Bladder Cancer

Understanding Bladder Cancer

The bladder is the hollow organ in the lower abdomen that stores urine. Bladder cancer occurs when abnormal, cancerous cells grow uncontrollably in the bladder lining. These cells begin to affect the bladder function. They also can spread to surrounding organs.

Bladder cancers can form in many locations in and around the bladder. The cancer cells can penetrate the layers of the bladder wall. The deeper the invasion, the more likely the cancer cells can spread to other organs.

The primary symptom of bladder cancer for both men and women is blood in your urine, known as hematuria. Some mistake blood in the urine for a urinary tract infection. Do not delay going to your doctor if you suspect you have blood in your urine. Other symptoms may include:

• Painful urination
• Frequently feeling the need to urinate without results
• Overactive bladder/frequent urination
• Incomplete emptying of the bladder
• Passage of tissue fragments in urine
• Lower back pain

Sometimes these symptoms are signs of other urologic conditions, not bladder cancer. If you have any of these symptoms, it is important to schedule an appointment with your doctor to get them checked out.

How Common is Bladder Cancer?

Bladder cancer is a relatively common cancer. It is more often found in men than women. It is the fourth most common cancer in men.

What are Risk Factors for Bladder Cancer?

The exact causes of bladder cancer are unknown. There is no standard or routine screening for bladder cancer. The most common and strongest risk factor for bladder cancer is smoking. Smokers are more than twice as likely as nonsmokers to develop bladder cancer, according to the American Cancer Society.

Other risk factors include:

• Family history of bladder cancer
• Diet high in fried meats and fat
• Chronic bladder inflammation
• Prior external beam radiation to the pelvis
• Regular exposure to industrial chemicals
• Lynch syndrome (autosomal dominant genetic condition)

Your risk for bladder cancer increases with age. Greater than 90 percent of people diagnosed are older than 55 with the average age being 73 years old.

If your doctor suspects you have bladder cancer, he or she may begin by sending a urine sample to the lab. The sample will be examined for blood or cellular abnormalities (such as cancerous or pre-cancerous cells in the urine). There are three main tests to investigate the potential of bladder cancer:

Urinalysis

A urinalysis is a test to check for blood in the urine. Blood in the urine could be an initial sign of bladder cancer. If blood is found in your sample, your doctor will request further screening be done to determine the presence of any cancer.

Urine Cytology

Your urine sample is sent to the lab where a physician (pathologist) will look at the urine cells under a microscope. The pathologist will determine if there are any irregularities or abnormalities in the cells.

Fluorescence in Situ Hybridization (FISH Test)

The FISH test uses a urine sample to map the genetic material in your cells and identify whether specific cancer cells are present.

How is Bladder Cancer Diagnosed?

Bladder cancer is difficult to find and has a high rate of recurrence. An inaccurate diagnosis can result in incomplete treatment. This may lead to serious complications. It can also lead to a lower chance of survival for patients with potentially aggressive tumors.

Bladder Cancer Imaging

Computerized tomography (CT) urogram is used to detect cancer and if blood in your urine is coming from the bladder.

A colorless dye is injected into your vein through an IV line, and X-rays are taken of your urinary system. If there is any cancer, it shows up as a blockage or an irregular outline on the wall of the bladder.

Cystoscopy (Bladder Scope)

A cystoscopy is a procedure that allows physicians to look directly into the bladder. Physicians inspect the bladder lining for abnormal growths. They also look for suspicious areas that may be causing worrisome symptoms. The cystoscopy is an important part of the diagnosis and treatment of bladder cancer.

Blue Light Cystoscopy

IU Health is one of the first centers in the US to use this new technology that allows doctors to clearly see cancerous growths in the bladder. The enhanced imaging allows us to detect bladder cancer more easily.

If you are suspected to have a high risk for bladder cancer or have had previous lesions, you may be eligible for the blue light cystoscopy. The technology detects more small scale cancer lesions than does the white light cystoscopy alone.

