Bladder cancer is the growth of abnormal tissue (tumour) in the bladder. There are several stages of bladder cancer. Your treatment and experience will depend on the specific characteristics of the tumour (referred to as “staging” the tumour) and the expertise of your medical team.
This section provides general information about bladder cancer, diagnosis, and various treatment options. Discuss with your doctor what is best in your individual situation.
What is the function of the bladder?
The urinary bladder (referred to as ‘the bladder’) is the organ that collects and stores urine produced by the kidneys (Fig. 1a & 1b). It is a hollow stretchy bag made of muscle tissue that sits on the pelvic floor muscles. The bladder expands as urine from the kidneys collects before being passed out of the body through the urethra (Fig 2.).
Signs and symptoms
Blood in the urine is the most common symptom when a bladder tumour is present. Tumours in the bladder lining (non–muscle-invasive) do not cause bladder pain and usually do not present with lower urinary tract symptoms (urge to urinate, irritation).
If you have urinary tract symptoms such as painful urination or need to urinate more often, a malignant tumour might be suspected, particularly if an infection is ruled out or treated and this does not reduce the symptoms. Muscle-invasive bladder cancer can cause symptoms as it grows into the muscle of the bladder and spreads into the surrounding muscles. Symptoms like pelvic pain, pain in the flank, weight loss, or the feeling of a mass in the lower abdomen may be present in some cases when tumours are more advanced.
Your doctor will take a detailed medical history and ask questions about your symptoms. You can help your doctor by preparing for the consultation.
- Make a list of your previous surgical procedures.
- Make a list of the medications that you take.
- Mention other diseases and allergies that you have.
- Describe your lifestyle, including exercise, smoking,
alcohol, and diet.
- Describe your current symptoms.
- Note how long you have had the current symptoms.
Because blood in the urine is the most common symptom when a bladder tumour is present, your doctor will test your urine to look for cancer cells and to exclude other possibilities like urinary tract infections. Your doctor may refer to this test as ‘urinary cytology’.
Physical examination does not reveal non–muscle-invasive bladder cancer, and seldom reveals a mass if cancer has advanced to the muscle-invasive stage. If muscle-invasive bladder cancer is suspected, your doctor should perform rectal and, for women, vaginal examinations by hand (bimanual palpation).
In addition, your doctor will do a series of tests to make the diagnosis.
Cystoscopy is the main test used to diagnose bladder cancer. It allows your doctor to look at the inside of your bladder and urethra using a thin, lighted tube called a cystoscope.
Computed tomography (CT scan) urography gives your doctor information about possible tumours in the kidneys or ureters, furthermore information about the lymph nodes and abdominal organs.
CT urography cannot detect small or superficial tumours (CIS). If small or superficial tumours are suspected further tests are needed.
Like CT scans, MRI scans show detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. MRI images are particularly useful in showing if the cancer has spread outside of the bladder into nearby tissues or lymph nodes.
Intravenous urography (IVU) is another imaging technique for examining the urinary tract. IVU may be used for the assessment of the upper urinary tract when CT-urography is not available. It cannot detect small or superficial tumours (CIS), and it’s not recommended for detecting lymph nodes or invasion of neighbouring organs.
Ultrasound is a non-invasive diagnostic tool that can visualize masses larger than 5-10mm in a full bladder. It cannot detect very small or superficial tumours (CIS). This study does not require intravenous contrast; however, ultrasound cannot replace CT urography or cystoscopy.
Bladder tumours are classified by tumour stage and subtype and by grade of aggressiveness of the tumour cells. Staging is a standard way to describe the extent of cancer spread. The kind of treatment you receive will depend on these elements.
Non-muscle invasive bladder cancer
Transurethral resection of bladder tumour (TURBT)
TURBT is the surgical removal (resection) of bladder tumours. This procedure is both diagnostic and therapeutic. It is diagnostic because the surgeon removes the tumour and all additional tissue necessary for examination under a microscope (histological assessment). TURBT is also therapeutic because complete removal of all visible tumours is the treatment for this cancer. Complete and correct TURBT is essential for good prognosis.
TURBT can eradicate stage Ta or T1 tumours, but some tumours commonly recur and can progress to invasive cancer. Intravesical (within the bladder) instillation treatment after TURBT should be considered for all patients.
With intravesical therapy for bladder cancer, drugs are put directly into the bladder through a catheter, instead of being injected into a vein or swallowed. Both immunotherapy and chemotherapy drugs can be given this way.
Muscle-invasive bladder cancer
Removal of the urinary bladder (cystectomy)
The mainstay of treatment for muscle-invasive bladder cancer is surgical removal of the urinary bladder.
Your doctor has several reasons for recommending removal of the whole bladder:
• Presence of a muscle-invasive tumour
• Presence of a tumour that grows aggressively (high grade), that has multiple cancerous areas (multifocal), or that is superficial, but has recurred after chemotherapy or immunotherapy
• Failure of or recurrence after a bladder-sparing approach (chemoradiation) or the occurrence of major side-effects
• Symptoms like bleeding or pain in patients with incurable disease
To evaluate and weight your individual risk of undergoing removal of the bladder, work with your physician to consult a multidisciplinary team (for example, urologist, surgeon, anaesthesiologist, nurse practitioner, general practitioner, cardiologist).
