The urinary bladder is a hollow muscle that stores urine made by the kidney. Urine flows from the kidney through tubes called ureters to the bladder. As the bladder fills, the muscular wall of the bladder stretches. Sensors in the muscle wall sense fullness and send a signal through your nervous system to the brain making you aware of the need to void (urinate). The bladder usually feels full when it is holding about 2 cups of urine. You will empty your bladder of urine through a tube, called the urethra, when it is socially acceptable. The muscle wall of the bladder is made up of three layers. The inner layer lining inside the kidney, ureters, bladder and urethra is made up of transitional cells. A support or basement membrane separates the inner lining from the middle layer. The middle layer is made up of connective tissue, and the outer layer is muscle tissue. 90% of bladder cancer in the United States is found in the inner lining (transitional cell lining) of the bladder.
Bladder cancer is the fourth most common cancer among men and the eighth most common cause of cancer among women. Approximately 68,800 new cases will occur in 2008 with an estimated 14,100 deaths. Bladder cancer occurs 2-3 times more often in men than women/ is more common in Caucasians than African Americans or Hispanics, and has an average age at diagnosis of 65 years.
Risk factors associated with increased chance for developing Bladder Cancer
- Smoking or second hand smoke exposure is the #1 risk factor for the development of bladder cancer
- Increasing age
- Family history or genetic defects
- Occupational exposure, especially in those who work with rubber, leather, textiles, and certain paint products and printing
- Chronic inflammation, chronic urinary tract infections caused by parasites (common outside the US) or chronic kidney stones
- Chronic inflammation associated with chronic indwelling urinary catheter
- History of previous bladder cancer
- Previous pelvic radiation
- Previous chemotherapy
What are the signs and symptoms of Bladder Cancer?
Often people have NO symptoms of bladder cancer. The most common sign of bladder cancer is visible blood in the urine, or blood that is only visible on microscopic examination of the urine. There is often no pain associated with the blood in the urine. Some symptoms that may be present include urinary urgency (strong sensation of the need to urinate), frequency, and waking frequently at night to urinate. There may be pain when urinating, flank pain, back or abdominal pain, and loss of appetite or weight loss. Many of these symptoms can also be due to bladder stones or infection.
How is Bladder Cancer detected?
- If your health care provider thinks your symptoms might be due to bladder cancer, then he/she will get a medical history including smoking history or second hand smoke exposure along with a physical examination. The health care provider will also order laboratory tests such as urine culture and cytology to look at urine cells under the microscope.
- For some cancers the health care provider can screen (look for) the cancer before you have symptoms. Screening is usually done by looking for substances or chemicals found in your blood or urine that are released by the cancer cells or as a response by the body to the cancer cells. These substances are called tumor markers.
- A cystoscopy is a minor procedure which involves the use of a scope placed through the urethra to visualize the bladder wall.
- Imaging studies are done to examine your kidneys, ureters, bladder and urethra. These include and IVP (intravenous pyelogram), a CT scan (computerized image x-ray), an MRI (magnetic resonance imaging scan) or a PET scan (positron emission tomography scan) or an ultrasound using sound waves. To look for spread of cancer your health care provider might also get chest x-ray and bone scan.
Diagnosis of Bladder Cancer
In order to diagnosis bladder cancer, the doctor will need to do a procedure called a cystoscopy, A flexible tube (cystoscope) is inserted through the urethra to visualize the bladder lining and obtain a small sample of tissue to examine under a microscope. This biopsy is the only way to know if bladder cancer cells are present. In order to grade the cell growth, the doctor will also be looking at the cancer cells for how fast the cells are growing. The more aggressively the cancer cells are growing, the higher the grade of cancer. The more slowly they are growing, the lower the grade.
Grade 1: low grade, looks like normal tissue, At this grade, cancer can recur but rarely spreads to the muscle
Grade 2: looks somewhat different than normal tissue, slow growing
Grade 3-4: high grade looks very little like normal tissue and is more likely to grow fast and invade bladder muscle wall
Carcinoma in situ (CIS) describes superficial tumors found within the support membrane separating the inner lining and middle layer of the bladder. They are flat and look very unlike normal cells and sometimes appear as inflammatory or reddened areas within the lining of the bladder. Another type of bladder tumor commonly seen is a papillary tumor, which is a raised tumor that lies on a stalk, with a shape similar to cauliflower. A papillary tumor can be a low grade or high grade tumor.
