Bladder Cancer, Symptoms, Treatment, Prevention. 

Cancer of the bladder is a malignancy that develops in the membrane that lines the inside of the bladder.  Bladder cancer occurs when healthy cells in the bladder begin to transform and divide in an uncontrolled manner to become cancerous. Your body is continuously attacked by internal and external aggressions that impact the life of your cells. Specific pathogenic attacks are carcinogenic causing some cells to mutate.

If your immune system is healthy, it will fight back the aggressor, and stop the mutation of those damaged cells. If the defense mechanism of your body is not able to destroy the diseased cells, their number continues to grow to form cancer.

At early stages, the cancer cells located within the bladder. Over time, will invade surrounding tissues and destroy them. Without medical intervention to slow their progression, cancer cells will travel through the bloodstream to reach other parts of the body far distant from the bladder, usually regional lymph nodes, bones, lungs, skin, and the liver. This condition is called metastatic bladder cancer.

1. Statistics.

Bladder cancer is prevalent, affecting about 10, 000 people per year. The incidence of bladder cancer is about 3% of cancers of adult aged around 65 years. Although the disease affects both men and women, the frequency of bladder cancer is about three times more among men than among women. It is estimated that each year more than 50,000 men and 16.000 women are diagnosed with bladder cancer in the U.S.

According to the National Cancer Institute (NCI), it is estimated that 70,980 men and women (52,810 men and 18,170 women) were diagnosed with bladder cancer in 2009; and 14,330 people died.

2. Causes.

The bladder is a hollow organ of the urinary system. Its primary function is to receive and store urine produced by the kidneys before evacuation. A healthy bladder can store up to 300 ml of urine before sending signals to the brain to trigger the urge to urinate.

The emptying of the bladder requires both the release of the occlusion system (sphincter) located at the outlet of the bladder and active contraction of muscle fibres found in the bladder wall.  Because the kidneys produce urine continuously, any disease of the bladder prevents urine retention and requires constant urination.

The bladder can be affected by many diseases; however, one of the major diseases of the bladder is cancer. Bladder cancer occurs when, due to some pathological factors, some healthy cells of the bladder begin to multiply uncontrollably in the bladder wall.

Those disordered cells invade the bladder and destroy healthy cells to give rise to malignant tissue; this is called bladder cancer. Depending on the type of cells affected, cancer of the bladder can be: 

• Transitional cell carcinoma (TCC) – also called urothelial cell carcinoma (UCC), TCC is the most common type of bladder cancer and other organs of the urinary system: ureter, urethra, and urachus. Transitional cell carcinoma account for 90% of all malign tumours of the bladder. Smoking, unhealthy diet and taking certain medications such as cyclophosphamide and phenacetin can lead to transitional cell carcinoma of the bladder.
• Squamous cell carcinoma – this type of bladder cancer is rare, accounting for about 5% of all bladder tumours. Its occurrence is linked to infection, irritation or inflammatory diseases of the bladder, especially bilharziasis.
• Adenocarcinoma – this type of bladder cancer develops in a group of cells of the bladder called secretary cells (also called glandular tubes or bladder epithelial cells). Adenocarcinoma of the bladder is a rare type of cancer, accounts for less than 5% of bladder tumours.

3. Risk Factors.

The exact causes of bladder cancer are not well known. However, specific factors are identified as contributors to the development of the disease. The most common include:

• Tobacco – cigarette is the primary causative factor of bladder cancer and many other cancers. Tobacco use – including first or second-hand cigarette smoke and chewing tobacco – is the enemy of your respiratory and urinary systems. Tobacco contains toxic substances that pass into your bloodstream and collected in your urinary tract. Their accumulation in your organism can lead to a variety of disease including other types of cancers. In fact, it is estimated that smokers face a risk twice as high of bladder cancer compared to non-smokers. Approximately 50% of people living with bladder cancer are smokers or former smokers.
• Age – with age, the risk of bladder cancer increases; the majority of people diagnosed with bladder cancer are aged 65 or over. This may be due to the ageing of the cells and prolonged exposure to pollution.
• Exposure to chemicals – prolonged or constant contact with certain toxic substances such as the polycyclic aromatic amine (inks, dyes.), hydrocarbons and some solvents can promote the occurrence of bladder cancer.

