Bladder cancer is cancer of the sac that collects and holds urine until it exits your body. It’s the fourth most frequently diagnosed cancer in men and the 10th most frequently diagnosed cancer in women. Most people who develop the disease are older adults – less than 1 percent of cases occur in people younger than 40.
Smoking is the greatest single risk factor for bladder cancer. Exposure to certain toxic chemicals and drugs also makes it more likely you’ll develop the disease. Although some of these risk factors can be controlled, the incidence of bladder cancer hasn’t decreased significantly in recent years. Even so, increased understanding of the disease means the outlook for people with this type of cancer is brighter now than in the past.
If the cancer is detected early – before it has moved beyond the lining of your bladder – you have a better chance of a successful treatment with minimal side effects. Treating bladder cancer that has spread is more difficult and involves more extensive procedures. But several new approaches can offer a better quality of life. In addition, researchers are studying ways to help prevent the disease in the first place. However, bladder cancer is overall considered one of the more surviveable cancers, with more than half of both men and women alive five years after diagnosis.
Among patients with invasive bladder cancer, treatment must be individualized accounting for general medical condition, extent of cancer, and personal preferences. Once it has been decided that more aggressive therapy is needed in the way of external beam irradiation, systemic chemotherapy, surgery or any combination thereof, the safety of bladder preservation should be considered. Although radiotherapy alone allows the bladder to be preserved, the five-year survival for patients with tumors into the innermost part of the muscle layer of the bladder is 40%, into the deep muscle layer or just beyond the muscle layer is 20%, and into adjacent organs (prostate or vagina) is 10%. Similarly, intravenous chemotherapy given as the only method of treatment produces a long term complete response in only about 20%. Recently, the combination of radiation therapy and intravenous chemotherapy (which sensitizes the cancer to irradiation) has given a glimmer of hope. 58% of patients treated with platinum-based combination chemotherapy and irradiation were able to preserve their bladders while remaining free of disease at 4 years. Long term follow-up is unavailable at this time and improvements using this strategy will rely on more effective chemotherapeutic agents.
For invasive cancer that appear to be within the bladder (stages T2-3a), complete surgical removal of the bladder provides the best chance of a cure. Partial removal of the bladder may be tried in some patients; it has the advantage of preserving bladder and sexual function. Patients with only one tumor located near the dome of the bladder and without carcinoma in situ in other areas of the bladder, are the best candidates for partial bladder removal. If patients with a single tumor located near the dome of the bladder have carcinoma in situ in other area, they may first be treated with intravesical BCG. If the carcinoma in situ is eradicated they may then be treated by partial bladder removal. Among some patients with locally extensive invasive tumor, if preoperative systemic chemotherapy shrinks the tumor, partial bladder removal may be tried. However, among patients treated with partial bladder removal, cancer may recur in the remaining bladder.
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Recommendations for Bladder Cancer
Patients with multiple tumors, high-grade, abnormal amounts of DNA ploidy (aneuploid), with carcinoma in situ or tumor penetration into the lamina propria are at high risk for tumor recurrence and progression. Usually, random bladder biopsy specimens and post resection cytologic examinations reveal abnormalities. High risk patients are candidates for intravesical therapy with bacillus Calmette-Guerin (BCG), mitomycin, doxorubicin or thiotepa. These agents are typically instilled into the bladder through a urethral catheter for two hours weekly for six to eight weeks. Occasionally, long-term maintenance treatment regimens are employed.
Risk factors are used to predict tumor aggressiveness and thereby provide logic on when to place medications into the bladder to treat the cancer (intravesical therapy). Patients with small, single low-grade tumor with a normal amount of DNA (diploid) that are limited to the urothelium are at low risk for recurrence. In these patients, random bladder biopsies and the results of post resection cytologic examinations are usually normal. Generally, these patients are treated by transurethral resection followed by periodic cystoscopy, cytology and DNA ploidy evaluations. In these, intravesical therapy in addition to removal of the tumor through the cystoscopic instrument is generally administered only following tumor recurrence.
When complete surgical removal of the bladder is performed, usually, in place of the bladder, a segment of small bowel is used to transfer urine directly from the kidneys and ureters through a stoma on the skin and into an external collection bag. This is called an ileal conduit. Most patients undergoing this form of diversion psychologically adjust to the change in body image with time. Since it is performed relatively quickly and with a low complication rate, the ileal conduit remains the diversion of choice with most surgeons. Today many patients opt for a form continent urinary reservoir, which eliminates the need for an external collection bag. Although the procedure requires special skills and increases the length of the operation, all appropriate candidates should be offered this form of diversion. Some continent diversions have a small stoma on the abdominal wall. The urine is drained 4 to 6 times daily by placing a catheter through the soma into a urinary reservoir made of bowel. The stoma which is flush with the skin is easily concealed with a gauze sponge.
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Refers to the various types of malignant neoplasms that contain cells growing out of control and invading adjacent tissues, which may metastasize to distant tissues.
A treatment of disease by any chemicals. Used most often to refer to the chemical treatments used to combat cancer cells.
The prostate gland in men that surrounds the neck of the bladder and the urethra and produces a secretion that liquefies coagulated semen.
Malignant growth of epithelial cells tending to infiltrate the surrounding tissue and giving rise to metastasis.