Bladder cancer is cancer that starts in the inner lining of the bladder Like cancers of other organs in the body, bladder cancer is essentially an abnormal growth and multiplication of cells present in the urinary bladder. Bladder cancer can metastasize or spread to various other regions in the body including the lungs, bones, and liver.
The most common types of bladder cancer are:
Urothelial carcinoma: Urothelial carcinoma is the most common type of bladder cancer. It is closely related with cigarette smoking.
Adenocarcinoma: This type of cancer constitutes only about 2% of all bladder cancers. It is closely associated with prolonged swelling and irritation.
Squamous cell carcinoma: This type of cancer constitutes only 1%-2% of bladder cancers and is also associated with infection, swelling, and irritation. In certain regions of the Middle East and Africa, Squamous Cell Carcinoma is the most prevalent form of bladder cancer and is related with chronic infection caused by Schistosoma worm. Schistosoma worm is a blood fluke which causes Schistosomiasis or bilharzia or ‘snail fever’.
Some of the rarest forms of bladder cancer are small cell cancer, pheochromocytoma, and sarcoma.
Causes:
- Cigarette smoking
- Age and family history
- Men are more vulnerable to developing bladder cancer possibly due to a greater incidence of cigarette smoking and exposure to toxic chemicals.
- Exposure to dangerous chemicals such as arsenic, phenols, aniline dyes
- Radiation therapy for prostate or cervical cancer and chemotherapy with cyclophosphamide (Cytoxan)
- Chronic infections of the bladder due to stones or other foreign substances
- Infections caused by blood fluke
Bladder cancer – Signs and Symptoms
- Blood in the urine or hematuria
- Irritations in the bladder with minimal or no bleeding.
- Frequent urge to urinate
- Urgency to urinate and inability to hold the urine for a long time
- Dysuria or burning sensation while passing urine
- Distended bladder
- Pain in the flanks
- Pain in the bones, or cough or blood in the phlegm
Diagnosis
Bladder cancer is mostly diagnosed by examining the cause of bleeding in the urine of a patient. Some of the tests that are used in diagnosis are:
Urinalysis: A urine test will help to confirm the potential cause of bleeding in the urine. It can also provide the doctor an idea about whether or not some kind of infection is present in the blood.
Urine cytology: Urine cytology is a test conducted on a centrifuged urine sample. The sediment is then closely examined under the microscope by a pathologist. This test aims to detect and identify malformed cancerous cells that may be shed into the urine due to the disease. If the test is positive, it confirms that cancer is present in the urinary system.
Ultrasound: An ultrasound examination of the bladder can help to detect the presence of bladder tumors or inflammation in the kidneys if the tumor in the bladder is identified at a spot where it can potentially interrupt the flow of urine from the kidneys to the bladder. The test also enables the detection of other factors responsible for bleeding, such as stones in the urinary system or prostate enlargement.
CT scan/MRI: A CT scan or MRI scan may help to detect small tumors in the kidneys or bladder. When compared to ultrasound, it can also efficiently detect other causes of bleeding particularly when intravenous contrast is used.
Cystoscopy and biopsy: Cytoscopy is probably the most critical investigation for bladder cancer. This test involves the use of a cystoscope; a thin, tube-like optical instrument which is attached to a camera and a light source. The cytoscope is inserted through the urinary passage into the bladder. The inner surface of the bladder thus gets visualized on a video monitor. Small or flat tumors which may not be conspicuous on other tests could be detected by this method and a small part of this tissue can be extracted for biopsy. The presence and type of bladder cancer can be effectively diagnosed by this method.
Bladder cancer grading
The grading of bladder cancer is usually performed by the pathologist by examining the specimen of the tumour under a microscope. The stage and grade of bladder cancer plays a very crucial role not just in deciding the type treatment that is appropriate for the patient but also in assessing the chances of success with that treatment.
Grade 1 cancer: The cancer cells resemble normal cells. These are called ‘low grade’ and tend to develop gradually and are not likely to spread to other regions.
Grade 2 cancer: The cells look more abnormal. They are called ‘medium grade’ or and may develop or spread more rapidly than low grade.
Grade 3 cancer: The cells look very abnormal. They are called ‘high grade’ and are more rapidly growing and have greater possibility to spread to other regions of the body.
Bladder cancer is staged using the ‘Tumor Node Metastases (TNM)’ system. This system has been developed by the International Union Against Cancer (UICC). The tumor or the T stage is confirmed only after a detailed pathological examination of the tumor specimen. The T stage essentially refers to the depth of penetration of the tumor, from the innermost lining of the bladder to the deeper layers.
