Urinary Bladder Cancer​

Urinary Bladder Cancer​

Urinary Bladder Cancer​

Cancer in the urinary bladder is the uncontrolled growth and multiplication of the abnormal cells in the urinary bladder; the urothelial cells that form the inner lining of urinary bladder. It then spreads into the deeper tissues of the urinary bladder wall over a period of time.

Cancer in the urinary bladder is the uncontrolled growth and multiplication of the abnormal cells in the urinary bladder; the urothelial cells that form the inner lining of urinary bladder. It then spreads into the deeper tissues of the urinary bladder wall over a period of time. Bladder cancers usually have a tendency to remain confined to the inner (also called the mucosal layer) for the longest period of time. As cancer advances to further stages, it spread to the neighbouring lymph nodes and subsequently to other body parts

Factors that may increase risk for getting urinary bladder cancer include:

  • Smoking: Smoking cigarettes, cigars, or pipes increases one’s risk of getting bladder cancer. Tobacco smokers have a three-fold increased risk of getting bladder cancer as compared to non-smokers and even ex-smokers have a two-fold increased risk,
  • Exposure to chemicals: Exposure to chemicals like aromatic amines, aniline dyes, nitrites and nitrates have all been implicated as increasing one’s risk of getting bladder cancer. Usually workers in industries manufacturing dyes, rubber, leather, textiles and paint products have an increased risk of getting exposed to these chemicals.
  • Chronic irritants: These include persons with recurrent urinary tract infections, long-term catheterization, parasitic infection with Schistosoma haematobium (Bilharziasis) have been shown to increase one’s risk of getting bladder cancer.
  • Long term treatment with drugs like cyclophosphamide: Long-term cyclophosphamide administration for treatment of other cancers or rheumatological conditions, particularly in patients with bladder outlet obstruction, results in an increased risk of getting bladder cancer.
  • Pelvic radiation: Radiation to pelvic region also increases one’s risk of getting bladder cancer.
  • Personal or family history of cancer: If an immediate family member such as siblings or parents have suffered from bladder cancer, it more likely increases one’s risk of having the same genetic mutations and thus getting bladder cancer. For e.g., family history of Lynch syndrome [hereditary nonpolyposis colorectal cancer (HNPCC)], can increase the risk of cancer in the urinary system.

There are the following types of urinary bladder cancer:

  • Urothelial carcinoma: Urothelial carcinoma is also known as transitional cell carcinoma and is the most common type of bladder cancer. These cancers initiate in the urothelial cells of the bladder, that form the innermost layer of the urinary bladder. The urothelial cells also line other parts of the urinary tract such as pelvis of the kidneys, which connect the kidneys to the ureters, the ureters itself as well as urethra. So, in a patient, who has been diagnosed of having urinary bladder cancer, may have synchronous tumours in pelvis, ureters and urethra too, making it important to check the entire urinary system, and plan treatment accordingly.
  • Squamous cell carcinoma: 1-2 % of bladder cancers are squamous cell carcinomas. Squamous cell carcinoma usually occurs following persistent irritation of bladder inner lining which can occur de to long-term urinary catheterization, bladder stone disease or schistosomial infection (Bilharziasis).
  • Adenocarcinoma: These also account for only about 1% of bladder cancers and usually arise in the upper part of urinary bladder (also called the dome of bladder).
  • Small cell carcinoma: They comprise less than 1% of bladder cancer. They start in nerve-like cells called neuroendocrine cells. These cancers often grow very fast and need chemotherapy for their treatment, similar to the treatment of small cell carcinoma of the lung.
  • Sarcoma of the urinary bladder: They start in the muscle layer of the urinary bladder and are very rare, but aggressive tumors.

The symptoms of urinary bladder cancer include the following:

  • Passing blood +/- blood clots in urine
  • Painful, frequent urination
  • Burning sensation while passing urine
  • Lower back pain

The symptoms can appear in different forms as mentioned above and hence, if you are experiencing any of these symptoms, especially for more than 2-3 weeks, you should consult a doctor.

Once, you see a specialist, the following tests may be carried out

  • A physical exam: A through physical examination will be carried out, after taking a detailed history of your symptoms
  • Ultrasound: An abdominal ultrasound is usually the first test done to see if any suspicious thickening or masses are present in the urinary bladder.
  • CT scan: A CT scan of the chest, abdomen and pelvis is done to determine the stage of disease; which in turn will help decide the best treatment sequence for a given patient.
  • MRI scan: An MRI scan may sometimes be asked to confirm or rule out suspicious findings on CECT scan.
  • PET CECT scan: A PET CT scan may be suggested in advanced or recurrent cases to rule out spread of cancer to other sites, eg lungs, liver, bone, etc.
  • Cystoscopy: A cystoscope (a thin tube with camera at the tip) is usually used to assess the size, number and location of the urinary bladder tumors. This procedure is usually carried out as a day care procedure, under general anaesthesia.
  • Biopsy or TURBT: Biopsy or complete tumor resection (called ‘Trans Urethral Resection of Bladder Tumor; TURBT) in case of superficial tumors is usually performed at the time of cystoscopy. The detailed biopsy/TURBT report then helps further decide the treatment plan in a given patient.
  • Urine cytology: Urine sample is tested in all patients of suspected urinary bladder cancer to rule out presence of free-floating cancerous cells in urine.

