Urinary Bladder Cancer

Bladder cancer is a type of malignancy arising from the epithelial lining (i.e., the urothelium) of the urinary bladder. It is a disease in which abnormal cells multiply without control in the bladder. The most common type of bladder cancer recapitulates the normal histology of the urothelium and is known as transitional cell carcinoma or more properly urothelial cell carcinoma.

Lack of awareness about bladder cancer risk factors and warning signs is costing lives. Approximately 70-75% of cases at the time of diagnosis are non-invasive or superficial tumours. These are not usually life-threatening, but difficult and costly to treat because they often come back. Life-long follow up is needed.

The remaining 20% of people with bladder cancer are diagnosed with invasive tumours. Bladder removal is still considered the best option for a cure. Funding for bladder cancer is among the lowest, while the cost of treating the disease is among the highest of all cancers due to its good prognosis and the need for life-long follow up.

Quitting smoking has been shown to decrease the risk, though not as much as if one never smoked.  For those with high-risk jobs that expose people to harmful chemicals, screening might prove to be worth the investment.

Women are all too often misdiagnosed and are twice as likely as men to die from the disease. Blood in the urine is most common symptom of bladder cancer and is often mistaken, ignored or not taken seriously enough by gynaecologists and women themselves. Other negative prognosis factors are a higher proportion of rare cell types found and the amount of women diagnosed with the more serious, invasive bladder cancer at later stages. Studies are suggesting that women may actually be more susceptible to the bladder carcinogens in cigarette smoke and perhaps other risk factors as well.

• Smoking: Smokers are more than twice as likely to get bladder cancer as those who do not.
• Chemicals: Working in the dye, rubber, leather, textile, paint or print industries, or working with organic chemicals or chemicals called aromatic amines, increases a person’s chances of developing cancer if appropriate safety measures are not followed.
• Race: Caucasians are twice as likely to develop bladder cancer as African-Americans.
• Age: Most people found to have this disease are in their late 60’s.
• Long-Standing (Chronic) Bladder Problems: Bladder infections and kidney or bladder stones have been linked with bladder cancer, although they are not causes of the cancer.
• Previously diagnosed with bladder cancer: Recurrence of bladder cancer occurs in 60% of patients. For this reason, follow-up is very important

• Not drinking enough fluids
• Whites are about twice as likely to develop bladder cancer as African Americans and Hispanics
• About 9 out of 10 people with bladder cancer are older than 55
• More common in men than in women
• Urinary infections, kidney and bladder stones, bladder catheters left in place a long time
• Personal history of bladder or other urothelial cancer
• Bladder birth defects
• Genetics and family history
• Prior chemotherapy or radiation therapy

Early stage tumour may not give any symptoms. Common symptoms of bladder cancer include: 

• Blood in the urine
• Pain or burning during urination
• Feeling as if you need to go right away, even when the bladder is not full
• Having trouble urinating or having a weak urine stream
• Frequent urination or feeling the need to urinate without results

These symptoms are not sure signs of bladder cancer. Infections, benign tumours, bladder stones or other problems also can cause these symptoms. Anyone with these symptoms should see a doctor so that the doctor can diagnose and treat any problem as early as possible. If there is blood in the urine, then one should be careful and should not neglect it.

• Adenocarcinoma, bladder
• Bladder polyp
• Carcinoma, bladder/transitional cell carcinoma
• Bladder calculus
• Bladder diverticulum
• Bladder fistula
• Bladder scarring/fibrosis
• Schistosomiasis, bladder
• Pelvic abscess

Like all cancers, bladder cancer is most likely to be successfully treated if detected early, when it is small and has not invaded surrounding tissues.

• If you have no risk factors, pay special attention to urinary symptoms or changes in your urinary habits. If you notice symptoms that last more than a few days, see your healthcare provider right away for evaluation.
• If you have risk factors, talk to your healthcare provider about screening tests, even if you have no symptoms. These tests are not performed to diagnose cancer but to look for abnormalities that suggest an early cancer. If these tests find abnormalities, they should be followed by other, more specific tests for bladder cancer.

