Bladder Cancer

Bladder cancer is the growth of abnormal cells in your bladder lining that develop into a mass of tissue called a tumour. Sometimes the tumour spreads into the bladder muscle. Over time, bladder cancer can spread to other parts of the body.

Bladder cancer is caused by certain changes in the DNA inside normal bladder cells that make them grow abnormally and form cancers. It is not known why this happens but there are some factors that make a person more at risk of developing bladder cancer.

Most bladder cancers appear to be caused by exposure to harmful substances that lead to abnormal changes in bladder cells over time. Smoking is the biggest risk factor for bladder cancer as tobacco contains cancer-causing chemicals. Exposure to certain chemicals at work is the second biggest risk factor. These substances are now banned or limited in exposure.

Other risk factors of bladder cancer include radiotherapy, chemotherapy medications, certain treatments for type 2 diabetes, having a tube in your bladder for a long time due to paralysis, ongoing and repeated urinary tract infections (UTIs), and long-term bladder stones.

What are the symptoms of bladder cancer?

Your bladder is a muscular organ in the pelvic area that stores urine. The most common symptom of bladder cancer is blood in your urine. You may see streaks of blood in your urine or the blood may turn your urine brown. This may come and go.

Other less common symptoms of bladder cancer include:

• more frequent need to urinate
• sudden urges to urinate
• a burning feeling when urinating

Advanced bladder cancer may have symptoms of pelvic and bone pain, unintentional weight loss and leg swelling.

Bladder cancer can be classified by how likely it is to spread (grading) and how far it has spread (staging). These classifications can help doctors to guide how fast bladder cancer will spread, your outlook, and the best treatment.

A grading number system from G1 to G3 is usually used as a guide to how your cancer may behave.

Bladder cancer cells are divided into three grades:

• Grade 1 (low grade) - the cancer cells look very much like normal cells. They tend to grow slowly and generally stay in the lining of your bladder.
• Grade 2 (medium grade) – the cancer cells look more abnormal. They are more likely to spread into the deeper muscle layer of your bladder or return after treatment.
• Grade 3 (high grade) - the cancer cells look very abnormal. They grow faster and are more likely to come back after treatment or spread into your bladder’s deeper muscle layer.

If the cancerous cells are only inside your bladder lining, they are called non-muscle-invasive bladder cancer or early bladder cancer. This is the most common type of bladder cancer.

When the cancerous cells spread past your bladder lining and into the surrounding bladder muscle, they are called muscle-invasive bladder cancer or invasive bladder cancer. Although less common, this has a higher chance of spreading to other parts of your body.

Bladder cancer that has spread to other parts of your body is known as advanced or metastatic bladder cancer.

The most widely used staging system for bladder cancer is known as the TNM system:

• T - how far into your bladder the tumour has grown
• N - whether your cancer has spread into nearby lymph nodes
• M - whether your cancer has spread into another part of your body (metastasis), such as your lungs.

You should see your GP if you have bladder cancer symptoms. Your GP may ask about your symptoms, family history, risk factors, request a urine sample, carry out a physical examination and /or refer you to a specialist or a hospital for further tests.

The following tests may be used to diagnose and learn more about bladder cancer:

• Cystoscopy – is usually the first diagnostic test. It is performed using a local anaesthetic gel and takes about five minutes. A specialist examines the inside of your bladder using a thin tube with a camera and light at the end, called a cystoscope. This is passed through your urethra and into your bladder.
• Imaging scans - a CT scan or an MRI scan may be performed if a more detailed picture of your bladder is needed. You may also have an intravenous (IV) urogram, where dye is injected into your bloodstream and X-rays follow it, to look at your whole urinary system before or after treatment for bladder cancer.
• Transurethral resection of a bladder tumour (TURBT) – is offered if abnormalities are found in your bladder during a cystoscopy. TURBT is carried out under general anaesthetic. A biopsy sample of any abnormal areas of tissue is removed and tested for cancer. A sample of your bladder muscle wall may be taken to check if cancer has spread. This may be a separate operation from your first biopsy.

Treatment depends on the type, stage, grade and size of your bladder cancer, and your general health.

Treatment for non-muscle-invasive bladder cancer depends on the risk of cancer returning or spreading beyond the lining of your bladder. It may include:

• Surgery to remove cancer. The most common operation is a TURBT. Small instruments are passed down the thin rigid tube called a cystoscope into your urethra to cut any tumours out of your bladder lining.
• Immunotherapy uses your own immune system to treat cancer. It uses a course of Bacillus Calmette-Guérin (BCG) treatment.
• Chemotherapy medication course of at least six doses to destroy or slow the growth of cancer cells, while causing the least possible damage to healthy cells. The chemotherapy goes directly into your bladder through a tube called a catheter.

Treatment for muscle-invasive bladder cancer depends on how far cancer has spread. It may include:

• Cystectomy - an operation to remove your bladder. It can be a radical cystectomy that removes all of your bladder or a partial cystectomy that removes part of your bladder. Radical cystectomy also removes some reproductive organs and sometimes part of your bowel. Your surgeon will talk this through with you in detail.
• Radiotherapy with a radiosensitiser. Radiotherapy gives a controlled dose of radiation to kill or damage cancer cells. Sessions are usually daily for five days a week over four to seven weeks with each session lasting about 10 to 15 minutes.
• A medicine called a radiosensitiser should also be given alongside radiotherapy for muscle-invasive bladder cancer. Radiosensitiser medicine affects the cancer tumour cells and enhances the effect of radiotherapy.
• Intravenous (systemic) chemotherapy is sometimes used where the medicine is put into a vein in your arm. It can be given before radiotherapy and surgery to shrink your tumour size, in combination with radiotherapy before surgery known as chemoradiation, or to slow the spread of incurable advanced bladder cancer, called palliative chemotherapy.

Treatment for advanced bladder cancer depends on how far cancer has spread. It may include:

• Systemic chemotherapy
• Immunotherapy
• Surgery
• Radiation therapy

If cancer is advanced and cannot be cured, your healthcare team will discuss the cancer progression and treatments to ease your symptoms.

Bladder cancer can usually be effectively treated if it is found early.

A patient’s prognosis depends on:

• The cancer stage and whether it has grown into the connective tissue beneath your bladder lining, the muscle of your bladder wall, through the muscle into the fat layer, or to the wall of your abdomen or pelvis, lymph nodes or other parts of your body.
• The grade of bladder cancer cells and how they look under a microscope.
• The number and size of tumours..
• Whether the tumour has come back after treatment..
• Your age and general health.