Bladder cancer accounts for approximately 90 percent of cancers of the urinary collecting system (renal pelvis, ureters, bladder, and urethra).The bladder is an organ located in the pelvic cavity that stores and discharges urine. Urine is produced by the kidneys, carried to the bladder by the ureters, and discharged from the bladder through the urethra.
Bladder cancer usually originates in the bladder lining, which consists of a mucous layer of surface cells that expand and deflate (transitional epithelial cells), smooth muscle, and a fibrous layer. Tumors are categorized as low-stage (superficial) or high-stage (muscle invasive).
In industrialized countries (e.g., United States, Canada, France), more than 90 percent of bladder cancer cases originate in the transitional epithelial cells (called transitional cell carcinoma; TCC). In developing countries, 75 percent of cases are squamous cell carcinomas caused by Schistosoma haematobium (parasitic organism) infection. Rare types of bladder cancer include small cell carcinoma, carcinosarcoma, primary lymphoma, and sarcoma.
Cancer-causing agents (carcinogens) in the urine may lead to the development of bladder cancer. Cigarette smoking contributes to more than 50% of cases, and smoking cigars or pipes also increases the risk.
Other bladder cancer risk factors include the following:
- Chronic bladder inflammation (recurrent urinary tract infections, urinary stones)
- Consumption of Aristolochia fangchi (herb used in some weight-loss formulas)
- Diet high in saturated fat
- Exposure to second-hand smoke
- External beam radiation
- Family history of bladder cancer (several genetic risk factors identified)
- Gender (male)
- Infection with Schistosoma haematobium (parasite found in many developing countries)
- Personal history of bladder cancer
- Race (Caucasian)
- Treatment with certain drugs (e.g., cyclophosfamide—used to treat cancer)
Exposure to carcinogens in the workplace also increases the risk for bladder cancer. Medical workers exposed during the preparation, storage, administration, or disposal of antineoplastic drugs (used in chemotherapy) are at increased risk. Occupational risk factors include recurrent and early exposure to hair dye, and exposure to dye containing aniline, a chemical used in medical and industrial dyes.
Workers at increased risk include the following:
- Truck drivers
- Workers in rubber, chemical, textile, metal, and leather industries
The primary symptom of bladder cancer is blood in the urine (hematuria). Hematuria may be visible to the naked eye (gross) or visible only under a microscope (microscopic) and is usually painless. Bladder cancer must be ruled out in any patient who develops gross, painless hematuria.
Other bladder cancer symptoms include frequent urination and pain upon urination (dysuria).
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Diagnosis of bladder cancer includes urological tests and imaging tests. A complete medical history is used to identify potential risk factors (e.g., smoking, exposure to dyes).
Laboratory tests may include the following:
- NMP22®BladderChek® (to detect elevated levels of tumor markers in the urine)
- BTA – STAT (to detect bladder tumor antigen in the urine of patients with a known history of bladder cancer; a positive test may prompt more thorough imaging and follow up)
- Urinalysis (to detect microscopic hematuria)
- Urine cytology (to detect cancer cells by examining cells flushed from the bladder during urination)
- Urine culture (to rule out urinary tract infection)
NMP22®BladderChek® is a urine test used to detect elevated levels of a nuclear matrix protein (called NMP22®). Bladder cancer increases levels of this protein in the urine, even during early stages of the disease.
Results of this test, which is noninvasive and is performed in a physician’s office, are available during the patient’s office visit. Studies have shown that when NMP22®BladderChek® is used with cystoscopy, it may increase the clinical sensitivity of the evaluation, compared to cystoscopy and urinalysis alone.
Various imaging tests may also be performed. Intravenous pyelogram (IVP) is the standard imaging test for bladder cancer. In this procedure, a contrast agent (radiopaque dye) is administered through a vein (intravenously) and x-rays are taken as the dye moves through the urinary tract. IVP provides information about the structure and function of the kidneys, ureters, and bladder. Other imaging tests include CT scan, MRI scan, bone scan, and ultrasound.
If bladder cancer is suspected, cystoscopy and biopsy are performed. Local anesthesia is administered and a cystoscope (thin, telescope-like tube with a tiny camera attached) is inserted into the bladder through the urethra to allow the physician to detect abnormalities. In biopsy, tissue samples are taken from the lesion(s) and examined for cancer cells. If the sample is positive, the cancer is staged using the tumor, node, metastases (TNM) system.
Bladder Cancer Treatment
Treatment for bladder cancer depends on the stage of the disease, the type of cancer, and the patient’s age and overall health. Options include surgery, chemotherapy, radiation, and immunotherapy. In some cases, treatments are combined (e.g., surgery or radiation and chemotherapy, preoperative radiation).
Bladder Cancer Surgery
The type of surgery used to treat bladder cancer depends on the stage of the disease. In early bladder cancer, the tumor may be removed (resected) using instruments inserted through the urethra (transurethral resection).
Bladder cancer that has spread to surrounding tissue (e.g., Stage T2 tumors, Stage T3a tumors) usually requires partial or radical removal of the bladder (cystectomy). Radical cystectomy also involves the removal of nearby lymph nodes and may require a urostomy (opening in the abdomen created for the discharge of urine). Complications include infection, urinary stones, and urine blockages. Newer surgical methods may eliminate the need for an external urinary appliance.
In men, the standard surgical procedure is a cystoprostatectomy (removal of the bladder and prostate) with pelvic lymphadenectomy (removal of the lymph nodes within the hip cavity). The seminal vesicles (semen-conducting tubes) also may be removed. In some cases, this can be performed in a manner that preserves sexual function.
In women with T2 to T3a tumors, the standard surgical procedure is radical cystectomy (removal of the bladder and surrounding organs) with pelvic lymphadenectomy. Radical cystectomy in women also involves removal of the uterus (womb), ovaries, fallopian tubes, anterior vaginal wall (front of the birth canal), and urethra (tube that carries urine from the bladder out of the body). Recent studies have shown some support for modifying this approach to help conserve sexual function.
Segmental cystectomy (partial removal of the bladder), which is a bladder-preserving procedure, may be used in some cases (e.g., patients with squamous cell carcinomas or adenocarcinomas that arise high in the bladder dome). When segmental cystectomy is performed, it may be preceded by radiation therapy in high-risk patients.