Bladder Cancer
What is it?
Bladder cancer is twice as common in men as it is in women, and mostly affects people who are over 50. In the UK it is the fourth most common cancer in men and the eighth most common in women, and there are over 12,000 cases each year.
As with any other type of cancer, cells in the bladder divide and grow in an abnormal way. These extra cells can form a mass of tissue called a growth or tumour, affecting how the bladder works. Most cancers of the bladder start in the cells that form the lining of the bladder. These are called transitional cell or urothelial cell cancers.
If a bladder cancer is limited to the inner lining of the bladder, it is known as a superficial cancer. If it has spread into the muscle wall of the bladder, it is called an invasive cancer. Invasive cancers can grow into nearby organs such as the uterus or vagina (in women) or the prostate (in men). They can also grow into the abdominal wall.
Over time, cells can break away from the original tumour and spread to another part of the body, growing tumours there. Therefore, it is very important that bladder cancer is identified in its early stages.
No-one knows the exact cause of bladder cancer, although smoking is a major factor.
What are the symptoms?
The most common symptom of bladder cancer is blood in the urine. This is known as haematuria. Blood may suddenly appear in the urine for no obvious reason, and there is rarely any pain associated with it. The colour of the urine can vary from rusty brown to deep red, depending on the amount of blood. It may not be there every time you urinate, and can sometimes disappear for weeks or months. The amount of blood is not related to the extent of the cancer. If blood clots form, these can cause pain or obstruction to the flow of urine. Some people find that they urinate more frequently or feel the need to urinate but without any urine coming through.
It should be remembered that blood in the urine can be caused by other conditions, such as an infection in your bladder, or by kidney stones. It does NOT necessarily indicate bladder cancer. However, if you have any of the symptoms mentioned above, you should see your GP as soon as possible so that a diagnosis can be made and appropriate treatment started.
How is it diagnosed?
As the symptoms of bladder cancer are very similar to many other conditions, it is very important that your doctor identifies the exact cause of your symptoms.
In the first instance, your GP will ask you for a urine sample to test for blood and infection. Your GP will then usually conduct a physical examination to feel for tumours in the abdomen and pelvis. This may also include an internal examination of the back passage (rectum) in men, and the birth canal (vagina) in women.
Further tests
Depending on the results of the examinations your GP may then refer you to a bladder specialist (urologist) at your local hospital. The urologist will then conduct further tests to determine whether you do have cancer, and if so, its exact type and how it has developed. These tests may include:
What is the treatment?
Once bladder cancer is diagnosed, a treatment plan is developed to meet your individual needs. The type of treatment will depend on the type of bladder cancer, the stage of the disease (how far it has spread) and the grade of the tumour (tumours are graded depending on how closely the cancer cells resemble normal cells). This gives the doctor an idea of how fast the tumour is likely to grow. The doctor will also take into consideration your age and general health.
Treatment for early (superficial) bladder cancer
Superficial cancers are usually removed surgically by a cystoscope (the camera that allows the doctor to look inside your bladder). The tumour or tumours (sometimes there is more than one) are simply cut off at the stem. This procedure is known as a transurethral resection of a bladder tumour (TURBT).
After this type of treatment, you will need follow-up cystoscopies at regular intervals (usually every three to four months at first) in case the tumours come back. Most follow-up cystoscopies can be carried out in your outpatients department or hospital daycase unit under local anaesthetic. If the cancer comes back, the tumours can usually be surgically removed while they are still in the early stages. However, at this stage you may also be offered anti-cancer drugs (chemotherapy or immunotherapy), which are given directly into the bladder (intravesical chemotherapy).
Intravesical chemotherapy
Chemotherapy given directly into the bladder is called intravesical chemotherapy. The drugs are given in this way so that they are in direct contact with the cancer cells in the lining of the bladder. The drugs are given into the bladder through a flexible tube (catheter). Giving drugs in this way also means that you are less likely to have side effects, as very little gets into the bloodstream to affect the rest of the body. The most common side effect you may experience is cystitis (inflammation of the bladder).
The drugs might be given as a one-off, or as a course of weekly treatments for about six weeks.
Intravesical immunotherapy
A vaccine called BCG is inserted directly into the bladder through a tube (catheter). The vaccine sets up a reaction in the bladder that triggers the body's immune system to make the cancer smaller or get rid of it completely.