Factors like your biological age (your body’s performance as it ages, measured as performance status or life expectancy) and other diseases that you have (diabetes, heart disease, high blood pressure) are also important. Patients older than 80 years of age have more problems recovering from such an operation. Physicians use special indexed scores to assess the risk of patients undergoing this stressful operation.
Prior abdominal surgery or radiotherapy makes surgery more difficult but is rarely a reason not to have surgery. Being overweight does not influence survival after surgery but does influence the risk of complications from wound healing.
Removal of the urinary bladder includes removal of the bladder, the endings of the ureters and the pelvic lymph nodes. Depending on factors like tumour location and type of urinary diversion part of the adjacent gender-specific organs (the prostate and seminal vesicles in men; the entire urethra, adjacent vagina, and uterus in women) are removed. Men should be aware that prostate cancer is sometimes found in removed prostates but generally does not affect long-term survival or treatment.
Chemotherapy before removal of the bladder
Chemotherapy is administered before bladder removal to potentially shrink the tumour and kill cells that have already entered the blood or lymph nodes.
Chemotherapy before the operation may be recommended for patients with muscle-invasive disease. It is also necessary if tumours are large (>3 cm) or if signs indicate that cancer has spread to the lymph nodes (metastatic disease) and the goal is treatment of the disease. The decision to administer chemotherapy is made by a multidisciplinary team (including an oncologist, a urologist, and a radiologist).
Adequate kidney function is necessary. Potential side-effects are usually monitored and managed by an oncologist.
A good response to chemotherapy improves survival but does not change the need for surgery. Although chemotherapy is currently advised before the surgery, physicians are unable to identify who will definitely benefit from chemotherapy before removal of the bladder.
Chemotherapy after removal of the urinary bladder
If a tumour is large (>3 cm), or could not be fully resected, or if cancer has spread to the lymph nodes (determined by the pathologist), chemotherapy after removal of the bladder is an option. Cancer that has spread to the lymph nodes indicates systemic disease and may need systemic treatment (with chemotherapy) in certain cases.
A bladder-sparing approach is currently used in a minority of cases worldwide but deserves consideration. Bladder preservation can be achieved at the cost of multiple therapies, including their side-effects. Transurethral resection of the bladder tumour (TURBT) and radiation is used to cure or control the tumour locally. Chemotherapy is used to treat the cancer cells that might already have spread within in the body (systemic disease). The goal is to preserve the bladder and its function as well as quality of life without compromising cancer treatment.
Studies in selected patient groups have shown good results for bladder-sparing approaches, about a third of patients still undergo bladder removal after failure of a bladder-sparing treatment.
Transurethral resection of bladder tumour
If you cannot undergo extended surgery, TURBT is possible if the tumour invades only the inner muscle layer of the bladder. With high recurrence and progression rates, this treatment alone cannot be considered a good option for controlling the disease long term.
Radiation therapy combined with sensitizing chemotherapy is a reasonable alternative for patients who
refuse or are not candidates for bladder removal. Evaluation for this approach will consider general
fitness (life expectancy), kidney fun tion, prior radiation, prior abdominal operations, and history of other cancers. A consultation with a radiation oncologist is advisable prior to deciding on this treatment.
Radiation therapy is an option for preserving the bladder in patients who are not candidates for surgery or who do not want surgery. Results from radiotherapy alone are worse than those from complete removal of the bladder, but if combined with chemotherapy (chemoradiation), acceptable results can be achieved. Side-effects include mild to strong irritation of the bladder and digestive tract as well as incontinence, increased risk of infections, and fistulas (abnormal passages that develop between organs).
Chemotherapy alone has only limited results and is not recommended as a sole treatment.
Prognostic factors and treatment decisions
If your bladder cancer has spread to another body organ (Fig. 4), treatment is unlikely to cure you. Treatment options are limited to controlling the spread of disease (metastasis) and reducing symptoms.
In 90-95% of bladder cancer cases the histological type is urothelial carcinoma. Chemotherapy that contains platinum is the most effective treatment against this type of cancer.
Chemotherapy combinations like MVAC (which uses the drugs methotrexate, vinblastine, Adriamycin
[doxorubicin], and cisplatin) or gemcitabine and cisplatin are prescribed most often. These treatments have side-effects that must be considered carefully if you cannot recover from your illness and the goal is to optimize your quality of life. Limited ability to perform daily activities (low performance status), other illnesses, or decreased kidney function could make you ineligible for these chemotherapies.
If you have reduced kidney function and cannot take the drug cisplatin, combinations like gemcitabine and carboplatin or M-CAVI (which uses the drugs methotrexate, carboplatin, and vinblastine) are slightly less effective options for treating bladder cancer.
Should your disease recur or progress while taking these therapies, treatment can be changed to another type of chemotherapy, but since there is no standard in this case, the choice will depend on you treating physician. Additional surgery to remove a metastatic or recurrent tumour mass is used only to relieve pain or obstruction and will not cure the disease. Radiotherapy can also be used to treat symptoms like pain or recurrent bleeding (haematuria).
