Bladder Cancer

In the urinary bladder, the cells most likely to become cancerous are the transitional cells. These are the elongated cells that form the lining or inner layer of the organ. This transitional cell carcinoma is the most common type of bladder cancer. It accounts for about 90% of cases. Urothelial carcinoma is another name for it.

Less common types of bladder cancer include:

• Adenocarcinoma: A relatively rare type of bladder cancer that may result from long-term inflammation or irritation. It accounts for about 1% of bladder cancers and is usually invasive.

• Sarcoma: A cancer that starts in the muscle fibers of the bladder walls. It is very rare.

• Small cell carcinoma: A cancer that starts in nerve-like cells and usually grows quickly. It is a rare bladder cancer, accounting for less than 1% of cases.

• Squamous cell carcinoma: A cancer that begins in thin, flat cells called squamous cells. This type may develop in the bladder after lasting infection or irritation. It accounts for about 4% of bladder cancers.

Many symptoms of bladder cancer resemble those of a bladder infection. Other symptoms, such as weight loss, often occur with late-stage cancers.

Common symptoms of bladder cancer include:

• Abdominal pain (indicates local spread)

• Bloody or pink-colored urine (hematuria)

• Difficult or painful urination, or burning with urination (dysuria)

• Fatigue

• Frequent urination

• Inability to control urine flow (urinary incontinence)

• Pale skin or pallor

• Urgent need to urinate

• Weight loss

In some cases, the complications of bladder cancer can be life-threatening. Seek immediate medical care (call 911) for any of these life-threatening symptoms including:

• Bluish coloration of the lips or fingernails

• Change in level of consciousness or alertness, such as passing out or unresponsiveness

• Change in mental status or sudden behavior change, such as confusion, delirium, lethargy, hallucinations and delusions

• Chest pain, chest tightness, chest pressure, palpitations

• Heavy bleeding

• Not producing any urine

• Rapid heart rate (tachycardia)

• Seizure

• Severe abdominal pain

Cancer staging tells doctors how widespread the cancer is. It lets them plan treatment accordingly and gives them an idea of how successful it will be. Doctors use imaging exams, such as CT scans and MRIs, to stage bladder cancer. The stage will depend on the following:

• How deep the tumor goes into the bladder wall

• Whether or not cancer cells are in lymph nodes

• Whether or not cancer has spread—or metastasized—to other areas and organs

There are five bladder cancer stages, with higher numbers indicating more advanced disease:

• Stage 0: The tumor is only in the bladder lining. Treatment involves removing the tumor or intravesical therapy (anticancer treatment instilled directly into the bladder).

• Stage I: The tumor has grown through the lining and is invading tissues underneath it. Treatment is usually surgery to remove the tumor, with intravesical therapy afterwards. Sometimes, doctors remove part or all of the bladder.

• Stage II: The cancer has spread deeper into the muscle layer of the bladder wall. It is still only in the bladder and has not spread to lymph nodes or other sites. Standard treatment involves bladder removal with chemotherapy.

• Stage III: The cancer has penetrated through the bladder wall. It has spread to the reproductive organs, but has not reached the abdominal wall, lymph nodes, or distant sites. Treatment involves removing the bladder, with chemotherapy beforehand and afterwards.

• Stage IV: This is advanced bladder cancer. It has spread to the abdominal wall, lymph nodes, or distant body sites. Chemotherapy with or without radiation therapy is standard treatment. Surgery cannot remove all the cancer.

Earlier stages tend to respond better to treatment and have a positive outlook.

All cancers are the result of DNA changes—or mutations—that affect the way cells grow. The changes occur in two types of genes that control cell growth—oncogenes and tumor suppressor genes. Oncogenes help cells stay alive, grow and divide. Some mutations keep these genes turned on when they should not be. Tumor suppressor genes are the brakes on cell growth. They make sure cells die when they should and repair DNA mistakes. Sometimes, mutations turn these genes off. In either case, the result is uncontrolled cell growth.

