What you should know about bladder cancer

What is the bladder?

The bladder lies in the lower abdomen and stores urine produced by the kidneys. Part of the urinary tract, it connects to kidneys through long ureters; urine then leaves through the short urethral tubes connected to it. Its wall has inner, middle and outer layers. Surface epithelial cells stretch when full and contract when empty, while the middle layer is muscle.

Bladder muscle expels urine. The outer layer contains fat, vessels and fibrous tissue. Inactivation of several tumor suppressor genes is thought important in cancer formation. Among men in our country, after lung, prostate and colorectal cancers, bladder cancer is the fourth most common cancer . It ranks lower in women.

Knowing more about this common cancer enables informed action. Let us examine what it is, contributing factors, symptoms and treatments.

What should you know?

• First, it can happen to you too.
• Bladder cancer's most common symptom is blood in urine. Frequency, burning and painful urination can also indicate it.
• Though rarer in women, its course is worse and mortality higher because gynecologists often treat common cystitis and urinary infections with months of antibiotics instead of considering cancer.
• Smoking and repeated hair dyeing are among the best-known risks.
• After complete removal in advanced disease, surgical options preserve reproductive organs and create a new internal pouch or reconstructed bladder.
• It is very rare in nonsmoking women younger than 40.

Can imaging detect it?

Imaging is possible only when persistent urinary problems and blood occur. Family history slightly increases risk, but many patients lack genetic risks and many carrying them never develop cancer. The highest-risk group comprises women smoking for 20 years or more, older than 50, with visible, painless blood in urine . These cases warrant imaging (computed tomography [CT] or intravenous pyelogram [IVP]) together with direct bladder cystoscopy to identify the affected area. Urine Pap testing, or cytology, is important. If all are negative, bladder cancer likelihood falls below %1.

How does bladder cancer develop?

Nearly %80 remain within the bladder or mucosa. Called superficial cancer or carcinoma in situ, they frequently recur after treatment.

When spread occurs, cancer extends to the bladder wall and may metastasize to bones, lymph nodes, reproductive organs, lungs, liver and pelvis.

What are the symptoms?

• Blood in urine (color ranging from red to dark red)
• Pain during urination
• Frequent urination or urges

These do not necessarily mean cancer. Infection, benign tumors, stones and other problems can cause them. Prompt consultation enables early identification.

How is it diagnosed?

If a patient has symptoms of bladder cancer, the doctor performs a comprehensive examination and requests laboratory tests. The methods used to diagnose bladder cancer are listed below.

Physical examination: The doctor examines the abdomen and pelvis for tumors; rectal or vaginal examination may be necessary.

Urine testing: The laboratory checks blood, cancer cells and other signs. Urine cytology, similar to a Pap test, is most common.

Intravenous pyelogram: Dye is injected into vessels, collects in urine and reveals bladder and kidneys on X-rays

Cystoscopy: A thin illuminated cystoscope enters through the urethra to examine the lining directly. General anesthesia may be used.

D(tissue sample): Taken with the cystoscope and sent for pathological examination, this is called biopsy when checking for cancer cells. It is often the only definitive diagnosis. Sometimes the entire cancer is removed during biopsy, diagnosing and treating with one procedure.

How is it staged?

Once bladder cancer is diagnosed, its stage or extent of spread must be determined to shape the treatment plan. Staging considers whether it reaches the bladder wall or other areas and, if so, which ones; it measures the disease's depth and width. Sometimes the doctor can determine stage at diagnosis, while other tests are needed for certainty. Imaging may include CT (computed tomography), MRI (magnetic resonance imaging), sonography, IVP (intravenous pyelogram), bone scanning or chest X-rays. Staging sometimes cannot be completed until surgery.

Stage characteristics are:

Stage 0: Cells are only in the inner lining, also called superficial cancer. Its aggressive high-grade surface-spreading form is carcinoma in situ.

Stage 1: Cells are deeper in the lining but not muscle. Despite spread, cystoscopic removal remains possible, so it is still called superficial cancer.

Stage 2: Cells have spread to bladder muscle.

Stage 3: Cells extend through muscle into surrounding tissue, possibly reaching reproductive organs.

Stage 4: Cancer spreads through abdomen and pelvis, possibly to nodes and distant lungs.

How do experts grade aggressiveness?

Beyond spread, aggressiveness matters. Pathologists examine cells microscopically. Least aggressive (low-grade) is grade 1, intermediate 2, and most aggressive (high-grade) 3 and 4. Grade is the most important predictor of superficial progression and increases in advanced disease.

How is it treated?

Surgery, radiotherapy, chemotherapy and immunological methods are used.

Surgery: Commonly used, with type depending mainly on tumor grade and type.

• Transurethral resection treats early superficial cancer. A cystoscope enters through the urethra; a small wire loop removes cancer, then electrical current burns the area against residual cells.
• Radical cystectomy is most common for invasive disease (superficial cancer spread widely). The entire bladder, nearby nodes, part of the urinary tract and affected neighboring organs are removed. In men this includes prostate, seminal vesicles and part of the sperm duct; in women uterus, ovaries, fallopian tubes and part of the vagina. After complete removal, another operation creates a urine pouch. Partial cystectomy can preserve the bladder while removing small localized cancers invading muscle.

When cancer extends outside, surgery aims mainly to relieve symptoms rather than remove cancer, with additional treatments afterward.

Radiotherapy: Radiotherapy kills cancer cells in a particular area using high-energy rays. Before surgery, it aims to shrink the tumor so removal is easier. After surgery, it may be used to kill any cancer cells potentially left behind.

Two methods are used:

• External radiation: outpatient treatment several days weekly for several weeks, focusing rays from outside the body.
• Internal radiation: inpatient placement of radioactive material through an abdominal incision or urethra. No radioactivity remains after implant removal.

Chemotherapy: Chemotherapy uses medicines to kill cancer cells. A single drug or a combination of several drugs may be used.

After transurethral resection of superficial disease, liquid chemotherapy enters through a catheter and remains for several hours, usually weekly for several weeks. It may then continue monthly once or more for 1 year.

With distant spread, intravenous drugs circulate throughout the body, usually in cycles with recovery monitored. Sometimes chemotherapy shrinks a tumor before surgery, called neoadjuvant therapy, improving survival in many needing radical cystectomy.

Immunological therapy: Also called immunotherapy or biological treatment, it uses natural immunity, usually preventing recurrence after transurethral removal of superficial early disease. It generally starts within several weeks afterward.

Two methods are tuberculosis vaccine (Bacillus Calmette-Guerin-BCG) and interferon (an immune-response-enhancing substance).

• BCG is most common, containing live weakened bacteria related to bovine tuberculosis that activate immunity to kill cells. Through a catheter, it remains approximately 2 hours, usually given weekly for about 6 weeks.
• Interferon gives large amounts of synthetic protein to stimulate immunity. Earlier studies suggested combined BCG and interferon may work against aggressive or treatment-resistant superficial cancer.
• An important development is new-generation immunotherapies called immune checkpoint regulators , found effective in bladder cancer. One, Atezolizumab, received FDA approval on 18 May 2016.

Dear readers, early diagnosis is crucial, as in many cancers. Medical checks 1-2 times yearly and/or immediate consultation for the symptoms above enable early treatment and improve recovery chances.