Some types of chemotherapy are quite intensive and can have a lot of side-effects. If you are not fit or if you feel unwell from the cancer, these side-effects can be quite severe. Older patients in particular may benefit from less intensive types of chemotherapy.
Treatment of bone metastases
When bladder cancer has spread to the bone, skeletal complications can occur, such as weakening of the bones or pathological fractures from minor incidents or everyday activity. This causes pain and can have a detrimental effect on your quality of life. Your doctor may suggest radiotherapy, or drug treatment to help strengthen your bones and control the pain.
Access to clinical trials
All patients with a diagnosis of recurrent or metastatic bladder cancer, and particularly those whose prior chemotherapy has been unsuccessful, should be considered for centres where clinical trials are available.
A limited but increasing number of studies are available in various settings for patients who have never
had chemotherapy as well as pre-treated patients. In addition, the recent experimental use of drugs called ‘immune checkpoint inhibitors’ in advanced bladder cancer appears effective in a subset of patients with this disease.
Access to clinical trials should be the first option to discuss with your physician. The therapeutic decision is made after reviewing thorough information on the pros and cons of each option and depending on the individual patient and disease characteristics.
Deciding on treatment
If treatment is intended to slow down the cancer and control the symptoms, deciding what treatment is best for you—or whether to have treatment at all— can be very difficult.
You will need a clear understanding of what drug treatment can do for you at this stage and how it will
affect your quality of life.
Talk to family or friends and people who are close to you. It can help to discuss things with someone
outside your inner circle. Your doctor may be able to refer you to a counsellor or specialist nurse.
Efforts are being made to promote patient advocacy for bladder cancer. Ask your oncologist if a bladder cancer patient representative is available near you.
Treatment of recurrence
When the tumour comes back
Local recurrence takes place in the soft tissue where the bladder has been before removal or at the site of the lymph nodes that were removed. This is due to the fact that even after removal of the local pelvic lymph nodes, some nodes are left in place. Most local recurrences appear within the first 2 years. Local recurrence after complete removal of the urinary bladder is associated with poor overall prognosis but can occasionally be treated (surgery, chemotherapy, targeted radiation therapy).
If the cancer recurs outside the pelvis, it is a distant recurrence. This type of recurrence is fairly common after bladder removal in patients with high risk of recurrence (larger tumours, positive resection margins, involvement of the removed lymph nodes). Distant recurrence happens mostly within the first 2 years after bladder removal. Sites of distant recurrences are lymph nodes, lungs, liver, and bones. Distant recurrence can be treated only by chemotherapy. Single or very few metastases may be surgically removed in addition to systemic treatment (= chemotherapy).
Medical trials might be available for your situation. Ask your doctor about these options.
Recurrence in the urothelial tract (urethra and ureters)
After complete removal of the bladder, the cancer can recur in the urethra, ureters and pyelum (urothelial tract). Most recurrences of the urothelial tract happen within the first 3 years after the operation. This type of recurrence is relatively rare.
If possible, a local treatment should be chosen to eliminate the cancer, unless systemic disease is suspected. In that case, chemotherapy or palliation should be used.
In case of bladder preserving therapy and a superficial (non–muscle-invasive) recurrence, washing the bladder with drugs to prevent the growth or spread of cancer cells (instillation therapy) is advised.
Risk factors for recurrence in the urethra after removal of the bladder:
• Prior superficial (non–muscle-invasive) bladder cancer
• Multiple bladder tumours
• Tumour involvement of the bladder neck (and/or the prostate in men)
• An unused/residual urethra after incontinent urinary diversion
• Local recurrence in the lower pelvis
Although routine removal of the urethra (urethrectomy) is considered overtreatment, monitoring of the urethra is indicated in men.
Risk factors for recurrence in the ureters after removal of the bladder:
• Prior superficial (non–muscle-invasive) bladder cancer
• Multiple bladder tumours
• Tumour involvement at the opening (orifice) of the ureter
• Local recurrence in the pelvis
For patients with risk factors for urothelial recurrences, stringent or adapted monitoring is indicated.
After any kind of cancer treatment follow-up is essential to minimize complications and to detect and treat recurrences early. After complete removal of the bladder or other treatments, you will be asked to see your general practitioner, urologist, oncologist, radiologist, or a nurse practitioner at specific, fixed time intervals for monitoring and evaluation.
A specialist should have the lead in coordinating and interpreting all of the results from the follow-up visits. That specialist—in most countries, the urologist— should also be the main contact for questions about your disease or related issues.
Symptoms of complications
After monitoring of cancer, the functional results must be observed and controlled. Functional complications after bladder removal include vitamin B12 deficiency, high acid levels in the blood (metabolic acidosis), worsening kidney function, urinary infections, urinary stone formation, tightening of stoma openings (stricture), other stoma complications in patients with ileal conduit diversions (leakage, inversion, skin irritation), neobladder continence problems, and emptying dysfunction. Ask your doctor for information about the major symptoms of these complications and their prevention.