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Introduction
Bladder cancer is a disease in which malignant (cancer) cells form in the tissues of the bladder.
The bladder is a hollow organ in the lower part of the abdomen. It is shaped like a small balloon and has a muscular wall that allows it to get larger or smaller to store urine made by the kidneys.
There are two kidneys, one on each side of the backbone, above the waist. Tiny tubules in the kidneys filter and clean the blood. They take out waste products and make urine.
The urine passes from each kidney through a long tube called a ureter into the bladder. The bladder holds the urine until it passes through the urethra and leaves the body.
What are the different types of bladder cancer?
Urothelial or Transitional cell carcinoma: Cancer that begins in cells in the innermost tissue layer of the bladder. These cells are able to stretch when the bladder is full and shrink when it is emptied. Most bladder cancers begin in the transitional cells. Transitional cell carcinoma can be low-grade or high-grade:
Low-grade transitional cell carcinoma often recurs (comes back) after treatment, but rarely grows deep into the muscle layer of the bladder or spreads to other parts of the body.
High-grade transitional cell carcinoma often recurs (comes back) after treatment and often grows deep into the muscle layer of the bladder and spreads to other parts of the body, and to lymph nodes. Almost all deaths from bladder cancer are due to high-grade disease.
Squamous cell carcinoma: Cancer that begins in squamous cells, which are thin, flat cells that may form in the bladder after long-term infection or irritation.
Adenocarcinoma: Cancer that begins in glandular (secretory) cells that are found in the lining of the bladder. This is a very rare type of bladder cancer.
Cancer that is in the lining of the bladder is called superficial bladder cancer. Cancer that has grown deep through the lining of the bladder and invades the muscle wall of the bladder or has spread to nearby organs and lymph nodes is called invasive bladder cancer.
What are the signs and symptoms of bladder cancer?
Signs and symptoms of bladder cancer include blood in the urine and pain during urination.
These and other signs and symptoms may be caused by bladder cancer or by other conditions. Check with your doctor if you have any of the following:
Blood in the urine (slightly rusty to bright red in color).
Frequent urination.
Note: Many people with bladder cancer may not have any symptoms at all.
Pain during urination.
Lower back pain.
What tests are used to help detect and diagnose bladder cancer?
Tests that examine the urine and bladder are used to help detect (find) and diagnose bladder cancer. The following tests and procedures may be used:
Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Internal exam : An exam of the vagina and/or rectum. The doctor inserts lubricated, gloved fingers into the vagina and/or rectum to feel for lumps.
Urinalysis : A test to check the color of urine and its contents, such as sugar, protein, red blood cells, and white blood cells.
Urine cytology : A laboratory test in which a sample of urine is checked under a microscope for abnormal cells.
Cystoscopy : A procedure to look inside the bladder and urethra to check for abnormal areas. A cystoscope is inserted through the urethra into the bladder. A cystoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
Intravenous pyelogram (IVP): A series of x-rays of the kidneys, ureters, and bladder to find out if cancer is present in these organs. A contrast dye is injected into a vein. As the contrast dye moves through the kidneys, ureters, and bladder, x-rays are taken to see if there are any blockages.
CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. To stage bladder cancer, the CT scan may take pictures of the chest, abdomen, and pelvis.
Biopsy : The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. A biopsy for bladder cancer is usually done during cystoscopy. It may be possible to remove the entire tumor during biopsy.
What factors affect prognosis (chance of recovery) and treatment options?
Certain factors affect prognosis (chance of recovery) and treatment options. The prognosis (chance of recovery) depends on the following:
The stage of the cancer (whether it is superficial or invasive bladder cancer, and whether it has spread to other places in the body). Bladder cancer in the early stages can often be cured.
The type of bladder cancer cells and how they look under a microscope.
Whether there is carcinoma in situ in other parts of the bladder.
The patient’s age and general health.
If the cancer is superficial, prognosis also depends on the following:
How many tumors there are.
The size of the tumors.
Whether the tumor has recurred (come back) after treatment.