In addition, certain chemicals used in hairdressing salons, workshops, paint, textile companies, and industries producing dyes, leather and rubber can concentrate in your urine and leads to the development of bladder cancer.

• A family history of cancer –certain cancers such as bladder cancer rarely run in families; however, over the years, researchers have found some cases of bladder cancer related to family history.
• Chemotherapy and radiotherapy – some drugs used in chemotherapy can significantly increase the risk of bladder cancer later in life. Among these drugs are cyclophosphamide (Cytoxan) and ifosfamide (IFEX); they are used in the treatment of breast cancer and lymphoma. Also, radiation therapy for cervical cancer has increased the risk for developing cancer of the bladder.
• Race – researches have revealed that the risk of bladder cancer is twice higher among whites than people of African descent.

• A congenital disability of the bladder– Birth defect of the bladder such as bladder exstrophy increases your chance of having adenocarcinoma of the bladder.
• Sex – cancer of the bladder is about three times more common among men than among women.
• Chronic urinary tract infection– persistent infection or inflammation of the urinary tract can lead to squamous cell carcinoma (squamous cell bladder cancer). The development of cancer can be due to complications of the infection or prolonged use of a urinary catheter.

4. Symptoms.

The beginning of bladder cancer is often asymptomatic; the disease invades the bladder cells without showing any noticeable symptoms. Urine discolouration is often the first sign of bladder cancer. Hematuria (presence of blood in the urine) is usually painless and can go unnoticed for several weeks or months. As cancer aggravates, you will experience urination problems:

• Pain or burning when you urinate.
• Pain in the region of the bladder (lower back).
• An urgent need to urinate.
• The feeling of not having emptied the bladder entirely after urinating.
• Persistent urinary tract infection.

   5. Complications.   

When it comes to bladder cancer, complications are not uncommon. If a tumour is putting pressure on the junction of one or both ureters, it can obstruct the kidneys. Your kidneys are involved in the purification of your body; its blockage may lead to severe medical conditions and even death.

Also, bladder cancer tends to relapse and reoccur anytime after the treatment. Therefore, avoiding all factors that can lead to bladder cancer during and after treatment is very important to increase your chance of surviving.

• Complications of the treatment  

While it is necessary to treat cancer, the treatment itself can cause problems. In fact, complications of bladder cancer arise mostly from the treatment than cancer itself.

Surgery is the type of therapy which is most often responsible for post-treatment complications. Usually, complications depend on the type of surgery performed. For instance, a partial cystectomy can damage the bladder, but the bladder will still be able to retain urine. After a total cystectomy, however, you will be without a bladder, so you need another way to store and eliminate urine.

In some cases, your urological surgeon can create a new bladder using a small section of your intestinal tissue. The prosthesis must be emptied regularly and manually, using a tube or catheter.  Similarly, your surgeon may perform a urostomy. During the procedure, your surgeon will connect your ureters to the abdominal wall to create an opening called stoma.

A plastic bag will be attached to the exterior of the stoma to collect urine and replace the bladder. The bag must also be emptied regularly.

Also, surgery for bladder cancer can lead to infertility in women, in case of removal of the uterus; menopause when the ovaries are removed; and sexual dysfunction, if the vagina has been shrunk or shorten. Men may also experience infertility and sexual dysfunction if the prostate and the glands producing sperm have been removed or severely damaged.

6. Diagnosis.

Like other cancers, early diagnosis of bladder cancer is vital to increase the chances of survival. If cancer remains untreated while progressing into the bladder, it would eventually lead to severe and even irreparable complications.

Your doctor may do a physical examination; ask you questions about your medical history and your experiences with the symptoms. Physical examination aims to determine the alteration of your health and detect the presence of pain and other signs indicating bladder cancer. Presence of pain often indicates an advanced stage of bladder cancer. However, clinical symptoms require confirmation with medical tests.

