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Bladder Cancer

Overview

Bladder cancer is the fifth most common cancer in the United States. Almost 60,000 cases are diagnosed each year, and more than 12,000 will die from the disease. Men, Caucasians and smokers have twice the risk of bladder cancer than the general population. When diagnosed and treated in a localized stage, bladder cancer is very treatable, with a five-year cancer-specific survival rate approaching 95 percent.

Smoking is the greatest risk factor for bladder cancer. The incidence increases in people 50 years of age and older. Chronic bladder problems like infections and kidney stones may also be risk factors, although no direct link has been established.

Types

The different types of bladder cancer are: Transitional cell bladder cancer: About 90 percent of bladder cancers are transitional cell carcinomas – cancers that begin in the cells lining the bladder.

Cancer that is confined to the lining of the bladder is superficial bladder cancer. Squamous cell bladder cancer: Bladder cancer that begins in squamous cells, which are thin, flat cells that may form in the bladder after long-term infection or irritation. Adenocarcinoma: Bladder cancer that develops in the inner lining of the bladder as a result of chronic irritation and inflammation.

Symptoms

The most common bladder cancer symptom is blood in the urine (hematuria), which causes the urine to appear rusty or deep red in color. However, hematuria cannot always be detected by the naked eye, and can also be a symptom of other conditions such as kidney stones and urinary tract infection. If you experience hematuria or any of the other bladder cancer symptoms listed below, let your doctor know:

  • Painful urination
  • Frequent urination
  • Having the urge to urinate, but without result

Diagnosis

Bladder cancer can be diagnosed by cystoscopy, imaging or cytology procedures. People considered at high risk should undergo one or more of these procedures on a regular basis so that the cancer is found at an early, more treatable stage.

People at high risk for bladder cancer are:

  • At least 50 years old with hematuria (blood in the urine)
  • Under age 50 with visible hematuria

Cystoscopy is the most common and reliable test for bladder cancer. A thin tube with a camera (cystoscope) is inserted into the bladder through the urethra to view the suspicious area. The cystoscope can also be used to take a tissue sample for biopsy, and to treat superficial tumors without surgery. However, cystoscopy is not perfect. Flat lesions (carcinoma in situ) and small papillary tumors can be missed. Imaging studies such as a CT scan, ultrasound or intravenous pyelogram (IVP) supplement the information provided by cystoscopy. IVP involves injecting a dye that shows up on an X-ray as it travels through the urinary system.

Urine-based tests use a urine sample to determine the presence of cancer. Cytology is the oldest urine test, which involves looking at the sample under a microscope for the presence of abnormal cells. There are several types of urine tests available that focus on specific bladder cancer "markers." The urologist will choose the most appropriate urine test for each patient.

Treatment

Different types of treatment are available for bladder cancer. Some treatments are standard and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial.

Surgery

Surgery to remove the bladder is called a cystectomy. Virtually all cystectomies for cancer are radical, meaning that the entire bladder is removed. Partial cystectomies are rare, but may be appropriate for very carefully selected patients. Minimally invasive surgery techniques such as laparoscopy are still considered experimental, and are not routinely performed at this time. In men, the bladder, prostate and lymph nodes are removed in a cystectomy. Surgical advances are allowing surgeons to spare the nerve bundles responsible for erection. In women, the bladder, uterus and part of the anterior vaginal wall are removed, but the vagina can now be spared in some cases. For some early-stage or superficial bladder cancers, a procedure called transurethral resection (TUR) may be used. A resectoscope, which is a thin tool with a wire loop on the end, is threaded through the urethra to scrape the tumor from the bladder wall. The resectoscope can also be used to deliver an electrical current to burn the tumor away.

Chemotherapy

Chemotherapy plays a major role in the treatment of metastatic bladder cancer that has spread to the lymph nodes, lungs, liver and other parts of the body. In patients who have metastases at diagnosis, chemotherapy is the frontline treatment. The "gold standard" chemotherapy for metastatic bladder cancer is a combination of four drugs known as MVAC: methotrexate, vinblastine, adriamycin and cisplatin. MVAC has provided good response rates since the 1980s. In recent years, the MVAC treatment regimen has been decreased from four weeks to two weeks, with less toxic side effects for the patient and an improved response rate of 50 percent and higher.

Another chemotherapy regimen is a combination of gemcitabine and cisplatinum. It is less toxic than MVAC, with similar response rates. Both chemotherapies have an average survival rate of 14 months.

Chemotherapy is also used in conjunction with surgery for patients who are at high risk for metastasis. Data suggest that bladder tumors that have invaded the muscle wall and have the potential to spread can benefit from chemotherapy before surgery (neoadjuvant therapy).

Radiation Therapy

Although surgery is the frontline treatment for bladder cancer, radiation treatment does have a role in certain patients. Simultaneous radiation and chemotherapy with cisplatin may be used instead of surgery in an effort to save the bladder. However, only about 40 percent of patients who undergo bladder-sparing treatment will be able to keep their bladder and not have the cancer come back.

The best candidates for radiation therapy:

  • Have locally resected tumors
  • Have only one tumor site
  • Can tolerate chemotherapy and 6 to 7 weeks of daily radiation treatments
  • Must undergo rigorous follow-up after treatment

Immunotherapy

In recent years, a significant amount of cancer research has been devoted to immunotherapy, which uses the body's own defense mechanisms to fight cancer.

All cells have protein markers, called antigens, on their surfaces that identify them as either "normal" or "foreign." The presence of foreign antigens (such as cancer cells) in the body provokes a sophisticated chemical reaction involving lymphocytes and other cells that defend the body against disease.

Some of these defender cells produce antibodies, which seek out and destroy specific antigens.

Immunotherapy & Bladder Cancer

For superficial bladder cancer, another type of immunotherapy has become the standard of care. Intravesical immunotherapy involves filling the bladder with a solution containing Bacillus Calmette-Guérin (BCG), a bacterial organism that is sometimes used to treat tuberculosis. The BCG, delivered through a catheter, stimulates an immune response within the bladder to destroy any remaining cancer cells. Intravesical immunotherapy is performed after the bladder wall has been scraped to remove superficial tumor cells. The treatment success rate with intravesical BCG is 70 percent to 80 percent.

Clinical Trials

New treatments are always being tested in clinical trials and some patients with cancer may want to consider participating in one of these research studies.

These studies are meant to help improve current cancer treatments or obtain information on new treatments. Talk to your doctor about the clinical trials that may be right for you.