Bladder cancer

Definition

Bladder cancer is a type of cancer that occurs in your bladder — a balloon-shaped organ in your pelvic area that stores urine. Bladder cancer begins most often in the cells that line the inside of the bladder. Bladder cancer typically affects older adults, though it can occur at any age.

The great majority of bladder cancers are diagnosed at an early stage — when bladder cancer is highly treatable. However, even early-stage bladder cancer is likely to recur. For this reason, bladder cancer survivors often undergo follow-up screening tests for years after treatment.

Symptoms

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Urinary tract

Bladder cancer signs and symptoms may include:

• Blood in urine (hematuria) — blood may appear cola colored or bright red in your urine, or may appear in a microscopic examination of your urine
• Frequent urination
• Painful urination
• Urinary tract infection
• Abdominal pain
• Back pain

Causes

Your bladder is a muscular, balloon-shaped organ located in your pelvis. It stores urine that your kidneys produce during the process of filtering your blood. Like a balloon, the bladder gets larger or smaller depending on the amount of urine it's holding. Urine passes from your kidneys into your bladder through thin tubes called ureters and is eliminated from your body through another narrow tube, the urethra.

How cancer develops
Cancer occurs when healthy cells go awry. Rather than grow and divide in an orderly way, these cells develop mutations that cause them to grow out of control and not die. These abnormal cells form a tumor.

Types of bladder cancer
Different types of cells in your bladder can become cancerous. The type of cell involved in your cancer determines the type of treatments that may work best for you. Types of bladder cancer include:

• Transitional cell carcinoma. Transitional cell carcinoma occurs in the cells that line the inside of your bladder. Transitional cells expand when your bladder is full and contract when your bladder is empty. These same cells line the inside of your ureters and your urethra, and tumors can form in those places as well. Transitional cell carcinoma is the most common type of bladder cancer in the United States.
• Squamous cell carcinoma. Squamous cells appear in your bladder in response to infection and irritation. Over time they can become cancerous. Squamous cell bladder cancer is rare in the United States. It's a more common type of bladder cancer in areas of the world where a certain parasitic infection (schistosomiasis) is a more prevalent cause of bladder infections.
• Adenocarcinoma. Adenocarcinoma begins in cells that make up mucus-secreting glands in the bladder. Adenocarcinoma of the bladder is rare in the United States.

Some bladder cancers include more than one type of cell.

Risk factors

A number of factors may increase your risk of bladder cancer, including:

• Smoking. Smoking may increase your risk of bladder cancer by causing harmful chemicals to accumulate in your urine. When you smoke, your body processes the chemicals in the smoke and excretes some of them in your urine. These harmful chemicals may damage the lining of your bladder, which can increase your risk of cancer.
• Chemical exposure. Your kidneys play a key role in filtering harmful chemicals from your bloodstream and moving them into your bladder. Because of this, it's thought that being around certain chemicals may increase your risk of bladder cancer. Chemicals linked to bladder cancer risk include arsenic and chemicals used in the manufacture of dyes, rubber, leather, textiles and paint products. Smokers who are exposed to toxic chemicals may have an even higher risk of bladder cancer.
• Chemotherapy and radiation therapy. Treatment with the anti-cancer drugs cyclophosphamide (Cytoxan) and ifosfamide (Ifex) increases your risk of bladder cancer. Studies of women treated with radiation therapy for cervical cancer have shown an elevated risk of subsequently developing bladder cancer. But the same doesn't appear to be true for men who receive primary radiation therapy for prostate cancer.
• Chronic bladder inflammation. Chronic or repeated urinary infections or inflammations (cystitis), such as may happen with long-term use of a urinary catheter, may increase your risk of a squamous cell bladder cancer. In some areas of the world, squamous cell carcinoma is linked to chronic inflammation caused by infection with a parasite.
• Personal or family history of cancer. If you've had bladder cancer, you're more likely to get it again. Cancer can recur in your ureters or urethra as well as in the bladder itself. If one or more of your immediate relatives have a history of bladder cancer, you may have an increased risk of the disease, although it's rare for bladder cancer to run in families. A family history of hereditary nonpolyposis colorectal cancer (HNPCC), sometimes called Lynch syndrome, can increase your risk of cancer in your urinary system, as well as in your colon, uterus, ovaries and other organs.
• Bladder birth defect. Rare birth defects of the bladder can increase your risk of adenocarcinoma of the bladder.
• Age. Older adults are more likely to be diagnosed with bladder cancer. Bladder cancer diagnosis typically occurs in people 65 and older. People younger than 40 rarely get bladder cancer.
• Race. Whites have a greater risk of bladder cancer than do people of other races.
• Sex. Men are more likely to develop bladder cancer than women are.