• Urine cytology – a cytological examination of urine is necessary to confirm, in your urine, the presence of abnormal cells: red blood cells, cancer cells. This test, however, has a low sensitivity.
• Cystoscopy – this test allows your doctor to visualise abnormalities in your bladder and perform at the same time a biopsy. The sample taken during the biopsy will be examined under a microscope to confirm cancer.

During the examination, your urologist introduces into your urethra a flexible instrument called a cystoscope. The cystoscope has a lens and fibre-optic lighting system that allows your doctor to detect anomalies inside the bladder accurately.

• Medical Imaging Examination –certain imaging techniques such as CT and MRI of the pelvis can be performed during the diagnosis of bladder cancer. During the procedure, your health care provider may inject a dye into your vein to detect not only the tumour but also lymph node metastases, even in small sizes.

• Intravenous urography (IVU) – IVU is a medical technique that allows your doctor to x-ray your urinary tract. Immediately before the test, an intravenous injection of a dye should be done to obtain a better image of organs of your urinary system: kidneys, ureters, bladder, and urethra.

The fundamental purpose of this test is to check if the kidneys and ureters are affected by a tumour.

• Biopsy – in cases that other tests have confirmed cancer, your doctor will collect cellular or tissue sample within the bladder to determine the type of a tumour you have. These procedures are essential to confirm not only cancer but also its stage.

  7. Stages.

Depending on its extension, bladder cancer is classified into four phases:

• Stage I: the cancer is present in the inner lining of the bladder; the muscular bladder wall is not affected.
• Stage II: cancer has extended from the inner lining of the bladder to the bladder wall
• Stage III: at this stage, the cancer cells have spread from the bladder wall to surrounding tissue: prostate gland, vagina, or uterus.
• Stage IV: at stage 4 (the last stage), the cancer cells have proliferated to the lymph nodes, abdominal wall, lungs, bones, and other organs.

8.Treatments.

Treatment recommended by your physician depends on the type of bladder cancer you have: transitional cell carcinoma (TCC), squamous cell carcinoma or adenocarcinoma. The stage of the cancer is also related to the therapeutic method used. Usually, the treatment of bladder cancer diagnosed at early stages is less rigorous than that of a final stage bladder cancer.

However, whatever the type or the severity of cancer, bladder cancer treatment always involves surgery, radiotherapy, immunotherapy or chemotherapy; sometimes, a combination of these therapies.

A. Surgery.

A less aggressive cancer confined within the wall of the bladder can be treated by endoscopic resection. This method consists of removing cancerous tissue from the bladder using an instrument called resector. A bladder cancer that has already metastases can be treated with cystectomy associated with chemotherapy combining several drugs. Usually, the surgery involves partial or total removal of the bladder.

• Partial Cystectomy – this is a segmental resection of the bladder which allows you to get rid of a tumour while maintaining normal, natural urination. After the operation, the bladder capacity is reduced, but a standard position is recovered in a few months.

In general, a partial cystectomy is indicated for bladder cancer located only on the bladder wall, which does not affect surrounding organs or tissues. The partial cystectomy, however, is associated with risk of recurrence. Radiotherapy can be combined to reduce the risk of recurrence.

• Total cystectomy (in men): This surgical procedure involving complete removal of the bladder and other tissues are surrounding it: the fatty tissue around the bladder, prostate, seminal vesicles, and possibly the urethra.

• Total cystectomy (in women)– In women, a total cystectomy consists of removing the bladder and urethra, the fatty tissue around the bladder, uterus, and part of the anterior wall of the vagina. The removal can be performed through the vaginal or abdominal area. In general, a reconstruction of the vagina after a total cystectomy is necessary.

These operations may cause a continual flow of urine which needs to be collected in a small plastic bag stuck to the skin of your abdomen. The bag must regularly be changed. If you wear an artificial bladder, you must learn to hold urine and control the discharge. Occasionally, you can experience some episodes of incontinence, which occurs mostly at night.

Also, the removal of the bladder almost always causes impotence in men and infertility in women.

