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Bladder Cancer

Anatomical facts:

The bladder is a hollow balloon-shaped organ in the lower abdomen. It stores urine, the liquid waste produced by the kidneys. Urine passes from each kidney into the bladder” through a tube called a ureter. Urine empties from the bladder through another tube called the urethra.

Approximately 67,000 Americans are diagnosed with bladder cancer each year. It is more prevalent in men than in women and more common in whites than in African Americans. The average age of diagnosis is 68. If caught in its early stages, bladder cancer can be successfully treated with minimal side effects.

Risk factors

The greatest risk factor for bladder cancer is smoking. Smokers are two to three times more likely to develop bladder cancer than are nonsmokers. Carcinogenic chemicals in the tobacco smoke get absorbed into the blood, are filtered by the kidneys, and collect in the urine. This urine damages the bladder cells. Exposure to other chemicals and recurrent bladder infections also predispose to cancer.

Bladder Cancer Types

The most common tumor type in the bladder is urothelial carcinoma, which is also known as transitional cell carcinoma or TCC. Less than 10% of bladder cancers are squamous cell carcinomas, or adenocarcinomas. For treatment purposes, bladder cancers are divided into two groups: superficial and invasive. Superficial cancer is confined to the inner lining of the bladder while invasive cancers spread deeper into the muscle wall of the bladder and  possibly to other tissues and organs.

Bladder cancer Treatment

Treatment for bladder cancer takes into consideration a number of factors such as type and stage of cancer and the overall health of the patient.

Surgery

Surgery is the mainstay treatment for urinary bladder cancer. Different forms of surgery can be used for the treatment of bladder cancer depending on the type and stage of cancer.

Types of surgery

The surgical procedure for treating superficial bladder cancer is called transurethral resection (TUR). TUR is performed by inserting a tube called a cystoscope through the urethra. This procedure enables the preservation of bladder function. Cancers that invade the muscle wall are removed with open surgery. The extent of the surgery depends on the spread of the tumors. Sometimes it is possible to preserve part of the bladder and normal  bladder function, but in advanced disease the entire bladder and even other organs, such as the prostate in men and uterus in women, will be removed. The extent of surgery also determines if it will be possible to reconstruct a bladder internally (“neo bladder”) or if the urine will have to be removed manually through a bag (“urostomy”). Another option is an internal diversion of the urine to the small bowel.

Segmental or partial cystectomy: Cystectomy refers to the surgical removal of all or part of the urinary bladder. Segmental or partial cystectomy refers to removal of the cancerous part of the bladder. This kind of surgery is done when the cancer is confined to a small region of the urinary bladder.

Radical cystectomy: It refers to the surgical removal of the entire bladder and surrounding tissues and lymph nodes where cancer has or may have spread. This surgery is usually recommended when the cancer has reached the muscular layer of the bladder or has spread over a wide region of the bladder.

In men, radical cystectomy usually involves surgical removal of the seminal vesicles and prostate. This may lead to cessation of semen production. However, nerve-sparing techniques can be applied in some cases so that erectile function in men remains unaffected. In women, a part of the vagina, uterus and ovaries are removed. This leads to cessation of menstruation and the patient can never be pregnant after the surgery.

New approaches are being tried by surgeons to avoid radical cystectomy. A proper use of chemotherapy, radiotherapy and new forms of treatments may allow patients to retain their bladder.

Surgery has been used create a different route for passage of urine. After the complete removal of the bladder a new route of urine passage needs to be created by the surgeon. This procedure is termed urinary diversion. The surgeon may use a portion of the intestine to form a tube to connect the kidneys with a pouch called urostomy bag. The patient simply wears the bag outside the body for urine collection. In a different procedure, a part of the intestine can be used to create a small space for holding urine inside the body. The urine can be drained through a hole in the abdomen by a catheter when required.

Biological therapy

Biological therapy is a kind of treatment which uses certain drugs that stimulate the body’s immune system to act against the growth of cancer. For the treatment of bladder cancer, the drugs can be administered through the urethra and directly into the bladder (intravesical therapy).

Drugs used for this purpose are the following:

Intravesical BCG treatment: The Bacille Calmette-Guerin (BCG) fluid is a biologic response modifier. It is given directly into the bladder through a urinary catheter. The fluid contains a weakened bacterium that stimulates the immune system to produce substances that can kill cancer cells. It can cause irritation in the urinary bladder, which is temporary.

Treatment with a synthetic variety of a protein of the immune system: A synthetic form of a protein called interferon alpha is also used for the treatment of bladder cancer. Interferons are proteins that help to combat infection in our bodies. They can be of various types (alpha, beta and gamma). The synthetic interferon alpha can also be given to the patient in combination with BCG.