When to seek medical advice

Make an appointment with your doctor if you develop any signs or symptoms that bother you.

See your doctor right away if you develop bloody or painful urination.

Tests and diagnosis

Tests and procedures used to diagnose bladder cancer may include:

• Using a scope to see inside your bladder. During cystoscopy, your doctor inserts a narrow tube (cystoscope) through your urethra. The cystoscope has a lens and fiber-optic lighting system, allowing your doctor to see the inside of your urethra and bladder. You usually receive a local anesthetic or light sedation during cystoscopy to make you more comfortable.
• Removing suspicious cells for testing. During a procedure similar to cystoscopy, your doctor may pass a special tool through your urethra and into your bladder in order to collect a small cell sample (biopsy) for testing. This procedure is sometimes called transurethral resection of bladder tumor (TURBT). TURBT can also be used to treat bladder cancer. TURBT is usually performed under general anesthesia.
• Testing your urine for cancer cells. A sample of your urine is analyzed under a microscope to check for cancer cells in a procedure called urine cytology.
• Imaging tests. Imaging tests allow your doctor to examine the structures of your urinary tract. You may receive a dye, which can be swallowed or injected into a vein, depending on the type of test you're undergoing. An intravenous pyelogram is a type of X-ray imaging test that uses a dye to highlight your kidneys, ureters and bladder. A computerized tomography (CT) scan is a type of X-ray test that allows your doctor to better see your urinary tract and the surrounding tissues.

Bladder cancer stages
Once it's confirmed that you have bladder cancer, your doctor may order additional tests to determine the extent, or stage, of the cancer. Staging tests may include:

• CT scan
• Magnetic resonance imaging (MRI)
• Bone scan
• Chest X-ray

The stages of bladder cancer are:

• Stage I. Cancer at this stage occurs in the bladder's inner lining, but hasn't invaded the muscular bladder wall.
• Stage II. At this stage, cancer has invaded the bladder wall.
• Stage III. The cancer cells have spread through the bladder wall to surrounding tissue. They may also have spread to the prostate in men or the uterus or vagina in women.
• Stage IV. By this stage, cancer cells may have spread to the lymph nodes and other organs, such as your lungs, bones or liver.

Complications

Bladder cancer often recurs. Because of this, bladder cancer survivors often undergo follow-up testing for years after successful treatment. What tests you'll undergo and how often will depend on your type of bladder cancer and your treatment, among other factors.

What types of tests are used to screen for bladder cancer recurrence?
Tests and procedures commonly used to screen for recurrent bladder cancer include:

• Looking for abnormal growths in your bladder. Cystoscopy is a common screening test for bladder cancer recurrence.
• Looking for cancer cells in your urine. Your doctor may recommend urine cytology testing every few months for the first few years after cancer treatment.
• Taking random samples of bladder tissue. If you have a high risk of bladder cancer recurrence, your doctor may recommend that samples of your bladder tissue be analyzed periodically. This may help doctors diagnose a bladder cancer recurrence before it can be seen with cystoscopy.

How often should you undergo screening for bladder cancer recurrence?
Ask your doctor to create a follow-up plan for you. In general, doctors recommend cystoscopy screening every three months for the first two years after bladder cancer treatment. For the next two years, you may undergo cystoscopy every six months. Then you may undergo cystoscopy every year. Your doctor may recommend other tests at various intervals as well.

People with aggressive cancers may undergo more frequent screening. Those with less aggressive cancers may undergo screening tests less often.

How can you prevent a bladder cancer recurrence?
Doctors don't yet know a reliable way to prevent bladder cancer recurrence. Talk to your doctor about ways to reduce your risk, such as:

• Stopping smoking. Ask your doctor about strategies to help you quit smoking. Support programs and medications can help.
• Increasing your intake of antioxidant vitamins. Some studies suggest that large amounts of certain vitamins may reduce the risk of recurrent bladder cancer in some people. But not enough study has been done to recommend taking big doses of antioxidants in pill form. In fact, large doses of vitamin supplements could be harmful. A safe way to increase your antioxidant intake is to increase fruits and vegetables in your diet. Talk to your doctor about other ways to get more vitamins.
• Joining a clinical trial. Consider joining a clinical trial that's studying a new way of preventing bladder cancer recurrence. These studies can't guarantee that you won't have a bladder cancer recurrence. But joining a clinical trial may help doctors discover ways to reduce the risk of bladder cancer recurrence for people in the future.

