Bladder Cancer

What are the risks for developing bladder cancer?

    • Smoking – the most common cause of bladder cancer
      • The greater the amount of cigarettes smoked, the greater the risk of bladder cancer
    • Chronic bladder irritation
      • Recurrent urinary tract infections (low risk)
      • Long term catheter use
      • Long term bladder stones
    • Chemical exposures:
      • Certain dyes used in some industries
      • Especially aniline dyes
    • Radiotherapy exposure to the bladder
    • Cyclophosphamide use

What types of bladder cancer are there?

    • Urothelial carcinoma (or TCC – transitional cell carcinoma) is far and away the most common type (>90% cases)
    • Squamous cell and adenocarcinoma are occasionally found

How is bladder cancer usually detected?

  • Blood in the urine (haematuria) may be present
    • Macroscopic – visible to the eye
    • Microscopic – detected on urine dipstick or urine test
  • Urinary symptoms may be present, particularly:
    • Urgency – compelling desire to void
    • Frequency – frequent passage of urine

If bladder cancer is suspected, what tests will be necessary?

  • Baseline blood tests to check kidney function
  • Urine tests
    • Culture – to rule out infection
    • Cytology – checks for cancerous cells in the urine
  • X-rays
    • Kidney and bladder ultrasound – may detect a mass within the bladder
    • CT IVP/Urogram – a CT scan with contrast specifically designed to look for any abnormalities within the kidney and ureters (tubes connecting the kidney to bladder)
  • Cystoscopy
    • Ultimately, all patients with blood in urine or suspected of having bladder cancer will need a cystoscopy
    • This involves a telescopic inspection of the bladder
    • It is the only sure way of detecting or ruling out bladder cancer as both ultrasound and CT are not 100% accurate

If bladder cancer is detected at cystoscopy, how is it treated?

  • The majority of bladder cancers can be treated at the time of cystoscopy, a procedure called a Trans Urethral Resection of Bladder Tumour (TURBT)
  • A small loop is used which is connected to the cystoscopy to shave away the tumour
  • The tumour will be sent for analysis to confirm the diagnosis
  • Depending on the size of the tumour, a catheter may be left in over night to wash out any blood after the resection

If bladder cancer is confirmed, what other treatments may be necessary?

  • This will be determined by 2 major factors of the tumour
    • Grade of tumour – low grade or high grade
    • Stage of tumour – how deeply the tumour has grown through the bladder wall
  • Low grade tumours
    • Are the most favourable tumours, however bladder cancers have a tendency to recur
    • Other than the TURBT, usually no other treatment is required
    • As these tumour can recur, you will require regular surveillance cystoscopies. The first cystoscopy will usually be 3 months after your TURBT.  If that is clear then an annual cystoscopy is usually indicated.
    • If tumour recur more frequency, then more regular cystoscopies ma be required
  • High grade tumours:
    • Are more aggressive tumours and require closer surveillance and more aggressive treatment
    • Usually a repeat cystoscopy and biopsy will be required 6 weeks after the initial resection to rule out residual cancer and ensure that the cancer has not infiltrated the muscle wall of the bladder
    • If the cancer is superficial (has not grown into the bladder muscle), then usually you will require a chemotherapy type agent (BCG or Mitomycin C) instilled into the bladder for a period of 6 weeks. These drugs are designed to reduce the chances of the cancer recurring as well as reducing the chance of the cancer growing deeper into the bladder wall
    • BCG and Mitomycin C are both instilled into the bladder via a catheter.  A typical course involves a once a week dose for 6 weeks.
    • Maintenance BCG may be required in some cases to further reduce the chance of tumour recurrence and progression.  This typically involves a once a week dose for 3 weeks usually at 3-6 month intervals for at least 1 year.

What are the typical side effects of BCG treatment?

  • Common side effects of BCG are usually limited to urinary symptoms, including: frequent need to void, feeling of urgency, burning on passage of urine, blood in urine, low grade fever
  • Serious complication are very uncommon but can occur. This can involve higher temperatures and serious urine infections. Rarely, BCGosis (essentially a re-activation of a Tuberculosis infection) can occur which may require 6-12 months of treatment with TB medications. Fortunately, this is very uncommon.

What if the cancer has grown into the muscle of the bladder wall?

  • When the cancer has grown into the muscle of the bladder wall (stage T2), the cancer can no longer be cured with a TURBT
  • Staging x-rays (CT chest/abdomen and bone scan) will be arranged to rule out any spread (metastasis) of the cancer
  • If there is no metastasis the most effective treatment for muscle invasive bladder cancer is a cystectomy (surgical removal of the entire bladder). This usually requires the urine being diverted into a short isolated segment of small intestine (ileal conduit) which is brought out at the skin as a stoma.  A urine bag is attached at the skin around the stoma to collect the urine.
  • Sometimes, in younger patients requiring a cystectomy a new bladder (neo-bladder) can be created out of intestine rather than a ileal conduit.  The neo-bladder can be re-attached to the urethra so that no external device/bag is required.  This is more complex surgery with a higher complication rate but may be more appropriate in selected patients.  The neo-bladder will not function like a native bladder and you will be required to drain the neo-bladder regularly with a catheter.
  • For patients, unfit for a cystectomy or unwilling to undergo a cystectomy, radiotherapy (with or without chemotherapy) is an alternative treatment.  Radiotherapy can be an effective treatment for some muscle invasive bladder cancer, however for more locally advanced cancers the best chance of cure long term remains cystectomy.