Biological therapy reduces the chances of recurrence of cancer when used after surgery. It is also used for treatment of early stage bladder cancer.

Chemotherapy

Chemotherapy is the use of drugs for the treatment of cancer.Chemotherapy may be taken alone or with other treatments, such as surgery or radiation. Drugs are normally used in combination. Drugs are administered through a vein or directly to the bladder by passing a tube through urethra.

Chemotherapy may be given before the surgery to reduce the size of the tumor so that the surgery becomes less invasive. It may also be used after surgery as adjuvant chemotherapy. It may be given to some patients to reduce chances of recurrence of cancer. Some patients may receive chemotherapy before surgery (neoadjuvant chemotherapy). It shrinks a large tumor of the bladder so that it can be more easily removed.

Radiation therapy

Radiation therapy uses high-energy beams that kill cancer cells. Radiation may be given for small muscle-invasive bladder cancers. It is may be used in place of surgery. Radiation can be given either externally or internally.

In addition to surgery, bladder cancer can be treated with chemotherapy and/or radiation therapy. In the early stages, chemotherapy can be delivered directly to the bladder (“intravesical”) to help reduce the systemic side effects of chemotherapy. Another treatment option for superficial bladder cancer is immunotherapy. With this method,  bacteria called BCG (Bacillus Calmette’-Gurin) is injected directly into the bladder through a catheter in order to stimulate the immune system to attack the cancer.

External radiation therapy: A beam of radiation from a machine outside the body is aimed at the affected site of the patient’s body.

Internal radiation therapy or brachytherapy: Radioactive substance sealed in small pellets is placed near the affected region. Cancer cells are killed by the radiations emitted from the radioactive substances.

Radiation therapy alone or in combination with chemotherapy may also be used before surgery to reduce the size of tumor or after the surgery to reduce chances of recurrence of cancer.

The use of chemotherapy in combination with radiation therapy (chemoradiation therapy) for muscle invasive bladder cancer has recently proven to be very successful in clinical trials. It has been shown to be more effective than radiation therapy alone.

Photodynamic therapy

Photodynamic therapy (PDT) is a new form of cancer treatment that involves the use of a laser beam and a kind of light sensitive drug for killing cancer cells. The drug, after administration, accumulates more in the tumor cells than in normal cells. It is then activated by a special type of laser light which is focused on the inner lining of the bladder through a cystoscope. The active drug then kills the cancer cells. This treatment has minimal side effects. This treatment is still in clinical trials.

Clinical trials

Clinical trials refer to those kinds of treatment which are not yet standardized. It is a part of research that aims to develop better strategies for the treatment of cancer. The patients may willingly participate in clinical trials, but side effects and benefits to the patient must be evaluated.

References

Lei AQ, Cheng L, Pan CX. Current treatment of metastatic bladder cancer and future directions. Expert Rev Anticancer Therapy. 2011 Dec; 11(12):1851-62.

American Cancer Society. Learn about Bladder Cancer. Access at www.cancer.org and select from the menu under “Choose a Cancer Topic.” A detailed guide about bladder cancer can be accessed as a pdf

National Cancer Institute. Bladder Cancer. Access at: www.cancer.gov and click on “Types of Cancer.” The top page of the section links to patientversions of PDQ@ statements, clinical rial information, and other NCI publications on this topic.

 

People Living with Cancer. Bladder Cancer. Access at: www.plwc.org and click on “Cancer Types.” The PLWC oncologist-approved bladder cancer guide can be printed in its entirety or by subtopic.

 

Ellsworth, Pamela, and Brett Carswell. 2006. / 100 Questions and Answers  about Bladder Cancer. Sudbury, MA: Jones and Bartlett.Detailed information about bladder cancer is presented in an easy  to read question-and-answer format. Terms are explained for the layman  by urologists and the book includes notable web sites, organizations, and literature  on specific topics related to bladder cancer.

 

Schoenberg, Mark P., Johns Hopkins University, and Genitourinary Oncology Group. 2000. The Guide to Living with Bladder Cancer. Baltimore: Johns Hopkins University. Dr. Schoenberg and the faculty and staff of the Johns Hopkins Genitourinary Oncology Group discuss the symptoms, diagnosis, and treatment of bladder cancer. The contents include anatomy of the bladder, diagnostic  tests, and descriptions of different surgical procedures, bladder removal, urinary tract reconstruction, and bladder preservation strategies. The insights and personal stories of patients who were treated by Dr. Schoenberg are presented in the last chapter.

This article was originally published on 7/12/2014 and last revision and update of it was 9/14/2015.