Treatments and drugs

Your treatment options for bladder cancer depend on a number of factors, including the type and stage of the cancer, your overall health and your treatment preferences. Discuss your options with your doctor to determine what treatments are best for you.

Surgical procedures

Most people with bladder cancer undergo surgery to remove the cancerous cells. The types of surgical procedures available to you may be based on factors such as the stage of your bladder cancer, your overall health and your preferences.

Surgery for early-stage bladder cancer
If your cancer is very small and hasn't invaded the wall of your bladder, your doctor may recommend:

• Surgery to remove the tumor. Transurethral resection of bladder tumor (TURBT) is often used to remove bladder cancers that are confined to the inner layers of the bladder. During TURBT, your doctor passes a small wire loop through your urethra and into your bladder. The loop is used to burn away cancer cells with an electric current (fulguration). In some cases, a high-energy laser may be used instead of electric current.

  TURBT may cause painful or bloody urination for a few days following the procedure.

• Surgery to remove the tumor and a small portion of the bladder. During segmental cystectomy, sometimes called partial cystectomy, the surgeon removes only the portion of the bladder that contains cancer cells. Segmental cystectomy may be an option if your cancer is limited to one area of the bladder that can easily be removed without harming bladder function. To remove the tumor, the surgeon makes an incision in your abdomen. General anesthesia is used, and you usually stay in the hospital for a week to 10 days.

  Surgery carries a risk of bleeding and infection. You may experience more frequent urination after segmental cystectomy, since the operation reduces the size of your bladder. Over time this may improve, though in some people it's permanent.

Surgery for invasive bladder cancer
If your cancer has invaded the deeper layers of the bladder wall, you may consider:

• Surgery to remove the entire bladder. A radical cystectomy is an operation to remove the entire bladder, as well as surrounding lymph nodes. In men, radical cystectomy typically includes removal of the prostate and seminal vesicles. In women, radical cystectomy involves removal of the uterus, ovaries and part of the vagina.

  Cystectomy carries a risk of infection, bleeding, blood clots and bowel obstruction. In men, removal of the prostate and seminal vesicles will cause infertility. But in most cases your surgeon will take care to spare the nerves necessary for an erection. In women, removal of the ovaries causes infertility and premature menopause in women who haven't experienced menopause prior to this surgery.

• Surgery to create a new way for urine to leave your body. Immediately after your radical cystectomy, your surgeon works to create a new way for your body to expel urine. Several options exist. Which option is best for you depends on your cancer, your health and your preferences. Your surgeon may create a tube (urinary conduit) using a piece of your intestine. The tube runs from your kidneys to the outside of your body, where your urine drains into a pouch (urostomy bag) you wear on your abdomen.

  In another procedure, your surgeon may use a section of intestine to create a small reservoir for urine inside your body (cutaneous continent urinary diversion). You can drain urine from the reservoir through a hole in your abdomen using a catheter a few times each day.

  In select cases, your surgeon may create a bladder-like reservoir out of a piece of your intestine (neobladder). This reservoir sits inside your body and is attached to your urethra, which allows you to urinate normally. You may need to use a catheter to drain all the urine from your new bladder.

Biological therapy (immunotherapy)

Biological therapy, sometimes called immunotherapy, works by signaling your body's immune system to help fight cancer cells. Biological therapy for bladder cancer is typically administered through your urethra and directly into the bladder (intravesical therapy).

Biological therapy drugs commonly used to treat bladder cancer include:

• An immune-stimulating bacterium. Bacille Calmette-Guerin (BCG) is a bacterium used in tuberculosis vaccines. BCG can cause bladder irritation and blood in your urine. Some people feel as if they have the flu after treatment with BCG.
• A synthetic version of immune system cell. An interferon is a type of cell your body uses to fight infections. A synthetic version of interferon, called interferon alfa, may be used to treat bladder cancer. Interferon alfa is sometimes used in combination with BCG. Interferon alfa can cause flu-like symptoms.

