Bladder Cancer

Bladder cancer accounts for 2500 cases of cancer in Australia each year and 1000 cancer deaths. It is a potentially serious disease. If detected early, before it has spread outside the bladder, it can be treated successfully and cured. In WA in 2013, Bladder cancer accounted for more deaths than Melanoma.

Symptoms

The most common symptom is blood in the urine (haematuria). Other symptoms may include:

  • Increased urinary frequency
  • Pain when urinating
  • Difficulty emptying the bladder

Risk factors:

  • Most commonly – smoking.
  • Exposure to environmental carcinogens (cancer causing chemicals) such as benzene/ petrochemicals, dyes, rubber manufacturing.
  • Exposure to cyclophosphamide – a drug that has been used in chemotherapy

Diagnosis:

A cystoscopy – (visual inspection of the bladder using an endoscopic camera) is required see if there is a tumour in the bladder.

Ultrasound scan or CT scan are required to rule out other causes of blood in the urine and can also pick up whether the upper tracts – kidneys and ureters are involved. In advanced cases of bladder cancer a CT scan can to some extent predict whether the tumour has spread outside the bladder.

Urine cytology – a urine test to pick up cancerous cells that are shed in the urine.

Stages of Bladder Cancer:

1. Superficial The Tumour is confined to the inner layer of cells lining the bladder (Ta) or may have gone just beyond this cell layer, but not into the muscle layer (T1). 

2. Carcinoma in situ (CiS) This is an aggressive variant of superficial bladder cancer which when left untreated has a high chance of developing into an invasive form.

3. Invasive The tumour has invaded into the muscle layer of the bladder (T2) or beyond, into the fatty tissue around the bladder (T3).  If very advanced, the cancer may invade nearby organs (T4). This is a very dangerous stage as the cancer cells can spread via the blood stream and lymphatic vessels to other parts of the body.

 

stages of bladder ca

 

Treatment:

  • Transurethral Resection of Bladder Tumour (TURBT)
    • Superficial bladder tumours are treated by resection through a telescope which is placed into the bladder through the urethra(Transurethral resection of Bladder tumour -TURBT). The bladder tumour is completely removed, bleeding is controlled with cauterisation and a catheter is left in the bladder until the next day.

      Surveillance is carried out every few months to check if there is tumour recurrence.

      For recurrent superficial tumours, or where CiS is detected, the recurrence rate and the risk of progression to invasive disease can be reduced by administering medicine into the bladder, which is called intravesical therapy.

  • Intravesical (in the bladder) Therapy
    • Mitomicin.  This is a type of chemotherapy agent that can reduce the risk of a cancer returning.  It may be given as a single dose after the resection of a tumor (TURBT) or as a six week course.  It is not associated with many side effects.
    • BCG.  This is the Tuberculosis vaccine that most people receive as part of their immunisation programs. When BCG is placed in the bladder, it stimulates the immune system to find and kill any cancer cells which are nearby.  This is called immunotherapy. This treatment can significantly decrease the chance of the cancer coming back or progressing to a more invasive stage.  Click here for detailed information about BCG treatment.

In cases of invasive disease or when there has been recurrent superficial disease of high grade which has failed to respond to intravesical treatment, radical surgery or chemoradiation is required.

  • Radical Cystectomy:
    • Removal of the bladder, lymph nodes near the bladder, and any nearby organs that contain cancer cells. This procedure is usually used when there are multiple areas of cancerous cells in the bladder.
    • When the bladder is removed, a urostomy or urinary diversion procedure is performed. This is a surgical approach to create another opening for urine to drain to.
    • Women who have a radical cystectomy usually have their uterus, ovaries, and part of the vagina removed as well. The prostate gland and seminal vesicles are usually removed in men who have a radical cystectomy.
    • Usually, a small portion of the small intestine is used to make a tube for urine passage to the outside of the body. The opening of this tube is called a stoma. Urine empties into a small pouch or bag attached over the stoma outside the body.
    • Another type of urinary diversion uses an internal pouch called a continent reservoir. This pouch, often made from the small intestine, is located inside the abdominal wall. It is connected to the urethra (orthotopic neobladder) or to a stoma (catheterisable pouch). Individuals with a continent reservoir learn to drain their urine using a catheter, either through the urethra or the stoma.
  • Neobladders and Continent Pouches
    • Neobladders are positioned inside your body in the same position as your original bladder. The kidneys will filter your system as they always did and deposit urine into your neobladder, which will hold the urine until you are able to release it. Most patients are able to learn how to control the release of urine from the neobladder much like they did with a normal bladder. In some cases however, either the neobladder doesn’t function completely or the patient can’t learn to control urine release and they patient must then insert a catheter multiple times during the day to empty the neobladder.
    • Not everyone is a candidate for a neobladder reconstruction, for example you must have full kidney and liver function and you cannot have cancer in your urethra. Most patients who are candidates for neobladder reconstruction prefer this approach over having an abdominal stoma (passage) attached to a bag that collects urine.
  • Chemoradiation (Bladder preservation)
    • After a thorough resection (TURBT), a combination of chemotherapy and radiotherapy can cure some advanced bladder cancers.  The cure rate is not as good as with surgery and there can be complications in terms of radiation damage to the bladder or bowel.