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BLADDER CANCER

 

Bladder cancer is the 7th most common malignancy in men worldwide.

 

What are the risks factors for developing bladder cancer?

  • Smoking – the most common cause of bladder cancer (more cigarettes = higher risk)

  • Chronic bladder inflammation form:

    • Recurrent urinary tract infections (low risk)

    • Long term catheter use

    • Long term bladder stones

  • Chemical/physical exposures:

    • Certain dyes used in some industries (containing aromatic amines)

    • Cyclophosphamide use

    • Radiotherapy to the bladder (eg. for treatment of rectal or prostate cancer)

 

What are the types of bladder cancer?

  • Urothelial carcinoma (or TCC – transitional cell carcinoma) is the most common type of bladder cancer (>90% cases)

  • Squamous cell carcinoma and adenocarcinoma are rare

 

What are the symptoms of bladder cancer?

  • Blood in the urine (haematuria)

    • Macroscopic – visible to the eye

    • Microscopic – detected on a urine test

  • Urinary symptoms

    • Urgency – compelling desire to void

    • Frequency – frequent passage of urine

    • Dysuria – burning/stinging when passing urine
       

How is bladder cancer diagnosed?

  • Blood test – to check kidney function

  • Urine test – to rule out infection

  • Urine cytologies test – 3 samples to check for cancerous cells in the urine

  • Imaging

    • Kidney and bladder ultrasound – may detect a mass within the bladder

    • CT IVP – more accurate for looking at the kidneys and ureters

  • Cystoscopy – telescope inserted via the urethra (water pipe) to directly visualise the bladder

    • It is best way to detect or rule out bladder cancer because imaging is not 100% accurate

    • A procedure called a transurethral resection of bladder tumour (TURBT) may be performed which acts to both establish the diagnosis and treatment

 

How is bladder cancer treated?

This largely depends on 2 major factors

  • Grade of tumour – low grade or high grade

  • Stage of tumour – how deeply the tumour has grown through the bladder wall

Low grade tumours

  • Have a good prognosis, however tend to recur

  • Other than the TURBT, usually no other treatment is required

  • You will require regular surveillance cystoscopies. The first cystoscopy is usually performed at 3 months after your TURBT. 

       If this is clear then an annual cystoscopy is performed.

  • If tumour(s) recur more frequency, more regular cystoscopies may be required

 

High grade tumours:

  • These are more aggressive tumours, with increased risk of progression and spread

  • They require closer surveillance and more aggressive treatment

  • Usually a repeat cystoscopy and biopsy will be required 6 weeks after the initial TURBT to rule out residual cancer and ensure that the cancer has not infiltrated the muscle wall of the bladder

  • If the cancer is superficial (has not grown into the bladder muscle), then usually you will require a chemotherapy type agent (BCG or Mitomycin C) instilled into the bladder. These drugs are designed to reduce the chances of the cancer recurring as well as reducing the chance of the cancer growing deeper into the bladder wall

  • BCG and Mitomycin C are both instilled into the bladder via a catheter.  A typical course involves a once a week dose for 6 weeks.

  • Maintenance BCG may be required in some cases to further reduce the chance of tumour recurrence and progression.  This typically involves a once a week dose for 3 weeks every 3-6 months for at least 1 year.
     

What are the side effects of BCG treatment? (Please refer to the BCG information sheet)

  • Common – Urinary symptoms: frequent need to void, feeling of urgency, burning on passage of urine, blood in urine, low grade fever

  • Serious complications are very uncommon but can occur – these can involve higher temperatures and serious urine infections. Rarely, BCGosis (essentially a Tuberculosis infection) can occur which may require 6-12 months of treatment with TB medications. Fortunately, this is very uncommon.

 

What if the cancer has grown into the muscle of the bladder wall?

  • This is known as stage T2 and it can no longer be cured with a TURBT

  • Staging x-rays (CT chest/abdomen) will be arranged to look for any spread (metastasis) of the cancer

  • If there are no metastases the most effective treatment for muscle invasive bladder cancer is a cystectomy (surgical removal of the entire bladder). This also will require the urine to be diverted into a short, disconnected segment of small intestine (ileal conduit) which is brought out at the skin as a stoma.  A urine bag is attached at the skin around the stoma to collect the urine.

  • Sometimes, in younger patients requiring a cystectomy a new bladder (neo-bladder) can be created out of intestine rather than an ileal conduit.  The neo-bladder can be re-attached to the urethra so that no external bag is required.  This is much more complex surgery with a higher complication rate but may be more appropriate in selected patients.  A neo-bladder does not function like a native bladder and you will be required to drain the neo-bladder regularly with a catheter.

  • For patients, unfit for a cystectomy or unwilling to undergo a cystectomy, radiotherapy (with or without chemotherapy) is an alternative treatment.  Radiotherapy can be an effective treatment for some muscle invasive bladder cancer, however for more locally advanced cancers the best chance of cure long term remains cystectomy.

 

What if the bladder cancer has spread (metastasised)?

  • This not curable but may be treated with chemotherapy, which is organised by a medical oncologist.