Treatment options depend on the stage of bladder cancer.
The prognosis (chance of recovery) depends on the following:
The stage of the cancer (whether it is superficial or invasive bladder cancer, and whether it has spread to other places in the body). Bladder cancer in the early stages can often be cured.
The type of bladder cancer cells and how they look under a microscope.
Whether there is carcinoma in situ in other parts of the bladder.
The patient’s age and general health.
If the cancer is superficial, prognosis also depends on the following:
How many tumors there are.
The size of the tumors.
Whether the tumor has recurred (come back) after treatment
Did you know?
Smoking can affect the risk of bladder cancer.
Stages of Bladder Cancer
After bladder cancer has been diagnosed, tests are done to find out if cancer cells have spread within the bladder or to other parts of the body. The process used to find out if cancer has grown deep within the bladder lining and muscle or spread to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.
The following tests and procedures may be used in the staging process:
MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
Chest x-ray : An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
Bone scan : A test to check if there is cancer in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.
How does cancer spread in the body?
There are three ways that cancer spreads in the body. Cancer can spread through tissue, the lymph system, and the blood:
Tissue. The cancer spreads from where it began by growing into nearby areas.
Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.
Cancer may spread from where it began to other parts of the body.
When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.
Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.
The metastatic tumor is the same type of cancer as the primary tumor. For example, if bladder cancer spreads to the bone, the cancer cells in the bone are actually bladder cancer cells. The disease is metastatic bladder cancer, not bone cancer.
Stages of Bladder Cancer
STAGE 0 :
Papillary Carcinoma and Carcinoma in Situ
In stage 0, abnormal cells are found in tissue lining the inside of the bladder. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is divided into stage 0a and stage 0is, depending on the type of the tumor:
Stage 0a is also called papillary carcinoma, which may look like tiny mushrooms growing from the lining of the bladder.
Stage 0 is also called carcinoma in situ, which is a flat tumor on the tissue lining the inside of the bladder.
STAGE I :
In Stage I, cancer has formed and spread to the layer of connective tissue (lamina propria) next to the inner lining of the bladder.
STAGE II :
In Stage II, cancer has grown deep into the layers of muscle tissue of the bladder
STAGE III :
In stage III, cancer has spread from the bladder to the layer of fat surrounding it and may have spread to the reproductive organs (prostate, seminal vesicles, uterus, or vagina).
STAGE IV:
In stage IV, one or more of the following is true:
Cancer has spread from the bladder to the wall of the abdomen or pelvis.
Cancer has spread to one or more lymph nodes.
Cancer has spread to other parts of the body, such as the lung, bone, or liver.
Recurrent Bladder Cancer
Recurrent bladder cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the bladder or in other parts of the body.
Treatment Options Overview
What are the types of treatment for patients with bladder cancer?
There are different types of treatment available for patients with bladder cancer.
Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer.
When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.
*Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
4 types of Standard Treatment used:
1. Surgery
One of the following types of surgery may be done:
Transurethral resection (TUR) with fulguration or transurethral resection of bladder tumor (TURBT): Surgery in which a cystoscope (a thin lighted tube) is inserted into the bladder through the urethra. A tool with a small wire loop on the end is then used to remove the cancer or to burn the tumor away with high-energy electricity. This is known as fulguration.
Radical cystectomy: Surgery to remove the bladder and any lymph nodes and nearby organs that contain cancer. This surgery may be done when the bladder cancer invades the muscle wall, or when superficial cancer involves a large part of the bladder. In men, the nearby organs that are removed are the prostate and the seminal vesicles. In women, the uterus, the ovaries, and part of the vagina are removed. Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, surgery to remove only the bladder may be done to reduce urinary symptoms caused by the cancer. When the bladder must be removed, the surgeon creates another way for urine to leave the body (urinary diversion procedure).
Partial cystectomy: Surgery to remove part of the bladder. This surgery may be done for patients who have a low-grade tumor that has invaded the wall of the bladder but is limited to one area of the bladder. Because only a part of the bladder is removed, patients are able to urinate normally after recovering from this surgery. This is also called segmental cystectomy.