Biological therapy can be administered after TURBT to reduce the risk that cancer will recur. Biological therapy can also be given before surgery to shrink a tumor to a more manageable size.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. Chemotherapy treatment for bladder cancer usually involves two or more chemotherapy drugs used in combination. Drugs can be given through a vein in your arm (intravenously), or they can be administered directly to your bladder by passing through your urethra (intravesical therapy).

Chemotherapy may be used to kill cancer cells that might remain after an operation. It may also be used before surgery. In this case, chemotherapy may shrink a tumor enough to allow the surgeon to perform a less invasive surgery. Chemotherapy is sometimes combined with radiation therapy.

Radiation therapy

Radiation therapy uses high-energy beams aimed at your cancer to destroy the cancer cells. Radiation therapy can come from a machine outside your body (external beam radiation) or it can come from a device placed inside your bladder (brachytherapy).

Radiation therapy may be used before surgery to shrink a tumor so that it can more easily be removed with surgery. Radiation therapy can also be used after surgery to kill cancer cells that might remain. Radiation therapy is sometimes combined with chemotherapy.

Prevention

Although there's no guaranteed way to prevent bladder cancer, you can take steps to help reduce your risk. For instance:

• Don't smoke. Not smoking means that cancer-causing chemicals in smoke can't collect in your bladder. If you don't smoke, don't start. If you smoke, talk to your doctor about a plan to help you quit. Support groups, medications and other methods may help you quit.
• Take caution with chemicals. If you work with chemicals, follow all safety instructions to avoid exposure.
• Have your well tested for arsenic. If you have your own well, consider having it tested for high levels of arsenic in the water.
• Drink plenty of fluids. Drinking liquids, especially water, dilutes toxic substances that may be concentrated in your urine and flushes them out of your bladder more quickly.
• Eat your fruits and vegetables. Choose a diet rich in a variety of colorful fruits and vegetables. The antioxidants in fruits and vegetables may help reduce your risk of cancer.

Coping and support

Living with the concern that your bladder cancer may recur can leave you feeling as if you have little control over your future. But while there's no way to ensure you won't have a recurrence of bladder cancer, you can take steps to manage the stress.

Over time you'll find what works for you, but until then, you might:

• Have a personalized schedule of follow-up tests, and go to each appointment. When you finish bladder cancer treatment, ask your doctor to create a personalized schedule of follow-up tests. Before each follow-up cystoscopy exam, expect to have some anxiety. You may fear that cancer has come back or worry about the uncomfortable exam. But don't let this stop you from going to your appointment. Instead, plan ways to cope with your concerns in the weeks and days leading to your appointment. Write your thoughts in a journal, talk with a friend or use relaxation techniques, such as meditation.
• Take care of yourself so that you're ready to fight cancer if it comes back. Take care of yourself by adjusting your diet to include plenty of fruits, vegetables and whole grains. Exercise for at least 30 minutes most days of the week. Get enough sleep so you wake feeling rested.
• Talk with other bladder cancer survivors. Connect with bladder cancer survivors who are experiencing the same fears you're feeling. Contact the American Cancer Society at 800-ACS-2345, or 800-227-2345, to ask about support groups in your community. Or contact CancerCare at 800-813-HOPE, or 800-813-4673, for information on telephone-based support groups. Or go online — message boards, such as the American Cancer Society's Cancer Survivors Network and the Bladder Cancer WebCafe, are another option.

Alternative medicine

No complementary or alternative bladder cancer treatments have been found to cure bladder cancer. But doctors are studying ways to prevent bladder cancer, including some complementary and alternative approaches. If you're worried about your risk of bladder cancer or that your cancer could recur, you may be interested in trying complementary and alternative treatments. Talk to your doctor about your options.

Vitamins
Fruits and vegetables are the safest way to get your vitamins. Some research suggests larger doses of certain vitamins, such as vitamin E, in pill form may help reduce the risk of bladder cancer. Studies of vitamin E showed a reduced risk of bladder cancer in people who took supplements for 10 years.

More study is needed to understand what dose is safest and most effective. Until then, talk to your doctor about the best way to get the vitamins you need. And if you're interested in vitamin supplements, ask your doctor about what doses may be reasonable.

Green tea
Drinking green tea has been linked to many health benefits. But whether it can reduce the risk of bladder cancer isn't clear. Animal studies have shown promise, but studies in humans have been mixed. For example, one study showed that people who drink the most green tea have a reduced risk of bladder cancer, while another study found that drinking green tea over many years increased the risk of bladder cancer. More study is needed to understand whether green tea is helpful or harmful when it comes to preventing bladder cancer.