The blue light cystoscopy rapidly and effectively highlights the cancer cells in the bladder. This makes the tumors located in the bladder easier for physicians to find. During the cystoscopy, blue light causes the tumor cells to spotlight a pink color which contrasts with normal tissue.

Learn more about cystoscopy at IU Health.

During the cystoscopy procedure your doctor may determine the tumor is not muscle-invasive and can be removed easily. In those cases, he or she may perform a procedure known as Transurethral Resection of the Bladder Tumor (TURBT). This removes the tumor from the lining of the bladder. Learn more about TURBT in the Treatment section.

Bladder Cancer Biopsy

If abnormal tissue is found during a cystoscopy, your doctor may do a biopsy. Your doctor will pass a special tool through the scope and into your bladder to collect a cell sample for testing.

Bladder Cancer Staging & Grading

Once your physician has observed the tumor directly and completed a biopsy they then stage and grade the cancer.

• Stage: The tumor’s location and extent
• Grade: The cancer’s aggressiveness and potential for spread

Your physician will use the tumor size, its location and how far it has progressed into the bladder wall and out into the rest of the body to evaluate your cancer.

After bladder cancer is confirmed, you may need more tests to see if the cancer has spread (metastasized). With the information, your physician will stage the cancer as follows:

TNM Staging

The TNM staging system is the widely-used reporting system for cancer. After each letter in the TNM system, there is a number, indicating the scale or volume of the tumor(s) within the bladder.

• T: Primary Tumor
  • Tx: The size of the tumor cannot be measured
  • T0: No tumor was found
  • T1-T4: Indicates the size of the tumor.
• N: Regional Lymph Nodes
  • Nx: Tumors in lymph nodes cannot be measured
  • N0: cancer not found in lymph nodes
  • N1-N3: The number and location of tumors found in the lymph nodes
• M: Distant Metastasis
  • Mx: Metastasis cannot be measured
  • M0: Cancer has not yet spread
  • M1: Cancer has spread to other parts of the body

When your doctor speaks to you about your diagnosis, he or she may refer to your stage of cancer in the more common staging language:

• Stage I: Cancer occurs in the bladder’s inner lining but hasn’t invaded the muscular bladder wall.
• Stage II: Cancer has invaded the bladder wall, but is still confined to the bladder.
• Stage III: Cancer has spread through the bladder wall to the surrounding tissue. It may have also spread to the prostate in men or the uterus or vagina in women.
• Stage IV: Cancer has spread to the lymph nodes or other sites such as lungs, bones or liver.
  • Early stage-non-muscle-invasive bladder cancer: This type of tumor looks more like normal tissue. It is less likely to invade the muscular wall of the bladder. Patients with low-grade bladder cancer usually have a good prognosis (outlook).
  • Advanced-stage-muscle invasive bladder cancer: This type of tumor looks less like normal tissue. It tends to grow aggressively, and may be more likely to spread to the muscular wall of the bladder and other tissues and organs. Patients with high-grade bladder cancer can be harder to treat.

How is Bladder Cancer Treated?

At IU Health, a team of highly-skilled cancer specialists from several disciplines work with you to determine the best path of care. Our goal is to achieve the best possible outcome.

Oncologists (cancer specialists), surgeons and other specialists will work to heal you as a whole person. That means we’ll address your emotional, spiritual and physical needs. Our patient- and family-centered approach means your treatment plan will fit your needs and preferences.

Learn more about cancer care at IU Health.

The stage of your cancer impacts your choice for treatment. At IU Health, your physician will discuss the treatment options. Together, you will decide what treatment choice is best for you based on your individual needs.

Surgery

Transurethral Resection of a Bladder Tumor (TURBT)

TURBT is a first-line treatment most often used if you have non-muscle-invasive bladder cancer. When your physicians catch your bladder cancer before it spreads, they can remove or destroy the tumor.

They will use special tools inserted through the urethra. These tools allow them to see and treat cancer inside the bladder without an incision.