The treatment for bladder cancer depends upon the stage and type of cancer.

  • Bladder cancer surgery: A few approaches to bladder cancer surgery include:
    • Transurethral resection of bladder tumour or TURBT: It is a procedure to diagnose as well as remove the bladder cancers, which are restricted to the inner layers of the bladder. During the procedure, an electric wire loop through a cystoscope is passed into the bladder. The electric current in the wire is used to remove the tumor completely. This procedure is done through the urethra so no cuts on the abdomen are present.
    • Cystectomy. This means removal of the bladder by surgically. This may be partial or radical:
      • Partial cystectomy: In this only a part of the bladder that contains the tumor along with margin of normal bladder is removed. This is done in very selected patients with small tumors in the upper part (dome) of the bladder.
      • Radical cystectomy: In this, the entire bladder is removed along with the surrounding lymph nodes. In men, it includes the removal of the prostate and seminal vesicles as well. In women, it includes the removal of uterus, ovaries and part of the vagina. Radical cystectomy is performed either with open surgery or through laparoscopic or robotic procedure. After radical cystectomy, reconstruction can be performed by two main methods:
        • Neobladder reconstruction: As the bladder is removed in a radical cystectomy there is no reservoir of urine left in the body. So, a neobladder (new-bladder) is created. A sphere-shaped reservoir is created from a part of the intestine. Both ureters draining urine from both the kidneys are anastomosed (stitched) to the upper part of this neobladder and urethra is anastomosed to its lower part. This allows most people to pass urine normally. A small number of people who have difficulty in emptying the bladder may need to use a catheter from time to time to drain all the urine from the neobladder, called ‘self-catheterization’ which is taught to the patients, by the treating doctors.
        • Ileal conduit: This is a type of urinary diversion in which a tube; called ‘ileal conduit’ is created from a part of intestine. Again, the ureters that drain urine from the kidneys are anastomosed to this ileal conduit on one part and the other end is brought out onto the abdominal wall as a ‘urostomy’. Through the urostomy opening, urine drains and is collected into the urostomy bag which is applied over the urostomy opening. Patients are trained to empty and change the urostomy bags periodically.
  • Chemotherapy: Chemotherapy in the form of injections may be suggested depending on the stage of disease.
    • Adjuvant chemotherapy: Is the chemotherapy given after surgery, usually, 6 cycles every 2-3 weeks.
    • Neoadjuvant chemotherapy: When chemotherapy is given before surgery it is called neoadjuvant chemotherapy, wherein 3 cycles are given every 3 weeks, before surgery, the remaining 3 cycles then given as adjuvant chemotherapy, after surgery.
    • In intravesical chemotherapy: In this a tube is passed from the urethra into the bladder and chemotherapy drug, usually Mitomycin C is introduced into the bladder, immediately after TURBT and retained for for a certain amount of time before being drained. This has been shown to reduce the risk of cancer recurrence.
  • Radiation therapy: Radiation therapy in the form of ‘Adjuvant radiation’, may be given after surgery especially in patients with positive margins. Radiation may also be given along with chemotherapy as a definitive treatment in some patients to preserve their bladder called ‘Definitive chemo-radiation’ or before surgery in advanced cases of bladder cancer to reduce the tumor burden called ‘Neoadjuvant chemo-radiation’.
  • Intravesical therapy: Intravesical BCG is often recommended after complete resection of early bladder cancer by TURBT procedure (mentioned earlier). This procedure uses the bacillus Calmette-Guerin (BCG), a vaccine developed against tuberculosis, that activates the immune system against bladder cancer cells. The schedule for administration of intravesical BCG, is decided by the treating doctor.
  • Targeted therapy: Targeted therapy uses drugs to target specific proteins within the cancer cells, to kill them. For example, Erdafitinib targeting FGFR2/3 protein in bladder cancer cells may be suggested during treatment for advanced bladder cancer.
  • Immunotherapy: In advanced cases, biological therapy or immunotherapy may be suggested for treatment. Immunotherapy targets the cells, which affect the body’s immune response and helps the body in killing cancer cells.

Preventive measures to reduce the risk of getting bladder cancer are:

  • Avoid smoking and exposure to tobacco.
  • Take all safety precautions to avoid exposure to harmful chemicals, especially workers in industries manufacturing dyes, rubber, leather, textiles and paint products.
  • Eat more fruits and vegetables. Add a spread of colourful fruits and vegetables to your diet to increase anti-oxidants in your diet, which help to boost your immune system to fight against development of cancers.