Bladder Cancer: What You Should Know

Bladder Cancer: What You Should Know

Bladder cancer comprises a large part of the practice of urology. The incidence of bladder cancer increases with age and is four times more common in men than women and twice as high in Caucasian men than African-American men. 80% of newly diagnosed individuals are 60 years of age or older. Excepting skin cancers, bladder cancers are the most frequently recurring cancer, with up to 70% of patients experiencing a recurrence. When the disease is diagnosed and treated in early stages, the chances of survival are excellent, highlighting the importance of a timely and accurate diagnosis.

Bladder Cancer: The Facts
Causes of Bladder Cancer

The highest prevalence of bladder cancer is in industrialized nations. Tobacco is the greatest risk factor for bladder cancer, accounting for half of all cases. Even if one stopped smoking years ago, the risk is related to the quantity of tobacco smoked over the years. Occupational exposure to cancer-causing chemicals (carcinogens) is another risk factor: dye, rubber, leather, aluminum, paint, and arsenic in drinking water. Occupations at higher risk for bladder cancer because chemical exposure include: hairdressers, painters, machinists, printers, and those who work with dyes, textiles, rubber, leather, and petrochemicals.

­The Relationship Between Tobacco and Bladder Cancer

Bladder cancer is second most common tobacco-related malignancy (#1 is lung cancer). Tobacco is the leading risk factor for bladder cancer and most newly diagnosed bladder cancer patients are smokers or former smokers. About 20% of newly diagnosed bladder cancer patients are current smokers. Carcinogens in tobacco (cancer causing chemicals) are absorbed through the lungs into the bloodstream, circulate throughout the body, filter through the kidneys into the urine and have prolonged contact time with the urinary bladder as urine is stored in the bladder. There is a long lag time between carcinogen exposure and the development of bladder cancer, often more than twenty years, similar to the relationship between sun exposure and skin cancer.

The health benefits of smoking cessation are considerable, decreasing chances of bladder cancer recurrence, progression and development of another tobacco-related cancer. Those smokers diagnosed with bladder cancer have a unique propensity to quit at the time of diagnosis, which seems to be a critical teachable moment, a window of opportunity where a lifestyle change can be leveraged. Continuing to smoke after diagnosis is associated with worse disease outcomes compared to those who quit.

Diagnosing Bladder Cancer

Bladder cancer typically presents with blood in the urine, either visible or microscopic (seen only under microscopic magnification). It may also cause irritative lower urinary tract symptoms including urgency, frequency, discomfort with urinating, and urinary leakage.

The evaluation of blood in the urine includes imaging, cytology, and cystoscopy. Imaging tests are means of visualizing the anatomy of the urinary tract, typically through ultrasound, computerized tomography (CT), or magnetic resonance imaging (MRI). Cytology is a microscopic inspection of a urine sample by a pathologist for the presence of abnormal or cancerous cells that slough off the lining of the bladder, similar to a Pap smear done to screen for cervical cancer. Cystoscopy is a visual inspection of the lower urinary tract (bladder and urethra) using a tiny, flexible, lighted instrument attached to a camera and monitor.

The Stages of Bladder Cancer

When a bladder tumor is identified on cystoscopy, attention is directed to the number of tumors present, their size, location within the bladder, and physical appearance. A papillary appearance consists of fronds (finger-like projections floating in the bladder) with a narrow attachment to the bladder lining versus a sessile appearance, in which the tumor appears solid and is widely attached to the bladder lining.

Once a bladder tumor is recognized, it needs to be removed and sent for pathological evaluation. This is performed under general or spinal anesthesia via cystoscopy, using an electric loop that is used to remove the area of concern as well as cauterize (use electricity to coagulate tissue) the underlying and adjacent tissue, both to stop bleeding and further destroy tumor cells.