For some cancers, inherited gene mutations play an important role. This does not seem to be the case with bladder cancer. It rarely runs in families.

Instead, bladder cancer is usually the result of acquired mutations. A person accumulates small changes in DNA over their lifetime. Sometimes, the cells become very abnormal and turn into cancer. In the bladder, this tends to happen as a result of exposure to chemicals the kidneys process as waste. For example, tobacco smoke has chemicals the body absorbs into the blood. These chemicals ultimately end up in the urine, which the bladder stores.

A number of factors increase the risk of developing bladder cancer. However, smoking is the main one. It is responsible for about 50% of bladder cancers in both men and women. People who smoke are three times as likely as people who do not smoke to get bladder cancer.

Other risk factors for bladder cancer include:

• Age over 55 years

• Being white

• Chronic bladder infections

• Exposure to certain chemicals, typically in certain industries, such as rubber, textile, printing, painting, and hairdressing

• Family history of bladder cancer

• History of previous chemotherapy or pelvic radiation

• Male sex assigned at birth

You may be able to lower your risk of bladder cancer by:

• Drinking plenty of water, which may limit damage from chemicals by keeping them from staying in the bladder too long
  
• Quitting smoking
  
• Taking precautions to limit exposure to chemicals in the workplace
  

There is no specific bladder cancer diet or foods to avoid. However, a healthy diet, in general, will help you care for yourself. And experts recommend certain dietary habits to prevent cancer and other conditions. This includes:

• Eating plenty of fruits, vegetables, whole grains, beans, and plant-based foods to provide antioxidants, fiber, vitamins and minerals

• Limiting red meat and processed meats

• Not drinking alcohol or limiting it

Ask your healthcare professional for guidance before making significant changes to your diet.

To diagnose bladder cancer, your doctor will take a medical history, perform an exam, and order testing. Questions your doctor may ask include:

• What symptoms are you experiencing?

• How long have you had these symptoms?

• Are your symptoms constant or do they come and go?

• What, if anything, seems to make your symptoms better or worse?

• Do you smoke?

• What do you do for a living?

• What other medical conditions do you have?

During the physical exam, your doctor may try to feel bladder tumors. For males, this may involve a digital rectal exam (DRE). Females may need a pelvic exam in addition to a DRE.

Tests your doctor may order include:

• Urine tests: This testing can help rule out other conditions, such as infections. It can also find cancer cells and tumor markers that cancer cells release into the urine.

• Cystoscopy: This procedure involves inserting a thin, fiber-optic tube through the urethra into the bladder. It allows your doctor to view the bladder lining and take a biopsy if necessary.

• Biopsy: This involves removing a small tissue sample to examine it and run tests on it. It is the only way to know for sure whether or not bladder cancer is present.

• Imaging exams: Doctors use imaging exams after a bladder cancer diagnosis to find out if it has spread. Exams may include an intravenous pyelogram (IVP), CT, MRI, ultrasound, chest X-ray, or bone scan. An IVP is a special X-ray of the urinary tract that uses an injectable dye. The kidneys remove the dye from the bloodstream and pass it through the ureters and bladder. This helps to clearly outline these organs in X-rays to help detect tumors.

The goal of bladder cancer treatment is to permanently cure the cancer or to bring about a complete remission of the disease. Remission means that there is no longer any sign of the disease in the body, although it may recur or relapse later.

Common treatments for bladder cancer include:

• Intravesical therapy (anticancer treatment instilled directly into the bladder) to attack cancer cells or to stimulate the body's immune system to attack cancer cells

• Radiation therapy to attack cancer cells

• Surgery to evaluate nearby lymph nodes for possible spread of cancer

• Surgery to remove the cancer

• Systemic, or body-wide, chemotherapy to attack cancer cells

• Targeted therapy in select cases with specific tumor mutations

• Transurethral resection (TUR) (surgery through the urethra, the tube that drains the bladder) to remove smaller cancers

Some people need repeat TURs and multiple intravesical therapy treatments.

