Bladder Cancer

What is bladder cancer?

Bladder cancer is the uncontrolled growth of the cells that make up the lining of the bladder.

Most cases are formed from this lining (known as the transitional cell lining) and this cancer is often referred to as transitional cell carcinoma. Some authorities have renamed this recently as 'urothelial carcinoma'.

Other variants of bladder cancer, such as adenocarcinoma (2 per cent of bladder cancers) and squamous cell carcinomas (1 to 2 per cent of cases), are much rarer.

Bladder cancer itself is rare in people under 40 years of age and the risk increases with age. This form of cancer develops most often in people between the ages of 60 and 79, with the average age being 67.

The disease is three times more common in men than in women. It is one of the most common forms of cancer to strike men. 

How does bladder cancer develop?

Cigarette smoking is now the biggest risk factor for the development of bladder cancer. The risk increases with the number of years smoked and the number of cigarettes smoked.

Occupational exposure to carcinogenic (cancer causing) agents, such as aromatic compounds and chemicals used in industry and elsewhere, can lead to bladder cancer.

It can take up to 25 years after exposure for such cancers to develop and with tighter health and safety rules these cases are now rare and mostly reflect industrial practices many years ago.

Stopping smoking, even after many years, can be beneficial because ex-smokers have a lower rate of bladder cancer than those who continue to smoke.

In the tropics, bladder cancer is often brought about by the widespread disease bilharziasis (river blindness), which is caused by a tiny micro-organism that invades the bladder.

What are the symptoms of bladder cancer?

Generally the first sign is blood in the urine. It may be visible or the amount may be so small that it can only be discovered by chemical testing (dipstick testing of the urine).

There doesn't need to be blood in the urine constantly. In fact, there are often periods in which there's no evidence of blood at all.

So one should not be fooled by a symptom that seems to have gone away. Any person with visible bleeding in the urine should consult their GP for advice because the majority of these cases will need referral to a urologist for investigation.

There may be frequent urination, stinging and pain across the pubic bone or exactly the same symptoms as in an ordinary bladder infection

How is bladder cancer diagnosed?

If blood is discovered in the urine or there are constant symptoms of bladder irritation of unknown cause, the patient should be examined by a doctor.

In order to reach a diagnosis, the GP will refer the patient urgently to the local hospital urology department for a series of special examinations.

Guidelines vary between hospitals with respect to the age cut off but in general any person over the age of 45 to 50 with visible blood in the urine will need investigation with a cystoscopy to inspect the bladder and a scan of the kidneys.

Blood in the urine, found on dipstick testing, is investigated in a similar manner.

Cystoscopy involves the passage of a thin fibre-optic telescope up the urethra (water pipe) into the bladder.

The whole of the inside lining of the bladder is then carefully inspected for any abnormalities. Most departments now offer this as a day case under local anaesthesia (anaesthetic gel placed into the urethra before the procedure).

If any abnormalities are detected then further arrangements can be made for treatment under a general anaesthetic.

The kidneys are also examined for abnormalities either by using an ultrasound scan or, increasingly, by CT scans. In many cases the cystoscopy and ultrasound or CT will be done on the same day in a one-stop clinic setting.

When the diagnosis has been made and the extent of the cancer is known, the type of treatment will be considered.

How is bladder cancer treated?

The treatment of bladder cancer differs depending on how deeply the wall of the bladder is involved. There are two main groups. 

Superficial cancer (non muscle-invasive)

This means there is no evidence that the tumour has spread into the muscle coat of the bladder. The majority fall into this category and can usually be cured.
The tumour is normally diagnosed by taking a sample down a cystoscope with a specially adapted telescopic instrument – the latter is known as transurethral resection of bladder tumour (or TURBT).
Anti-cancer drugs, such as mitomycin C or BCG (Bacillus Calmette-Guerin), are often used by instillation into the bladder after a TURBT has been performed. There's good evidence that even a single dose of these drugs can reduce the rate of recurrence of bladder tumours.
Most superficial cancers are treated by surveillance, with periodic scheduled cystoscopic examinations of the bladder.
The frequency of these examinations will depend on how often recurrences are found. These examinations are often performed under local anaesthetic and any recurrences can be easily dealt with by cauterisation down a cystoscope under a subsequent general anaesthetic.
Surveillance has a second purpose of inspecting the bladder for any suggestion that the tumours are becoming more deeply involved in the bladder.
A small proportion of patients who initially present with superficial bladder tumours will subsequently show signs of tumours with muscle invasion, which has implications for management.

Muscle invasive bladder cancers
In these cancers, the tumour grows deeper to involve the muscle lining of the bladder.
This is more serious because there's a greater risk that the cancer may spread to the lymph nodes or other organs such as the liver or bone.
Further tests like a CT scan or MRI scans will help to confirm that the cancer is confined to the bladder.
Treatment is usually a choice between radiation treatment or the total surgical removal of the bladder, known as cystectomy.
If the bladder has to be surgically removed, urine from the kidneys is normally diverted to the skin surface just below the waistline using a small portion of the small bowel (known an ileal loop diversion).
In this procedure, the tubes from the kidneys are joined to one end of a 12cm length of small bowel and the other end is brought out through the abdominal wall and onto the skin to form a stoma.
A special adhesive bag is placed over the stoma to collect the urine. There is a tap on the bag to drain off the urine when necessary.
In certain circumstances, a more sophisticated form of diversion can be constructed. Bowel can be made into a pouch with a tunnel to the skin surface through which the patient passes a small tube to drain the urine.
Occasionally, a functioning bladder can be constructed from segments of bowel to form a continent bladder substitute, known as an orthotopic bladder substitute.
If the cancer has spread to the lymph nodes or other organs, treatment with medicines (chemotherapy) may be offered.