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Bladder cancer is the sixth most common cancer in the United States. About 65,000 Americans are diagnosed with bladder cancer each year. Early diagnosis and treatment can often lead to successful cure or management of bladder cancer.
Dr. Shaw believes in early detection through simple office tests, cures whenever possible, and long-term followup on a regular basis to ensure that the bladder tumors do not return. We use the latest screening tests of the urine, as well as in-office fiberoptic digital technology to ensure that the bladder is completely and thoroughly evaluated.
The bladder is a hollow balloon-shaped, mostly muscular, organ that stores urine until ready for release. The urine is produced in the kidneys. It flows through tubes called the ureters into the bladder and is discharged through the urethra during urination. The bladder muscle aids urination by contracting (tightening) to help force out the urine.
A thin surface layer called the urothelium lines the inside of the bladder. Next is a layer of loose connective tissue called the lamina propria. Covering the lamina propria is the bladder muscle. Outside of the bladder is a layer of fat.
The ways in which bladder cancers develop and progress are only partly understood. However, a number of substances that cause the cancers to develop have been identified.
Various industrial chemicals – Long-term workplace exposure to chemical compounds such as paints and solvents has been estimated to cause another 20 to 25 percent of bladder cancer cases.
Carcinogens, or cancer causing agents, in the blood stream are filtered out by the kidneys to eliminate them from the body. However, these carcinogens remain in the bladder for a few hours interacting with the lining of the bladder before they are removed by urination. Through this process the bladder becomes a high risk organ for cancer, particularly in smokers.
More than 90 percent of all bladder cancers originate in the urothelium, the inner lining of the bladder.
Smokers develop bladder cancer at two to three times the rate of non-smokers. People who work with dyes, metal, paints, leather, textile and organic chemicals may be at a higher risk. People who have chronic bladder infections may also be at higher risk.
It is important to remember that these symptoms do not on their own indicate or confirm the presence of bladder cancer. These are also common symptoms of other issues such as kidney stones or urinary tract infections. We will do a thorough and complete evaluation if you complain of these symptoms, in order to exclude the possibility of bladder cancer.
History and Physical Exam – We will ask the patient about past exposure to known causes of bladder cancer, such as cigarette smoke (either through personal smoking or through “second-hand” smoke) or chemicals. We will also evaluate your symptoms if you have any.
Urine Cytology – With cytology, the urine is examined under a microscope to look for cancer cells that may have been shed into the urine from the bladder lining. Urine can also be tested for substances known to be closely associated with cancer cells (tumor markers).
CT scan – Because blood in the urine can come from anywhere in the urinary tract, we typically order radiological imaging of the kidneys, ureter and bladder to check for problems in these organs.
Cystoscopy – Cystoscopy is the most important diagnostic tool. It is an in-office procedure, in which a fiber-optic camera is inserted through the urethra into the bladder. The camera allows for direct visualization inside the bladder to look for any tumors, masses, or any other abnormalities. Modern cystoscopes are soft and flexible, and this procedure is generally well tolerated.
If tumors are present on the cystoscopy, the doctor notes their appearance, number, location and size. As removal (resection) of the tumors cannot usually be done under local anesthesia, the patient is then scheduled to return for a surgical procedure to remove the tumor under general anesthesia. In a manner as before, the doctor inserts an instrument, called a resectoscope, into the bladder. This is a viewing instrument similar to the cystoscope, but contains a wire loop at the end for removing tissue. This procedure is done through the urethra and is called a transurethral resection of bladder tumor or “TURBT”. The removed tissue is sent to a pathologist for examination.
Tumor Staging and Grading – If a biopsy is taken and bladder cancer is found, the pathologist who examines the tissue will grade the tumor according to how aggressive the cells appear. The most widely used grading systems classify tumors into two main grades: low and high. The cells of low-grade tumors have minimal abnormalities. In high-grade tumors, the cells have become disorganized and many abnormalities are apparent. The grade indicates the tumor’s “aggression level”—how fast it is likely to grow and spread. High-grade tumors are the most aggressive and the most likely to progress into the muscle. Staging of bladder cancers is based on how deeply a tumor has penetrated the bladder wall.
Table 1 lists stages of penetration using the TNM classification system:
|Table 1 — Staging of primary bladder cancer tumors (T)|
|Ta:||Noninvasive papillary tumor (confined to urothelium)|
|Tis:||CIS carcinoma (high grade “flat tumor” confined to urothelium)|
|T1:||Tumor invades lamina propria|
|T2:||Tumor invades bladder muscle|
|T2a:||Invades superficial bladder muscle|
|T2b:||Invades deep bladder muscle|
|T3:||Tumor invades perivesical fat|
|T3a:||Microscopic perivesical fat invasion|
|T3b:||Macroscopic perivesical fat invasion (and progressing beyond bladder)|
|T4:||Tumor invades prostate, uterus, vagina, pelvic wall or abdominal wall|
|T4a:||Invades adjacent organs (uterus, ovaries, prostate)|
|T4b:||Invades pelvic wall and/or abdominal wall|
TURBT – Transurethral resection of the bladder, is the usual treatment method for patients who, when examined with a cystoscope, are found to have abnormal growths in the bladder. Also explained above.
Intravesical chemotherapy and immunotherapy – Following removal, intravesical chemotherapy or immunotherapy may be used to try to prevent tumor recurrences. Intravesical means “within the bladder”. These therapeutic agents are put directly into the bladder through a catheter in the urethra (the catheter only stays in for a few minutes), are retained for one to two hours and are then urinated out.
The chief intravesical agents currently available are thiotepa, doxorubicin, mitomycin C and bacillus Calmette-Guérin (BCG). The first three are chemotherapy drugs. The fourth, BCG, is a live but weakened vaccine strain of bovine tuberculosis. It was first used to immunize humans against tuberculosis. It is now one of the most effective agents for treating bladder cancer.
Each of the four agents may produce irritative side effects such as painful urination and the need to urinate frequently. In addition, BCG therapy carries a 24 percent risk of flu-like symptoms.
Once the grade and stage of the tumor has been determined, the urologist may decide to initiate a course of intravesical therapy with these agents. In general, six weekly treatments are given, in which a catheter is placed in the bladder, the medication is instilled, the catheter is removed, and the patient is instructed not to urinate for at least an hour. Periodic cystoscopies and urine tests are required to detect tumor recurrence early, if it is going to develop. During the first one to two years surveillance is carried out on a quarterly basis but then can gradually be reduced to twice and eventually even once per year thereafter.
Cystectomy – Surgical removal of the entire bladder may be an option for patients with high-grade cancers that have persisted or recurred after intravesical treatments. There is a substantial risk of progression to muscle-invasive cancer in such cases, and some patients may want to consider cystectomy as a first choice of treatment. If so, they should ask their doctor for information about both the risks of cystectomy and the methods of urinary reconstruction (“urinary diversion”).
Fortunately, bladder tumors are rare in children.
Not at this time, although periodic check of the urine for microscopic blood may promote earlier detection.