The first surgical procedure which a patient undergoes following the confirmed diagnosis of bladder cancer is a Transurethral Resection of Bladder Tumor or “TURBT.” This procedure is performed with the help of special instruments connected to a cystoscope and involves removing the tumor from the bladder with the help of electrical cautery equipment. This surgery is primarily done through the normal urinary passage and does not involve an external incision on the body.
Treatment of superficial bladder cancer
Superficial bladder cancer refers to a cancer which has not yet spread to the bladder muscle walls and is restricted to the inner lining of the bladder. In the case of low-grade, superficial bladder cancers, after the initial TURBT, only repeated cystoscopy examinations at regular intervals may be required. Recurrent tumors could be surgically removed or fulgurated using special equipments passed through the Cystoscope. It is extremely important to note that 30%-40% of these tumors have the tendency to recur and these recurrences may not be related with any particular symptoms. Therefore, it is crucial to stick to a regular follow-up procedure in order to ensure that the disease is kept under control.
High-grade, multiple, or recurrent superficial bladder cancers may necessitate additional treatment following the initial TURBT. One of the most effective and recommended medications used in such cases is the Bacille Calmette Guerin, commonly known as BCG. With the help of a catheter positioned in the urinary passage, BCG is instilled into the bladder in the form of a solution. The solution stimulates the immune system in the body protects the organs from the cancerous bladder cells and inhibits the growth and development of the affected cells. This treatment reduces the chances of recurrence of bladder cancer as well as its tendency to spread to the muscle layer of the bladder. BCG is generally administered in six doses at weekly intervals. This is followed by a “maintenance” schedule recommended for at least once a year. However, it may be required for as long as three years.
Patients, who do not respond well to the BCG treatment or if the disease recurs despite the treatment or those who have medical problems which preclude the use of BCG, may need other forms of treatment. Some of these treatments include bladder instillation of immunotherapy agents such as Interferon or chemotherapy medicines.
A major surgical procedure known as Radical Cystectomy is also recommended in cases where the patient has not responded well to the BCG treatment or if the disease has recurred in spite of the treatment. This procedure involves the removal of the bladder and the prostate and diverting the urinary stream using intestinal segments.
Treatment of muscle-invasive bladder cancer
Muscle invasive bladder cancer normally requires an aggressive treatment plan when compared to superficial bladder cancer. The most effective treatment for muscle-invasive bladder cancer is Radical Cystectomy. This process involves the surgical removal of the bladder and diverting the urinary stream using intestinal segments.
The procedure involves removal of the bladder, prostate, seminal vesicles, and the fatty tissue surrounding the bladder through an incision created in the abdomen. The lymph nodes in the pelvis are also removed in order to detect the presence of cancerous cells. This also helps in deciding further management measures post- surgery including the requirement for chemotherapy.
Radical cystectomy could be performed either through open surgery, laparoscopy, or with robotic assistance. Laparoscopic and robotic approaches considerably reduces blood loss during the surgery, minimizes the need for blood transfusions, and may assist in early recovery by reducing postoperative pain at the surgical site. An additional advantage of robotic assistance is that it facilitates enhanced magnification of the surgical field using three-dimensional vision capabilities. This further helps to increase surgical precision. All these approaches can help to achieve more or less equal results in terms of cancer control if it is done by highly skilled and well- experienced surgeons.
After the removal of the bladder, the urine has to be diverted. This is done using any of the three urinary diversion methods namely; Ileal conduit, Orthotopic neobladder (where the patient passes urine from the normal passage) or Continent catheterizable pouch. All these methods use intestinal segments which are still attached to their blood supply but have been separated from the gastrointestinal tract
Radical cystectomy in combination with one of the three urinary diversion methods is the accepted and most effective treatment of muscle invasive bladder cancer and certain cases of high-grade superficial bladder cancer.
Chemotherapy
Patients who have been diagnosed with metastatic bladder cancer are generally treated with chemotherapy. Chemotherapy may also be recommended for “locally advanced” bladder cancer in order to reduce the chances of recurrence of cancer after radical cystectomy. This process is called “Adjuvant chemotherapy.” “Neoadjuvant chemotherapy” is sometimes administered before radical cystectomy so as to improve the results of surgery and to reduce the size of the tumor.
Dr Pradeep Rao gives one of the best bladder cancer treatment in India.