Bladder Cancer - staging, signs, symptoms, treatment and prognosis

What is Bladder Cancer and Definition

The growth of a malignant (cancerous) tumor in the BLADDER. Bladder CANCER may be primary or metastatic (travel to the bladder from a point of origin elsewhere in the body). Doctors diagnose bladder cancer in about 55,000 Americans each year. Bladder cancer is about three times more common in men, and in the United States is the fourth most common cancer among men. Bladder cancer claims about 12,000 lives in the United States each year. The likelihood of developing bladder cancer increases with age.

Cigarette smoking causes about 50 percent of bladder cancers, and exposure to industrial chemicals accounts for another 25 to 30 percent. Among the chemicals known to cause bladder cancer are the aromatic amines: aniline, benzidine, chlornaphazine, methylene dianiline, naphthylamine, and xenylamine. Numerous industries use these chemicals. Tobacco smoke, too, contains aromatic amines.

There are several types of bladder cancers though in the United States one type, transitionalcell CARCINOMA (TCC), accounts for more than 90 percent of bladder cancers. TCC arises from the epithelial (also called urothelial) cells that form the innermost layer of the bladder’s structure and typically undergo a series of predictable cell structure changes before becoming malignant. Other types of bladder cancer are relatively rare and include squamous cell carcinoma, small-cell carcinoma, LYMPHOMA, ADENOCARCINOMA, leiomyosarcoma, and metastatic malignant melanoma. Treatment options and outlook differ among the types of cancer.

Symptoms of Bladder Cancer and Diagnostic Path

Painless HEMATURIA (bloody URINE) is often the earliest indication of bladder cancer. The hematuria may be gross, meaning there is enough BLOOD present to discolor the URINE, or microscopic, detected through urinalysis. Symptoms and signs of bladder cancer may include

  • pink, red, or dark brown urine (hematuria)
  • DYSURIA (discomfort when urinating)
  • sensation of incomplete emptying of the bladder with URINATION

The diagnostic path begins with a standard urinalysis as well as specific urine tests to measure antigens and proteins present in the urine with TCC. These tests include

  • NMP22 BladderChek, which detects the presence of nuclear matrix protein (NMP) 22
  • BTA-Stat, which detects the presence of bladder tumor antigen (BTA)
  • fibrin degradation products (FDPs), which detects the breakdown of blood clots

Further diagnostic procedures include CYSTOSCOPY, INTRAVENOUS PYELOGRAM (IVP), or COMPUTED TOMOGRAPHY (CT) SCAN to visualize the bladder and urethra to detect tumors, and biopsy (which the urologist typically does during cystoscopy) of identified tumors or suspicious tissue. Biopsy provides the conclusive diagnosis, allowing the pathologist to identify the type of cancer and degree to which it has spread (staging and grading).

StageExtent of CancerTreatment Protocols/Options
Stage 0 cancer cells are in a single localized area in the the superficial cells of the urothelium (epithelial cells that form the lining of the BLADDER)
also called carcinoma in situ (CIS)
one or a combination of
  • transurethral resection (TUR) with fulguration (cystoscopic removal of the tumor and electrocautery to the adjacent tissue)
  • intravesical BCG (bacillus Calmette-Guérin instilled into the bladder via urethral catheter)
  • intravesical chemotherapy (chemotherapy instilled into the bladder via urethral catheter)
  • photodynamic therapy
Stage 1 tumor remains confined to the urothelium TUR with fulguration or segmental cystectomy (partial removal of the bladder) in combination with one or more adjunctive therapies:
  • intravesical BCG
  • intravesical CHEMOTHERAPY
  • radioactive seeding (implantation of radioactive pellets)
  • systemic chemotherapy
Stage 2 tumor extends into but not beyond the detrusor MUSCLE radical cystectomy (removal of bladder and surrounding organs and tissues in combination with one or more adjunctive therapies: urinary diversion (urostomy, reservoir)
Stage 3 tumor extends beyond the bladder wall to surrounding tissue
tumor may invade the PROSTATE GLAND (men) or CERVIX, UTERUS, VAGINA, or OVARIES (women)
preoperative chemotherapy
radical cystectomy (including removal of lymph nodes and any other organs to which the cancer has spread)
urinary diversion
postoperative radiation therapy, chemotherapy, or both
Stage 4 tumor extends into the structures of the pelvis and abdomen
tumor may extend into adjacent lymph nodes
metastatic cancer may appear in sites distant from the bladder
preoperative chemotherapy
radical cystectomy (including removal of lymph nodes and any other organs or structures to which the cancer has spread)
urinary diversion
postoperative chemotherapy, radiation therapy, or both
alternatively, palliative radiation therapy to shrink the tumors and relieve symptoms
Recurrent tumor comes back after treatment
tumor may recur in the bladder or appear
elsewhere in the urinary tract or distant from the bladder
surgery, chemotherapy, radiation therapy or a combination, depending on the cancer’s location and previous treatments