Doctors may add other therapies to maintain your general health and relieve side effects of treatment. Treatments may include:

• Antinausea medications

• Blood cell growth factors to increase the number of white blood cells if the level gets low during treatment

• Blood transfusions to temporarily replace blood components (such as red blood cells) that have dropped to low levels as a result of treatment

• Consultation with a wound, ostomy and continence nurse if doctors remove the bladder and create a new bladder surgically

• Dietary counseling to help maintain strength and nutritional status

• Pain medications to increase comfort

Some complementary treatments may help some people to better deal with bladder cancer and its treatments. Complementary treatments are not a substitute for traditional medical care. Be sure to notify your doctor if you are using nutritional supplements or homeopathic remedies. They may interact with the prescribed medical therapy.

Complementary treatments may include:

• Acupuncture

• Massage therapy

• Nutritional dietary supplements, herbal remedies, tea beverages, and similar products

• Yoga

When bladder cancer is in an advanced stage and is unresponsive to treatment, the goal of treatment may shift. Instead of curing the disease, it may focus on measures to keep a person comfortable and maximize quality of life. Hospice care involves medically controlling pain and other symptoms. It also provides psychological and spiritual support, as well as services to support the patient’s family.

Health-related quality of life (HRQoL) looks at the effect a disease and its treatment has on a person’s perception of their health. This includes physical, mental, emotional and social health, and financial and general well-being. HRQoL helps doctors and patients understand the benefits, such as symptom control, and risks, such as side effects, of treatments. It also helps cancer care teams tailor interventions to help patients live better.

Most people with bladder cancer have a reduced HRQoL according to research. Factors that can decrease HRQoL scores in bladder cancer include:

• Age

• Bladder cancer stage

• Comorbid conditions, such as high blood pressure or diabetes

The areas bladder cancer tends to affect the most are urinary function, bowel function, sexual well-being, and mental well-being. It may seem obvious that treatment will affect urinary function, and even that you may deal with anxiety and depression as part of cancer treatment. But many people do not realize the effect bladder cancer treatment can have on sexual and bowel health. It is important to discuss these issues when deciding on treatments.

Support groups can play an important role in coping with quality of life issues. Connecting with people who understand your challenges can be comforting. Ask your doctor about groups in your area or contact the American Cancer Society to find a group.

Left untreated, bladder cancer can spread to nearby and more distant organs. Also, bleeding can occur that can be serious and even life threatening in some cases. You can reduce your risk of serious complications by following your treatment plan.

Complications of bladder cancer include:

• Adverse effects of chemotherapy

• Adverse effects of radiation therapy

• Anemia (low red blood cell count)

• Changes in bowel movements

• Hemorrhage (bleeding)

• Recurrence of cancer after treatment

• Spread of cancer

• Ureteral obstruction (blockage of one of the tubes that carries urine from the kidneys to the bladder)

• Urinary incontinence (inability to control urine flow)

About half of new bladder cancers are in very early, high treatable stages at diagnosis. This is good news for prognosis and survival. When discussing survival, it is common to use a 5-year relative survival rate. This rate looks at people with cancer living five years after diagnosis compared to similar people without cancer. It gives you an idea of how much cancer may shorten life expectancy.

The overall 5-year relative bladder cancer survival rate is 77%. However, the stage plays a role in prognosis:

• Cancer remains in the bladder lining: 96%

• Cancer is invasive but remains localized to the bladder: 69%

• Cancer has spread regionally: 37%

• Cancer has spread distantly: 6%

Keep in mind, these numbers are only statistics. Experts arrive at them by looking at large groups of people with cancer several years ago. Survival rates cannot tell you how long you will live. There are many factors specific to you that can influence your outlook. Your doctor is the best source for information on your outlook.

May is bladder cancer awareness month. The Bladder Cancer Advocacy Network spends the month raising funds for research, education, and support and resources for those with the disease. Look for the marigold, blue and purple ribbon signifying bladder cancer awareness.