Side effects of treatment include general feelings of unwellness, pain when you pass urine and skin rashes. These side effects are fairly common and they usually go away on their own, but you should tell your doctor about them at your next appointment.
Treatment for invasive bladder cancer
Surgery
Surgery is the most common treatment for invasive cancers.
Cystectomy
If a tumour is too large to be removed by the cystoscope method, or if it has started to grow into the bladder wall, all or part of the bladder might have to be removed.
If the whole bladder is removed, the operation is called a total cystectomy, and a new storage place for urine has to be created.
Rarely, if part of the bladder is removed, the operation is called a partial cystectomy. You will still be able to pass urine as usual after this operation. However, as your bladder will be smaller, and will therefore hold less urine, you may need to pass urine more often.
Urostomy
The most common way of providing a new storage place for urine is to make a urostomy. While you are under a general anaesthetic, both ureters are disconnected from the bladder and redirected into a short piece of bowel so that the water comes out of a small hole in your abdomen. This hole is called a stoma. Urine will be collected from the stoma in a flat watertight bag, which you will have to empty as required.
Continent urinary diversion
One alternative to the above method of collecting urine is the continent urinary diversion. Although urine is removed from the stoma on the abdomen in the same way as the above method, the main advantage of this technique is that it is not necessary to wear a stoma bag. During the operation a pouch is formed in the abdomen, using a piece of bowel. This pouch holds the urine. Rather than wearing a bag to collect the urine, about 4 or 5 times a day a small plastic tube (catheter) is passed through the stoma into the pouch to drain the urine. This is called self-catheterisation. As with any treatment approach, continent urinary diversions may not be suitable for everybody, so you would need to discuss with your urologist whether this would be a suitable treatment in your situation.
Bladder reconstruction
Another way of providing a new storage place for urine, is to make a completely new bladder out of a piece of the small or large intestine. It is then possible to pass urine in the usual way through the urethra, rather than needing to wear a stoma bag or use a catheter. However, unlike your old bladder, you will need to remember to empty it, as you will have lost the nerves that tell your brain when your bladder is full. The new bladder is emptied by tensing your stomach muscles.
Your doctor can advise whether it is possible for you to have bladder reconstruction. It is not suitable for everyone.
Radiotherapy
Radiotherapy is often used as an alternative to surgery. Radiotherapy uses high-energy rays to destroy the cancer cells, while avoiding damaging the surrounding normal cells. It is also sometimes given before surgery to make it easier for the tumour to be removed and to reduce the risk of cancer cells being left after surgery. It can also be given after surgery if the surgeon thinks there is a chance that cancer cells might have been left behind.
Radiotherapy is usually given as a series of short daily treatments at your hospital. The number of treatments will depend on the size and type of cancer, but each treatment takes 10-15 minutes and usually continues for 4-6 weeks.
Other treatments
Chemotherapy
Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. For invasive cancers and cancers that have spread elsewhere in the body, the chemotherapy drugs are given by injection into a vein (intravenously). This is so the drugs can travel round the bloodstream and reach cancer cells anywhere in the body. This means that other cells in the body can also be affected, resulting in side effects such as sickness and hair loss. A course of several drugs is given over a few days. The course may then be repeated every few weeks for several months. In some cases chemotherapy is given before surgery or radiotherapy to try to shrink the tumour so that it can be more effectively treated. Chemotherapy is also sometimes used after surgery to make the tumour less likely to come back.
Treatment for advanced bladder cancer
If the cancer has spread outside the bladder, or comes back after the initial treatment, the main treatment is chemotherapy. Chemotherapy given in this situation is known as palliative chemotherapy. The aim of palliative chemotherapy is to try to slow the growth of the cancer or shrink the size of the tumour to improve symptoms. Chemotherapy can also help to keep up a good quality of life and to prolong life for as long as possible. Unfortunately, once cancer has spread to other parts of the body, the chance of a cure is rare. If you have been offered chemotherapy, it is helpful to discuss with your doctor the pros and cons of having it. There are other options available to you to control your symptoms of cancer and these will vary depending on what your individual symptoms are, for example, pain, nausea, lethargy etc. Your doctors will be able to discuss your options with you.
Further information
Your local GP surgery is the best place for you to find information on bladder cancer, especially if you have specific concerns about your symptoms and treatment. Cancer charities related to the bladder can also be useful sources of information and support.
Cancer Research Campaign www.cancerhelp.org.uk
Cancer BACUP www.cancerbacup.org.uk