The biopsied tissue is examined by a pathologist, who provides information regarding malignancy vs. benignity, tumor type, depth, and grade. The vast majority of bladder tumors are urothelial cancers, referring to the cells that line the bladder. A minority of bladder tumors are squamous cell cancers or adenocarcinomas. Depth refers to the degree that the cancer is growing into the bladder wall. Bladder cancers are broadly categorized into superficial and deep. Superficial tumors are largely confined to the bladder lining and superficial layers and do not penetrate the muscle layer of the bladder, whereas deep tumors have “roots” that penetrate the muscular wall of the bladder. Tumor grade refers to how much the microscopic appearance of the cancer deviates from the microscopic appearance of healthy bladder cells. Low-grade cancers are similar in cellular appearance to normal bladder cells and generally behave in an indolent (slow) fashion versus high-grade cancers that can often behave aggressively. Other factors of prognostic importance are the number of tumors present, the size of the tumors, and their physical characteristics.

In general, the best prognosis is for a solitary, small, superficial, low-grade papillary tumor and the worst prognosis is for multi-focal (originating from many different areas of the bladder), large, invasive (deep), sessile, high-grade tumors.

The biopsy information enables staging of the bladder cancer, a means of classifying the cancer, as follows:

  • Ta: Superficial cancer is found only in polyps (papillary) on the surface of the inner lining of the bladder.
  • Tis: Carcinoma-in-situ. Tumor is found only in flat lesions on the surface of the inner lining of the bladder.
  • T1: Tumor is found in the connective tissue below the lining of the bladder but has not spread to the bladder muscle.
  • T2: Tumor has spread to the muscle layer deep to the lining of the bladder.
  • T3a: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer as identified under microscopic examination.
  • T3b: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer and is capable of being identified without a microscope.
  • T4: Tumor has spread to the prostate in men and to the uterus or vagina in women, or to the pelvic or abdominal wall in either gender.

STAGES OF BLADDER CANCER

The majority of patients with newly diagnosed bladder cancer have superficial cancer that involves the inner layers of the bladder wall, 20% have invasive disease that involves the deeper layers of the bladder wall, and 5% present with metastatic disease, defined as spread beyond the confines of the bladder.

Treating Bladder Cancer

Superficial cancers are managed with regular “surveillance” due to the high predilection for recurrence. Surveillance includes cystoscopy, urinary cytology, and upper urinary tract imaging on a scheduled basis.

Under certain circumstances, it is beneficial to use a medication that is instilled in the bladder to help prevent recurrences. This is especially the case when many tumors are present, in the presence of a high-grade tumor, or cancers that have recurred. It is particularly useful for carcinoma-in-situ (CIS), a variant of bladder cancer that is superficial, flat, yet high-grade. The medication of choice is often tuberculosis vaccine—BCG (bacillus Calmette Guerin), which is a live, attenuated (weakened) form of tuberculosis bacteria. There are also several chemotherapy alternatives to BCG that are used by bladder instillation.

Muscle-invasive cancers most often need to be treated with a surgical procedure involving either partial or complete removal of the urinary bladder. In the circumstance that the entire bladder needs to be removed, the ureters (tubes that conduct the urine from the kidneys to the bladder) need to be diverted to a piece of intestine that is either attached to the skin to a collection bag (ileal conduit) or attached to the urethra (neo-bladder or “reconstructed” bladder). At times, in lieu of surgery, chemo-radiation can be utilized (a combination of radiation therapy provided by the radiation oncologist and chemotherapy provided by the medical oncologist).

Bladder cancer often behaves as two separate types of diseases: one that typically presents as multiple, superficial papillary tumors, which tend to reoccur, but are not lethal (similar to many skin cancers), versus another more deadly form characterized by high-grade, non-papillary, muscle-invasive tumors that have a tendency to metastasize. Fortunately, the vast majority of bladder cancers are the superficial type.

5 Signs of Bladder Cancer: What Women Should Know

Bladder cancer may not be on your radar even if you’re vigilant about getting routine GYN care. After all, it’s far more common among men than women, and the majority of cases affect patients over age 65. However, don’t let those stats keep you from learning to spot the warning signs.

While bladder cancer isn’t one of the most common cancers in women, about 18,000 women are diagnosed with bladder cancer every year in the United States (Source: CDC – Bladder Cancer)The Bladder Cancer Advocacy Network reports that women are more likely to be diagnosed with bladder cancer at an advanced stage because they may not be on the lookout for early signs.