Urinary diversion: Surgery to make a new way for the body to store and pass urine.
2. Radiation Therapy
Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy after surgery to kill any cancer cells that are left. Treatment given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
3. Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy).
When chemotherapy is placed directly into an organ or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).
For bladder cancer, regional chemotherapy may be intravesical (put into the bladder through a tube inserted into the urethra).
The way the chemotherapy is given depends on the type and stage of the cancer being treated. Combination chemotherapy is treatment using more than one anticancer drug.
Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.
Bladder cancer may be treated with an intravesical biologic therapy called BCG (bacillus Calmette-Guérin). The BCG is given in a solution that is placed directly into the bladder using a catheter (thin tube).
4. Biologic Therapy
New types of treatment are being tested in clinical trials.
Information about clinical trials is available from the National Cancer Institute Web site.
Patients may want to think about taking part in a clinical trial.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Patients can enter clinical trials before, during, or after starting their cancer treatment
Some clinical trials only include patients who have not yet received treatment.
Other trials test treatments for patients whose cancer has not gotten better.
There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from the National Cancer Institute’s listing of clinical trials.
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.
Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.
Recurrence
Bladder cancer often recurs (comes back), even when the cancer is superficial.
Surveillance of the urinary tract to check for recurrence is standard after a diagnosis of bladder cancer. Surveillance is closely watching a patient’s condition but not giving any treatment unless there are changes in test results that show the condition is getting worse. During active surveillance, certain exams and tests are done on a regular schedule. Surveillance may include ureteroscopy and imaging tests.
Treatment by Stages
Stages of Bladder Cancer
STAGE 0 :
Papillary Carcinoma and Carcinoma in Situ. Treatment of stage 0 (papillary carcinoma and carcinoma in situ) may include the following:
Transurethral resection with fulguration. This may be followed by one of the following:
Intravesical chemotherapy given right after surgery.
Intravesical chemotherapy given right after surgery and then regular treatments with intravesical BCG or intravesical chemotherapy.
Partial cystectomy.
Radical cystectomy.
A clinical trial of a new treatment.
STAGE I :
Treatment of stage I bladder cancer may include the following:
Transurethral resection with fulguration. This may be followed by one of the following:
Intravesical chemotherapy given right after surgery.
Intravesical chemotherapy given right after surgery and then regular treatments with intravesical BCG or intravesical chemotherapy.
Repeat TURBT especially if the pathology report did not show muscle in the resected tissue
Partial cystectomy.
Radical cystectomy.
A clinical trial of a new treatment.
STAGE II & STAGE III:
Treatment of stages II and III bladder cancer may include the following:
Radical cystectomy.
Combination chemotherapy followed by radical cystectomy. A urinary diversion may be done. .
External radiation therapy with or without chemotherapy.
Partial cystectomy with or without chemotherapy.
Transurethral resection with fulguration.
A clinical trial of a new treatment.
Treatment of stage IV bladder cancer that has not spread to other parts of the body may include the following:
Chemotherapy.
Radical cystectomy alone or followed by chemotherapy.
External-beam radiation therapy with or without chemotherapy.
Urinary diversion or cystectomy as palliative therapy to relieve symptoms and improve quality of life.
STAGE IV :
Treatment of stage IV bladder cancer that has spread to other parts of the body, such as the lung, bone, or liver, may include the following:
Chemotherapy with or without local treatment (surgery or radiation therapy).
External-beam radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
Urinary diversion or cystectomy as palliative therapy to relieve symptoms and improve quality of life.
A clinical trial of new anticancer drugs.
Recurrent Bladder Cancer :
Recurrent bladder cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the bladder or in other parts of the body.
Treatment of recurrent bladder cancer depends on previous treatment and where the cancer has recurred. Treatment for recurrent bladder cancer may include the following:
Combination chemotherapy.
Surgery for superficial or localized tumors. Surgery may be followed by biologic therapy and/or chemotherapy.
Radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
A clinical trial of a new treatment.
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