Bladder Cancer Treatment and Information

Taussig Cancer Institute's GU Medical Oncology Program has ongoing multidisciplinary clinics with colleagues from the Glickman Urologic and Kidney Institute and the GU section of the Department of Radiation Oncology. Urologic oncologists, pediatric urologists, medical and radiation oncologists, radiologists, and genitourinary pathologists at the Clinic collaborate to provide cancer treatment services for more than 1,000 adrenal, renal (kidney), bladder, prostate and testicular cancer and Wilms’ tumor patients annually. More than 350 surgical procedures for urologic cancer are performed each year, as well as other cancer treatments.

What is the bladder?

The bladder is a hollow organ (bag) located in the pelvic region. It stores urine, the liquid waste produced by the kidneys. After urine is produced, it passes from each kidney into the bladder through a tube called a “ureter.” The urine is then stored in the bladder. When the bladder is full, the muscles in the bladder wall tighten and allow urination. The urine is discharged from the bladder through another tube called the “urethra.” In women, the urethra is a short tube that ends in front of the vagina. In men, the urethra is longer. It passes through the prostate gland and the penis, and ends at the tip of the penis.

The wall of the bladder has several layers. A layer of transitional cells lines the inside of ureter, bladder and urethra. Beneath that layer, there is a thin zone of connective tissue called the lamina propria. The next deeper layer is a wider zone of muscle tissue. Beyond the muscle, another zone of fatty tissue separates the bladder from other nearby organs.

These layers are very important in understanding bladder cancer. As the cancer penetrates through these layers into the wall of the bladder, it becomes harder to treat.

What is bladder cancer?

Bladder cancer is a disease in which a tumor (an abnormal uncontrolled growth of cells) is found in the tissues of the bladder. Bladder cancers can form in many locations in and around the bladder, including the ureters and the lining of the kidneys (called renal pelvis). Bladder cancer cells can penetrate through the different layers of the wall of the bladder. The deeper the invasion, the more likely for those cancer cells to spread outside of the bladder to near or distant organs. Spreading of cancer cells beyond the bladder muscle makes this cancer difficult to treat. Bladder tumors are also grouped into several types by the way they appear under a microscope.

• Transitional cell carcinoma: This is the most common form of bladder cancer, accounting for more than 90 percent of these cancers.
  Squamous cell carcinoma: A rare form, accounting for 5 percent of all bladder cancers.
• Adenocarcinoma: Although rare, these are very aggressive tumors accounting for 1-3 percent of bladder cancers.
  Small cell: Extremely rare, approximately 1-2 percent of all bladder cancers. Patients often are treated with similar therapies as those used for lung cancer.

What causes bladder cancer?

Unfortunately, we still do not know exactly what causes most bladder cancers. However, we have identified some risk factors that would increase the likelihood of a person to develop bladder cancer. The most common risk factors include:

• Smoking
• Being exposed to certain substances at work, such as rubber, certain dyes and textiles, paint, and hairdressing supplies
• A diet high in fried meats and fat
• Being older, male, or white
• Chronic bladder inflammation (recurrent urinary tract infections, urinary stones)
• External beam radiation
• Consumption of Aristolochia fangchi (herb used in some weight-loss formulas)
• Infection with Schistosoma haematobium (parasite found in many developing countries)

What are the symptoms of bladder cancer?

• Blood in the urine (hematuria)
• Macroscopic, when you can see blood in the urine
• Microscopic, when small amounts of blood can be found by urine tests done because of other symptoms or as part of a general medical checkup
• Change in bladder habits
• Frequent urination or feeling the need to urinate without being able to do so
• Pain during urination
• Lower back pain

How is bladder cancer diagnosed?

All patients should undergo a complete medical history and general physical exam. Sometimes the physical exam includes an examination of the rectum and the vagina (in women) to determine if and how far the tumor has spread.

A urine analysis should be also obtained as urinary infections can sometimes cause similar symptoms. The urine specimen often is sent for microscopic analysis (cytology) to determine the presence of cancerous cells.

Cystoscopy

A urology doctor will insert a cystoscope (thin, lighted tube) into the bladder through the urethra to directly look and examine the lining of the bladder. Some sort of anesthesia is used prior to the procedure. This is usually local, but can be general or spinal.

In patients with a negative cystoscopy (no evidence of bladder tumor), an intravenous pyelogram (IVP) can be performed. This test involves the injection of a special dye into a blood vessel (usually given through a vein from the arm or hand). The dye collects in the urine, making the urinary tract (kidneys, ureters and bladder) show up on X-rays.

Bladder Biopsy

During cystoscopy, a sample of bladder tissue may be removed from a suspicious area or growth. The sample is then examined under the microscope. This can identify bladder cancers and tell what type of cancer (urothelial carcinoma, squamous cell carcinoma, adenocarcinoma, etc.) is present. It can also tell how deeply the cancer has penetrated.

Chest X-ray

A chest X-ray is done to look for any mass or spot on the lungs that might be a metastatic tumor, if it is suspected that the bladder cancer has spread distantly.

Ultrasound

This is a test that uses high-frequency sound waves that are transmitted through body tissues. The echoes vary according to the tissue density. The echoes are recorded and translated into video or photographic images that are displayed on a monitor. This is helpful in detecting tumors.