The physician will insert a resectoscope through the urethra and into the bladder. The end of the scope contains an electrified wire loop that acts as a saw. This wire cuts through the tissue to remove the tumor from the lining of the bladder.

A blue light cystoscopy is often used to provide the best imaging during this procedure.

After surgery, some bleeding and discomfort may occur. Most of the time you can return home the same day and resume normal activities in less than one week. This procedure can be repeated if you have recurrences of non-muscle-invasive tumors.

Partial Cystectomy

Partial cystectomy is the removal of a portion of the bladder. It is an option when a tumor is invasive but when all evidence shows that it is a single tumor limited to a specific region of the bladder. The procedure reduces the size of the bladder but preserves a significant portion.

Partial cystectomies may be followed by radiation and chemotherapy treatment. Because only a portion of the bladder is removed, you are able to urinate normally after recovering from the surgery. Few patients with invasive bladder cancer will qualify for partial cystectomy.

Radical Cystectomy

Radical cystectomy is the complete removal of the bladder. It is the most common treatment for muscle-invasive bladder cancer.

In this procedure, your urologist makes an incision in your abdomen, bladder, surrounding lymph nodes and nearby structures and organs. Your urologist removes your bladder along with any other affected organs.

For some selected patients with bladder cancer, urologists will use a robot to help them perform the surgery. With robots, we’re able to make a smaller incision, and you’ll have less pain and a faster recovery.

Bladder Replacement & Bladder Reconstruction Treatment Options

The bladder may need to be completely removed due to muscle invasive bladder cancer. If so, your treatment options available include:

Ileal Conduit Urinary Diversion

This surgical procedure creates a tube from a 6-8 inch piece of the small intestine. This tube allows your kidneys to drain and urine to exit the body through a small opening called a stoma.

The urine output cannot be controlled and a collection pouch will have to be worn at all times.

Neobladder Reconstruction

This surgical procedure uses a piece of the intestine to construct a new artificial bladder. This allows you to urinate voluntarily and maintain continence.

Urinary retention (difficulty urinating and emptying the bladder) is a potential complication of neobladder reconstruction. Because of this, you need to be willing to put a catheter in (self-catheterization) to drain urine and relieve pressure on the bladder.

Indiana Pouch Continent Urinary Reservoir

Developed at IU Health, this breakthrough surgery reconstructs the bladder from the colon. This allows urine to be kept in a pouch inside the body, instead of a pouch outside the body.

The Indiana Pouch is a longer, more complicated procedure that maintains urinary function. It has the highest rate of urinary continence compared to other surgical treatment options.

With the Indiana Pouch, urine is drained through a small stoma (artificial opening) that is barely visible. The result is a better body image and broader clothing options.

Chemotherapy

Chemotherapy uses special drugs either to kill cancer cells or to help manage side effects of cancer. Sometimes more than one of these drugs is combined to treat cancer. You might hear such combinations referred to as a “drug cocktail” or regimen.

Chemotherapy is most commonly used if your cancer has spread beyond the bladder to other organs. Depending on the stage and grade of your cancer (along with other factors), you and your physicians will discuss a couple types of chemotherapy:

• Neoadjuvant chemotherapy is chemotherapy prior to surgical removal of a bladder tumor. This chemotherapy may help shrink the tumor to make it easier to remove. It also may lessen the chance of recurrence.
• Adjuvant chemotherapy is chemotherapy after surgery. It may kill any remaining cancer cells and decrease the likelihood of recurrence and spread

Learn more about chemotherapy treatment at IU Health.

Radiation Therapy

Radiation therapy uses high-energy waves such as x-rays to kill cancer cells. It is usually delivered from outside the body (this is called external beam radiation).

For certain patients, radiation therapy can be used with chemotherapy as an organ-sparing alternative to bladder-removal surgery. Radiation therapy alone also may be used as a treatment alternative for patients not medically suited for surgery. It is slightly less-effective than combination therapy.

Radiation therapy is routinely performed as an outpatient treatment.