What is bladder cancer?

Bladder cancer affects both men and women across many parts of the world.

The risk of developing bladder cancer increases with age. In fact, most people diagnosed are 60 or older (Cancer Council NSW, 2013), with men about three times more likely than women to be diagnosed with bladder cancer.

Bladder Cancer develops when cells within the bladder grow abnormally which causes them to multiply and divide uncontrollably. More than 90% of bladder cancers form in the lining of the bladder (the urothelium) and are known as urothelial carcinomas, or transitional cell carcinomas.

If cancer cells stay within the lining of the bladder, it is referred to as a superficial bladder cancer. Around 90% of bladder cancers are superficial (Cancer Council NSW, 2012) and can be treated simply and effectively.

Sometimes though, cancer cells can spread to the muscle wall of the bladder, to other organs and into lymph nodes. When this happens, it is called invasive bladder cancer and partial or complete removal of the bladder is necessary.

Bladder cancer risk and causes

Although definite causes are unknown at this stage, certain factors are known to be associated with the risk of developing the disease. These include:

• Smoking — smokers are three to four times more likely to get the disease than nonsmokers.
• Age — the older you are the more susceptible you are to the disease
• Gender — men are four times more likely to develop bladder cancer
• Exposure to chemicals — especially in the textile, petrochemical and rubber industries
• Repeated chronic bladder infections — particularly if inflammation from foreign objects (eg a catheter) is ever-present
• Treatments for other cancers— including some chemotherapy and radiography treatments

Types of bladder cancer

Non-invasive vs invasive

Bladder cancer can either be superficial (non-invasive) or invasive. Non-invasive bladder cancer means that the cancer is contained to the lining of the bladder. Invasive bladder describes a cancer that has moved in the bladder muscle wall and possibly beyond. These type of cancers are much harder to treat.

Generally though, there are three main types of bladder cancer and each is determined by the type of cell in which the cancer first develops.

Urothelial carcinoma

Most types of all bladder cancers (80–90%) start in the urothelial cells lining the bladder wall. This is sometimes called transitional cell carcinoma. Urothelial carcinoma can be papillary or flat:

• Papillary urothelial carcinoma has slender, finger-like projections and grows towards the hollow centre of the bladder.
• Flat urothelial carcinoma, such as carcinoma in-situ, spreads along the inner lining of the bladder. There is about a 50% risk of it developing into an invasive cancer (Aua.com.au, n.d.).

Squamous cell carcinoma

This type of cancer starts in the thin, flat cells in the lining of the bladder. It accounts for 1–2% of all bladder cancers (Cancer council, 2019) and is more likely to be invasive.

Adenocarcinoma

This cancer develops from the glandular cells of the bladder. It makes up about 1% of all cases and is likely to be invasive.

Bladder cancer symptoms

Unfortunately, bladder cancer doesn’t present itself with definitive symptoms. In fact, bladder cancer is often picked up as a result of a routine urine tests. Generally though, symptoms may include:

• Blood in the urine — the most common bladder cancer symptom and may only occur periodically
• Change of urinary habits — including a need to urinate more often, not being able to urinate when you feel the urge, urinary incontinence or a burning pain when passing urine
• Back/lower abdomen pain — less common than above, but sometimes this pain has been known to occur with bladder cancer

Important!

It’s important to note that if you have any of these symptoms, it doesn’t necessarily mean that bladder cancer is present. These symptoms are often associated with a bladder or urinary tract infection. Kidney or bladder stones, or an enlargement of the prostate in men, could also cause the presence of blood in your urine. In any event, consult your doctor as soon as possible if you have any of these symptoms.

Diagnosis

If your doctor suspects bladder cancer, there are a number of tests he will order to confirm diagnosis including:

• urine test — urine is examined under a microscope for cancer cells.
• physical examination — includes the pelvis and other organs.
• cystoscopy and biopsy — involves threading a small flexible telescope through the urethra to take a look at the lining of the bladder and urethra. A small sample is removed for further examination if anything abnormal is detected. intravenous pyelogram (IVP) — dye is injected into a vein in the arm and monitored as it travels through the blood to the kidneys to pick up anything unusual.
• CT scans, MRI scans, ultrasound, radioisotope bone scans and x-rays — to determine how far the cancer has spread after confirmation of diagnosis.

Bladder cancer grading

Bladder cancer grading describes how quickly a cancer might grow. By determining the grade your doctor/specialist can decide how likely the cancer is to come back and what treatment (if any) you need after surgery.

Low grade

The cells look like normal bladder cells, are slow growing and there is little likelihood of them spreading.

High grade

The cells look abnormal, are growing aggressively and there is a likelihood of them spreading to the muscle wall.

Treatment

Treatments for bladder cancer vary according on whether the cancer is determined to be non-invasive or invasive.

Non-invasive carcinoma

• A transurethral resection (using a cytoscope) is performed under a general anaesthetic to remove the cancer. Patients will need regular review comprising regular check-up cytoscopies (under local anaesthetic) for up to a decade after their initial surgery.
• Sometimes if there are many tumours or they are aggressive in nature, your specialist may recommend chemotherapy or immunotherapy — usually intravesical chemotherapy. This procedure involves delivering a fluid via a catheter into the bladder once a week for about six weeks Generally, an anaesthetic is unnecessary and it can be done in an outpatient setting.

Invasive carcinoma

If the bladder cancer is found to be invasive, a partial or complete removal of the bladder, known as cystectomy, is often recommended. This is a lengthy operation performed under general anaesthetic.

After surgery for a cystectomy, urine needs to be expelled from the body in one of the following ways:

• Redirected through the intestinal tissue, known as an ileal conduit, with an opening or ‘stoma’ on the abdominal wall. The patient wears a pouch externally on the skin to collect urine; or
• The patient’s bladder is removed and replaced with loops of their own bowel, fashioned into a pouch. This is known as an orthotopic neobladder and there is no change to normal bowel function as the patient continues to pass urine naturally through the urethra.

You specialist will discuss with you which option is best suited to your circumstances.

Prognosis

It’s very difficult for a doctor to offer a prognosis for bladder cancer largely because effective recovery from the disease depends on a range of different factors including:

• the type and stage of cancer
• the patient’s age and general health at the time of diagnosis.
• test results
• the type of cancer you have
• its stage and grade
• how well you respond to treatment
• medical history

Bladder cancer can be effectively treated if found in the early stages and before it spreads outside the bladder.

Life after bladder cancer surgery

You should be aware that life after a cystectomy (bladder removal) will be dramatically different.

For men: surgery for bladder cancer ultimately damages nerves to the penis, and the removal of the bladder usually includes the prostate, which unfortunately results in impotence and infertility.

For women: part of the interior vaginal wall may be removed along with the bladder, which means a narrowing/shortening of the vagina which can cause discomfort during sex. Sometimes, the ovaries, fallopian tubes and uterus are removed also leading to infertility and immediate menopause.

Living with a urostomy

If you have a cystectomy, the surgeon will create an artificial opening to your urinary system called a urostomy. This involves the diversion of urine through an opening or ‘stoma’ on the abdominal wall, which is then collected in an external pouch. The doctor and stoma nurse will discuss the position of the stoma with you before the operation and how to look after it post operation.

Even though it’s a significant change, with time and patience you’ll find you can resume your regular activities.

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