Computed tomography (CT or CAT) scan

This is a special X-ray that uses a computer to create a series of images, or slices, of the inside of the body.

Magnetic resonance imaging (MRI)

This is a test that produces images of the inside of the body using a large magnet, radio waves and a computer.

What is the treatment for bladder cancer?

The cancer treatment for bladder cancer depends on how deeply the cancer has penetrated into the bladder wall, the stage of the cancer (whether it is only in the bladder or has spread to other places), and the patient’s general health. Cancer treatments for bladder cancer include:

Transurethral resection of bladder tumor (TURBT)

This is the most common cancer treatment procedure for early stage or superficial cancers. Patients will undergo general or regional anesthesia. Doctors will then introduce a cystoscope into the bladder to perform the tumor resection (removal). It is important that your doctor include muscle tissue in the specimen resected as this will impact the need for further treatment. After surgery is completed, some bleeding and discomfort may occur, however you can return home the same day and resume your usual activities in less than one week. This procedure can be repeated if patients have superficial tumor recurrences.

Intravesical therapy

Cancer treatment that is placed directly into the bladder through a catheter rather than being given by mouth or injected into a vein. The most common form of intravesical therapy used in bladder cancer is immunotherapy. This treatment causes the body's own immune system to attack the cancer. Bacillus Calmette-Guerin (BCG) is considered to be quite effective for treating low-stage bladder cancer. BCG, a vaccine derived from the bacteria that causes tuberculosis, is placed into the bladder. The body's immune system will then respond to the cancer treatment and destroy bladder cancer cells. BCG is usually given once a week for six weeks. Sometimes long-term "maintenance" BCG therapy is given. BCG therapy may be combined with a transurethral resection of the tumor. Other intravesical therapies include interferon (immunotherapy) and mitomycin C (chemotherapy). Interferons are naturally occurring compounds that can help slow the growth of tumors. They are administered directly into the bladder through a catheter, just as BCG. Chemotherapy with mitomycin C can also be administered directly into the bladder. The way chemotherapy works as a cancer treatment is by affecting the DNA of any growing cancer cell. When given directly into the bladder, chemotherapy won’t reach other parts of the body, thus limiting unwanted side effects that can occur with systemic chemotherapy, which affects other organs.

Cystectomy

When the bladder cancer has invaded the muscle wall of the bladder, the recommended cancer treatment is to remove the entire bladder and nearby lymph nodes. In men, the prostate is also removed. In women, the uterus (womb), ovaries, a small portion of the vagina and fallopian tubes (tubes that connect the ovaries and uterus) are often removed with the bladder. General anesthesia is required and patients often remain in the hospital for seven to 10 days after cancer treatment surgery.

Recently, new surgical techniques have allowed for the removal of the bladder and at the same time, the creation of another system for draining urine. Thus, it is crucial to have an experienced urologic surgeon performing this procedure. Another possibility is the creation of a urostomy where a short piece of the small intestine (small bowel) or part of the large intestine (colon) is removed and relocated as a passageway (conduit) for urine to pass from the kidneys to the outside of the body.

Another type of urostomy is the continent diversion. In this procedure, a valve is constructed on the pouch created from the piece of intestine. This allows the urine to be stored in the pouch and emptied several times each day by placing a drainage tube (catheter) through the valve. Some patients prefer this because there is no bag needed on the outside. New reconstructive surgery methods can route the urine back into the urethra, restoring close to normal urination. One method is the creation of a “neobladder,” in which a urinary reservoir made of a piece of intestine is sewn to the urethra. This allows the patient to urinate normally.

Radiation therapy

This is a cancer treatment that uses high-energy rays (such as X-rays) to kill cancer cells. It is usually delivered from the outside of the body (external beam radiation), and it is routinely performed as an outpatient treatment. It is usually given daily (each session lasting for approximately 20-25 minutes) daily for up to five to seven weeks. It can also be given with weekly chemotherapy (low-dose) with the goal of enhancing the killing effects of the radiation. For selected patients with bladder cancer, radiation therapy can be used instead of surgery; however, it's much less effective than surgery. You need to discuss with your physician whether you are a candidate for radiation and its potential side effects.

Systemic chemotherapy

This therapy uses drugs that kill cancer cells. Usually the drugs are given into the patient’s vein. Once the drug enters the bloodstream, it will go to every place in your body destroying any cancer cell. Chemotherapy is most commonly used once the cancer cells have spread beyond the bladder to distant organs (i.e. lungs or liver). However, there is evidence to suggest that giving chemotherapy before or after removal of the bladder may decrease the likelihood of cancer spreading after surgery. Your physician will decide if and when to use chemotherapy. Several different chemotherapy agents can be used. Most chemotherapy drugs in bladder cancer have similar activity. However, they may differ in their side effect profile. Your physician will decide which chemotherapy agent is best for you after a careful discussion of the benefits and potential side effects these drugs may cause. While chemotherapy drugs kill cancer cells, they also damage some normal cells and this can lead to side effects. Side effects depend on the type of drugs used, the amount given, and the length of treatment. Your physician should discuss side effects in detail with you.