Bladder Cancer Treatment Options and Outlook

The cancer’s type and stage determine treatment options and outlook. Doctors diagnose about 70 percent of TCC in its early stages, when the tumor is small and remains confined to a localized region of the epithelium. These tumors, designated as superficial or stage 0, are highly treatable with minimally invasive therapies that generally preserve the bladder and normal urinary functions. These therapies may include

  • transurethral resection (TUR) with fulguration, a bladder-sparing treatment in which the urologist removes the tumor via cystoscopy and uses electrocautery to burn an area of surrounding tissue to kill any stray cancer cells
  • intravesical BCC, in which the urologist instills a solution of bacillus Calmette-Guérin (BCC) to stimulate an IMMUNE RESPONSE that targets any residual cancer cells or islated cancer cells elsewhere in the urothelium
  • intravesical CHEMOTHERAPY, in which the urologist instills chemotherapy drugs into the bladder to target residual cancer cells topically
  • photodynamic therapy, in which the person takes a chemical the cancer cells absorb that makes them extraordinarily sensitive to certain frequencies of light

Cancer that spreads into the urothelium or beyond requires more aggressive treatment, typically surgery to remove the tumor and surrounding tissue in combination with chemotherapy, RADIATION THERAPY, or both, and sometimes other therapies such as photodynamic therapy and intravesical BCC. In a segmental cystectomy the urologist removes part of the bladder; in a radical cystectomy the urologist removes all the bladder along with adjacent structures and organs, depending on the extent of the cancer. Segmental cystectomy usually preserves enough of the bladder to retain function and urinary continence.

Radical cystectomy requires further surgery to construct URINARY DIVERSION such as a urostomy, which drains urine continuously into a bag worn attached to the outside of the body, or an internal pouch structured from a loop of intestine that collects urine. With the pouch method, the urologist may be able to fashion a reservoir that collects the urine from the kidneys, and attach it to the urethra for normal continence and urination. When this is not possible or practical, the urologist may be able to construct an opening (stoma) into which the person inserts a catheter to regularly drain urine that collects in the reservoir.

Many of the treatment options for bladder cancer entail significant lifestyle changes. Radical cystectomy and radiation therapy often result in ERECTILE DYSFUNCTION in men, inability to have vaginal intercourse in women, and sterility in men and women. It is important to fully understand the potential side effects, complications, and QUALITY OF LIFE implications of the various treatment options when making treatment decisions and to obtain a second opinion consultation. Research is ongoing for new therapies, and some people may benefit from participating in clinical trials.

Bladder Cancer - Risk Factors and Preventive Measures

Bladder cancer is very rare in people under age 40. Cigarette smoking and occupational exposure to aromatic amines are the leading causes of bladder cancer, and health experts believe both to be preventable. It appears the highest risk of bladder cancer associated with cigarette smoking is for people who have smoked for several decades. The risk for bladder cancer appears to remain elevated even after stopping smoking. Some health experts believe current and former smokers should have annual urinalysis and urine cytology tests such as NMP22 BladderChek beginning at age 60.

Though exposure-related bladder cancer takes years to decades to develop, researchers believe even brief, limited exposure to aromatic amines may be sufficient to cause damage to the cells of the bladder that later results in bladder cancer. Most people who develop exposure-related bladder cancer have had long-term exposure to aromatic amines, however. Exposure-related bladder cancer generally develops over 15 to 20 years from the time of exposure, though can emerge up to 40 or 50 years later. Strict federal regulations limiting occupational exposure to known carcinogens such as aromatic amines have reduced risk somewhat over the past several decades, though the use of these chemicals remains so pervasive across numerous industries that exposure remains second only to cigarette smoking as a risk factor for bladder cancer.

chemical manufacturing hairdresser
leatherworker machinist
metalworker painter
printer rubber manufacturing
textile worker  

Certain treatments for other cancer may raise the risk for bladder cancer. These include radiation therapy to the pelvic region, notably women who received such treatment for ENDOMETRIAL CANCER or CERVICAL CANCER or men for PROSTATE CANCER, and chemotherapy with cyclophosphamide or ifosfamide. People who have had such treatments should receive ROUTINE MEDICAL EXAMINATION with urinalysis and diagnostic procedures as doctor recommended for early detection of bladder cancer.


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