B. Radiotherapy. 

Radiotherapy is the use of high-energy beams to kill cancer cells. In general, two types of radiation are used in the treatment of bladder cancer, internal radiation therapy, and external radiotherapy.

• External radiation therapy – is external beam radiotherapy, cancer cells of the bladder are exposed to the radiation source. The rays of the radiation prevent the proliferation of the cancerous cells and cause their destruction. External radiation therapy can be administered before surgery to reduce the size of a tumour or after surgery in combination with chemotherapy.
• Internal radiotherapy – during internal radiation, a radiation therapist places radioactive implants directly into the bladder to destroy the cancer cells. Unlike external beam radiation, internal radiation therapy requires a short hospitalisation to protect patients from the radiation. In some cases, your oncologist can use both types of radiation: internal radiotherapy therapy and external radiotherapy.

Whether internal or external, radiation always causes at least one of these side effects:

• Fatigue.
• Nausea.
• Diarrhoea.
• Loss of appetite.
• Decreased sexual desire.
• Dryness and redness skin at the radiation site.

C. Chemotherapy 

Chemotherapy is a systemic treatment that affects the entire organism. Depending on the aggressiveness of a tumour, your oncologist may use chemotherapy alone or in combination with radiation or surgery.

The chemotherapy drugs can be administered intravenously or as local treatment.

• Local chemotherapy – this therapy involves introducing chemotherapy drugs directly into the bladder to destroy the cancer cells. Local chemotherapy is less toxic, causing fewer side effects. However, it is only useful in less advanced cancer or cancer that has been excised by a partial cystoscopy.
• General chemotherapy – this method is systematic, drugs affect all organs of the body, thus causing more side effects. Routine chemotherapy is generally used in the treatment of advanced bladder cancers or cancers that are untreatable by local chemotherapy.

Systematic chemotherapy increases your survival chance; however, it is still prone to side effects; the most common include:

• Hair loss.
• Shortness of breath.
• Mouth sores.

D. Immunotherapy. 

Immunotherapy, also called biological therapy, is based on the iterative intravesical administration (administered directly into the bladder) of Bacille Calmette-Guerin ( BCG) or interferon alpha 2a. These drugs are recommended in non-invasive cancers, after surgery. The purpose of the immunotherapy is to fortify your immune system and help your body to destroy cancer cells.

9. Prognosis.

Unlike many other forms of cancer, bladder cancer has a prognostic less alarming. 85% of superficial bladder cancer patients have at least, a five-year survival chance. In fact, there is a definitive cure in nearly 50% of cases of bladder cancers diagnosed early.  A patient with a metastasised bladder cancer, however, often lives less than three years after diagnosis.

According to the National Cancer Institute, the overall five-year relative survival rate for bladder cancer for 1999-2005 from 17 SEER (Surveillance Epidemiology and End Results) geographic areas was 80.0%. Five-year comparable survival rates by race and sex were:

• 81.7% for white men
• 77.0% for white women
• 71.5% for black men
• 57.3% for black women.

 10. Preventions.  

Some types of cancer are complicated; however, there are steps you can take to prevent bladder cancer:

• Lifestyle – To reduce your risk of developing bladder cancer, stop smoking and regular use of analgesics; they are two most certain methods to reduce the risk of developing cancer of the bladder.
• Diet -Eat lots of fruits and cruciferous vegetables daily. Drinking plenty of fluids daily is also important.
• Early detection: early detection is used to prevent complications and increase your chance of complete recovery. Therefore, if you notice blood in your urine, it is essential that you see your urologist without delay. If your occupation exposes you regularly to toxic substances that may lead to cancer of the bladder, consult your urologist regularly to detect possible tumours at an early stage.
• Recurrence Prevention – Bladder cancer tends to reoccur. If you have been diagnosed with cancer of the bladder, it is essential to have regular medical checkups for the rest of your life to detect recurrence as early as possible.

If you have undergone surgery for invasive bladder cancer, it is necessary that you regularly check the opening of the artificial diversion; ask your healthcare provider for more information and If you wear an artificial bladder, learn to urinate and do regular blood tests to determine if your kidneys function normally.