Facts About Bladder Cancer in Women

While bladder cancer typically hasn’t been associated with women, it is important to understand the unique way that bladder cancer does affect women, and why it’s critical that bladder cancer isn’t overlooked.

  • Approximately 50% of cases are diagnosed while the cancer is still in the bladder. However, that percentage is lower in women, because symptoms are often overlooked.
  • Women have a 1 in 89 chance of developing bladder cancer in their lifetime (Source: American Cancer Society – Key Statistics for Bladder Cancer). However, bladder cancer in women is on the rise.
  • Approximately 90% of bladder cancer cases are in individuals over 55 years old, so it is important to be extra vigilant of early signs of bladder cancer as you age.
  • Bladder cancer has a high recurrence rate. If you have been diagnosed with bladder cancer, it is important to continue to receive regular exams in order to handle any potential recurrence.

Early Signs of Bladder Cancer in Women

Knowing the signs and symptoms can help you get diagnosed sooner, which may improve your prognosis. Here are five warning signs to watch for:

  1. Blood in the urine (hematuria). This is the most common early symptom of bladder cancer and typically the first sign of bladder cancer that is seen. It’s easy for women to overlook because it’s typically painless and can go weeks or even months between occurrences. Many women ignore this symptom because they attribute it to menstruation or menopause. If you are unsure if there is an issue, your best bet is to consult a urologist
  2. UTI-like symptoms. Bladder cancer can be mistaken for a Urinary Tract Infection (UTI) because many of the symptoms overlap. Patients may experience increased frequency and urgency of urination, pain with urination, or urinary incontinence. If you’ve noticed any urinary problems—you have to go all the time, or you feel like you have to go but can’t, or you have a hard time emptying your bladder—or if antibiotics don’t seem to be helping your UTI symptoms, talk to your doctor.
  3. Unexplained pain. More advanced bladder cancers are often associated with pain. Pain can occur in the flank area, abdomen, or pelvis. Patients can also develop pain in their bones if the cancer has spread to their bones. If you’re having aches and pains in those areas, tell your doctor—especially if you’ve also noticed spotting or UTI symptoms.
  4. Decreased appetite. Appetite loss is a common cancer symptom, and bladder cancer is no exception. If the cancer has grown or spread, you might experience weight loss or feel tired and weak. Of course, there are plenty of other things that can mess with your appetite, so don’t automatically assume the worst—but do talk to your doctor about it if it persists.
  5. Postmenopausal uterine bleeding. Any blood or spotting that you notice after menopause could be a symptom of bladder cancer or some other underlying issue. Similarly to blood in the urine, it may be easy to overlook, but it is recommended that you see your urologist to be safe.

Risk Factors of Bladder Cancer

By far, smoking is the biggest risk factor to be concerned about when it comes to bladder cancer. According to the National Institutes of Health, about 50% of women diagnosed with bladder cancer are smokers. Because the rate of occurrence is so much higher for smokers, if you notice any of the above symptoms and you smoke, let your doctor know as soon as possible.

Another major risk factor is previously having bladder cancer.  Bladder cancer has a 50-80% recurrence rate, which is among the highest of any form of cancer. This is why it is imperative to continue to see your physician and be on the lookout for any symptoms of bladder cancer if you’ve had it before.  When in doubt, get it checked out.

Age is another major factor. The average age of diagnosis in women is 73. Any woman over the age of 55 years old should keep an extra eye out for symptoms.

When to Make an Appointment with Your Urologist

Bladder cancer may be overlooked in women because it’s easy to chalk up symptoms to a stubborn UTI or normal vaginal spotting. Unfortunately, this means women are often diagnosed after the cancer has spread and become harder to treat. So if you’re worried, don’t just write off your symptoms. Call your doctor to determine if it’s a minor infection or something more serious. If it is bladder cancer, it’s easier to treat if you catch it early.

If you would like to talk to a urologist, you can see if we have a location near you or you can contact us to ask a question or make an appointment.

Written by Dr. Paul Littman


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