Screening Tests

Screening tests are usually performed periodically, for example, once a year or once every five years. The most widely used screening tests are medical interview, physical examination, urinalysis, urine cytology, ultrasonography and cystoscopy

The choice of treatment depends on the type of tumour and the stage of disease when it is found; however, age, health, and personal preferences are also factors.

Surgery:

• TUR: Transurethral resection is the primary treatment for most tumours. It is a minimally invasive surgical technique where tumours are removed through the urethra via an endoscope equipped with a special tool on the end for excision of tissue.
• Radical Cystectomy: In invasive forms of bladder cancer, extensive surgery to excise the bladder and replace it by a new bladder made of bowel or urinary diversion to the skin (stoma) where it is collected in a bag. This can be achieved either by open surgery or more recently with Robotic Surgery which is less painful key hole surgery with less blood loss and early recovery.

Radiation Therapy:

Primary radiation therapy generally involves a radiation dose of 6,000 to 7,000 rad to the bladder in patients not fit or not willing to undergo surgery

Chemotherapy

Chemotherapy used to treat bladder cancer can be either local or systemic.

• Intravesical chemotherapy is placed directly into the bladder, and is therefore, considered local chemotherapy.
• A combination of chemotherapy drugs injected in the veins (systemic chemotherapy) is used in the treatment of more advanced bladder cancers. The combination used most often for bladder cancer is M-VAC [methotrexate, vinblastine, adriamycin (doxorubicin), and cisplatin] and GC (gemcitabine and cisplatin).

Immunotherapy

BCG is the most commonly prescribed immunotherapeutic agent for use in bladder cancer treatment to prevent recurrences in superficial bladder cancer.

Progression

• Stage I: Most bladder cancers start in the innermost lining of the bladder.
• Stage II/III: Cancer grows into or through the other layers in the bladder wall
• Stage IV: Cancer grows outside the bladder and into nearby structures (lymph nodes, bones, lungs, liver)

Diagnosis

• Primary diagnosis: Cystoscopy, Biopsy, Urine Cytology.
• Advanced diagnosis: Imaging like Computed Tomography (CT or CAT) scan, Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET) scan

The outlook for people with bladder cancer varies dramatically depending on the stage of the cancer at the time of diagnosis.

• Nearly 90% of people treated for superficial bladder cancer (Ta, T1, CIS) survive for at least five-ten years after treatment.
• 50-70% of invasive bladder cancer patients survive for up to 5 years.
• Only about 5% of people with metastatic bladder cancer survive for at least two years after the diagnosis.

Treatment in a nutshell

Treatment options depend on the stage of bladder cancer. Three types of standard treatment are used, as follows:

• Surgery: Different types of surgeries such as Transurethral Resection (TUR) with fulguration, Radical Cystectomy, Partial Cystectomy or Urinary Diversion can be performed based on requirement. It is done by Endoscopy, Robotic or open approach.
• Radiation therapy: In radiation therapy, high-energy x-rays or other types of radiation is used to kill cancer cells or keep them from growing.
• Chemotherapy: In chemotherapy, drugs are used to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing.

Milestones

• Our specialists have managed more than 250 kidney cancers in last four years, and most recently, da Vinci Robotic surgeries have been done with internationally acceptable outcomes.
• Our outcomes are in accordance with international guidelines of prostate cancer management. We, in India, are the first ones to perform the fastest 100 robotic surgeries after installing the da Vinci robot with excellent outcomes.

Reported outcomes

Top tips

• Choose a low-fat, low-cholesterol diet.
• Stop smoking.
• Avoid dehydration. Increase your fluid intake, particularly water. Water dilutes cancer-causing chemicals.
• Choose a diet rich in a variety of colourful fruits and vegetables. The antioxidants in fruits and vegetables may help reduce your risk of cancer.
• Keep a check on the risk factors.

We, at our hospital, have uro-oncology service comprising of experienced Uro-Onco Surgeon who performs open, laparoscopic and robotic surgery trained at Prestigious Tata Memorial Hospital, Mumbai and have dedicated Radiation, Medical Oncologist and Onco Pathologist. In addition we have state-of-the-art technology including Da Vinci Robot, IMRT and IGRT, specialised stoma management team, and Pain and Palliative Medicine department. We are committed to provide highest internationally accepted evidence based management for urological cancers under one roof.