Trials are available for all stages of cancer. Please visit our clinical trials research webpage to learn more.
You should expect to return to your doctor for re-evaluation and further tests for some time after treatment and surgery. After you complete your initial evaluation and treatment for NMIBC, your healthcare provider may bring you back in, within three to four months, for a cystoscopy to see how you are doing. This helps him/her evaluate if the entire tumor was removed and assess your risk for the tumor to recur.
If your healthcare provider stages you as low-risk for cancer progression, then you will be asked to return, usually in three months, just for a surveillance scope of your bladder.
If you are an intermediate-risk patient, then your healthcare provider may ask you to return for a cystoscopy with cytology every 3-6 months for two years, then 6-12 months for three to four years, and then every year after. Cytology is the examination of cells from the body under a microscope. If you are intermediate to high risk, your urologist may place you on maintenance therapy as described before.
If you are high-risk for cancer progression, your healthcare provider may bring you back every three to four months for two years, then six months for three to four years, and then every year after.
You may also be given imaging tests as your healthcare provider sees fit. These imaging tests will be done to look for cancer in your kidneys and ureters.
If you had surgery, it takes time to heal. The time needed to recover is different for each person. It is common to feel weak or tired for a while. However, like any other major surgery, bladder surgery may have complications. Older patients and women are more likely to get complications after cystectomy.
There are some things you can do before surgery to help your recovery. If you smoke, try to get help so that you can quit before and after surgery. You also need to make sure you eat right so that your body can heal and can cope with the changes.
Here are some possible problems you may have after treatment:
Remember that each person is different and each body may respond differently to therapy. It is important that you take care of yourself and remain in contact with your healthcare provider. Try to adopt healthy lifestyle habits including exercise, a well-balanced diet and no smoking. Your healthcare provider also may recommend a cancer support group or individual counseling.
Content provided courtesy & permission of the American
Urological Association Foundation, and is current as of 3/2019.
Visit us at www.urologyhealth.org for additional information.