Once bladder cancer is diagnosed, the doctor needs to find out the extent of disease and whether or not is spread to other areas of the body. This is done through staging.
Stage 0: The cancer is in the cells lining the bladder and is considered a superficial surface tumor, or carcinoma in situ (CIS)
Stage 1: The cancer is into a deeper layer of the bladder lining (lamina propria) but not in the muscle
Stage 2: The cancer has spread to the muscle layer of the bladder
Stage 3: The cancer has spread to perivesical fat, which is a lining of fatty tissue that surrounds the bladder.
Stage 4: The cancer has spread into the organs near the bladder; for men this is usually the prostate, and for women, this is often the uterus and vagina. In men or women, it can also spread to the pelvic area, lymph nodes and beyond.
Treatment of Bladder Cancer
Decisions about what treatment is best will be made by you and the doctor based on the stage and grade of tumor. It will also be important to consider your age, general health, and benefits and side effects of the treatment options.
Generally for superficial bladder (stage 1) cancer the following treatment options are suggested alone or in combination with one another:
Surgery is the most common treatment for bladder cancer. Transurethral resection (TUR) is done to remove the superficial cancer cells. Using a cystoscope inserted through the urethra the doctor will insert a tool with a small wire loop at the end to remove the cancer and to burn (fulgurate) the base of the tumor, or he/she might use a high-energy laser to destroy any remaining cells.
After surgically removing the cancer, the doctor may fill the bladder with Mitomycin C (MMC) and Thiotepa are antitumor agents (cancer killing drugs) that might be used by filling the bladder immediately after surgical resection to kill any remaining cancer cells.
An immunotherapy solution of Bacillus Calmette-Guerin (BCG) with or without interferon-alpha may be given at weekly intervals for up to 6 weeks following surgical removal of the tumor. Immunotherapy uses the body’s own immune system to attack the cancer cells; BCG is usually started 2-4 weeks after surgery.
For muscle-invasive bladder cancer (stage II-IV) the doctor might recommend the following options:
Bladder saving surgery, also called a segmental or partial cystectomy, removes only the part of the bladder affected by cancer, along with nearby lymph nodes.
If removal of the cancer alone is not an option then the doctor might suggest bladder removal (radical cystectomy) with removal of nearby lymph nodes, as well as any organs in the area where the cancer may have spread. For men this might require removal of the prostate gland and seminal vesicles. For women this may include removal of the cervix, ovaries, uterus, part of the vagina, urethra and fallopian tubes.
When removing the bladder the doctor will need to create a new way to store and /or drain urine. This is called a urinary diversion. There are two types of urinary diversions, continent or incontinent. For the continent diversion, the doctor might use part of your small intestine to create an internal pouch with a valve that allows drainage of urine several times a day using a catheter. An incontinent diversion—the ileal conduit or urostomy—uses a section of small bowel to create a passageway for urine to flow from the ureter to the outside through an opening (stoma) in your skin. The urine drains through the stoma into a bag or pouch worn on the outside of the body.
External beam radiation therapy is usually offered to you when you cannot have surgery because you are too ill or the tumor cells cannot be removed without harm to you. Side effects from radiation include bladder infection, infection of the prostate, diarrhea, and local skin irritation.
Chemotherapy can either be given before surgery (neoadjuvant) or after surgery (adjuvant). Many clinical trials are evaluating the benefit of both these treatment options.
Prevention/detection of Bladder Cancer
Stop smoking and avoid tobacco smoke in your environment. There are multiple programs and medications available to help with quitting smoking.
Drinking lots of water, at least 8 glasses a day and eating a diet high in fruits and vegetables may help prevent bladder cancer.
Adding antioxidants to your diet may play a role in cancer prevention. Sources of antioxidants include: berries, nuts, beans, coffee, russet potatoes, and artichokes, to name a few.
Robin Gemmill, MSN, RN, CNS, CWOCN
Lee Ann Boyd, MSN, ARNP-C, CUNP
Used with permission from SUNA