Bladder Cancer: Diagnosis, Staging and Treatment Strategies

June 14 05:00 2023 by admin-blog-kh Print This Article

Overview

Bladder Cancer is one of those rarer cancers. However, if detected late or left untreated, it can metastasize to other parts of the body, making it a serious condition. There are various stages of the disease, and various treatment options. This article will cover all that and more.

Introduction

The bladder is a hollow pouch-like organ in the lower part of the pelvis. It acts as temporary storage for urine generated by the kidneys. The urine is brought from the kidneys to the bladder through two thin pipes called ureters, one each for each kidney. The bladder is made up a lining called urothelium and a wall of muscles behind that. When urine fills up in the bladder, certain receptor cells located inside the wall bladder get stretched. This stimulates the contraction of muscles of the bladder. Then the sphincter (a ring of muscles) of the bladder relaxes after which, the urine is squeezed out of the bladder, through a thin tube called the urethra, to outside of the body.

In majority of the cases, bladder cancer happens when there is uncontrolled growth of cells in the urothelium or lining of the bladder.

Causes

As we know, cancer is nothing but abnormal growth of cells caused by genetic mutation in a particular part of the body. DNA is the chemical that constitutes our genes. Genes control how we look physically (resemblance to our parents and kin). But they do more than that. They also control the growth, functioning and death of cells.

Again, there are 2 types of genes:

• Oncogenes: These help the cells grow, multiply or divide and also remain alive.
• Tumour suppressor genes: These genes help repair problems in the DNA, regulate the cell division and destruction or death of cells.

Certain genetic mutations, which are basically changes in the DNA can trigger oncogenes and suppress or shut-down tumour suppressor genes. This leads to an uncontrolled growth or division of cells, and such a condition is called Cancer. However, one should note that, it takes multiple mutations to cause cancer. When such a cancerous growth occurs in the bladder, it is called bladder cancer.

Risk Factors

• Smoking (both primary and secondary): This is the most prominent risk factor. Chemicals in tobacco are removed by the kidneys and get into the urine. Here, they can irritate the cells of the bladder, eventually triggering bladder cancer.
• Exposure to workplace toxins: Similarly, toxins that are inhaled at the workplace get into the urine, thereon to the bladder and can trigger bladder cancer. Such chemicals include:
  • Aromatic amines: examples include benzidine and beta-naphthylamine: these are used to make dyes for the textiles, cosmetics and printing industry. Workers at such factories as well as hairdressers in salons are exposed to these chemicals.
  • Other chemicals used in manufacture of rubber and paints. So, machinists at these factories and painters who apply these paints are at high risk.
  • Hydrocarbons such as benzene that are used in petrochemicals. So, attendants at gas stations, commercial-vehicle drivers and traffic cops, who are all exposed to petrol and diesel fumes, are at high risk.
• Drugs/Medication: Such as pioglitazone (Actos®) used by diabetics, drugs that contain aristolochic acid, cyclophosphamide (Cytoxan®) used in chemotherapy and drugs used in radiation therapy for cancer can irritate the bladder and trigger bladder cancer.
• Drinking water that contains arsenic
• Not staying hydrated: Drinking enough water or fluids ensures frequent urination that helps flush out toxins in the urine quickly. Not drinking enough fluids, or holding the urine for long, increases the risk of bladder cancer, especially for smokers and those exposed to workplace toxins.
• Race and ethnicity: White Caucasians are at more risk than other races
• Age: People above 55 years of age are at more risk than younger people.
• Gender: Men are at more risk than women. Women are also at risk because blood in the urine, which is one of the symptoms, is generally ignored by women as a gynaecological condition.
• Infections and irritations: Urinary tract infection (UTI), bladder stones, kidney stones and prolonged usage of bladder catheter (used for bedridden patients to drain out the urine) can all irritate or infect the bladder and eventually trigger bladder cancer.
• Parasitic worms that enter the bladder and cause infections (called Schistosomiasis)
• A personal or family history of bladder cancer, or any type of urothelial cancer
• Congenital defects in the bladder (since birth)
• Genetic conditions: Mutations to the RB1 gene, PTEN gene and Lynch syndrome increases the risk.

Types of Bladder Cancer

Based on origin

• Transitional cell carcinoma: The urothelium is called transitional epithelium. So, this type of bladder cancer starts in the urothelium which is the inner-lining of the bladder. 90% of all bladder cancers are of this type, also called urothelial bladder cancer.
• Squamous cell carcinoma: Squamous cells are a type of urothelial cells. This accounts for 5% of the cases, and generally causes when the person has suffered a long bout of irritation or inflammation of the bladder.
• Adenocarcinoma: There are glands which line all organs including the bladder. Adenocarcinomas are cancers that start in these glands. These are rare and account for around 1.5% of all cases.
• Small cell carcinoma of the bladder: Extremely rare type
• Soft-tissue Sarcoma: Rare, starts in the cells of bladder muscles

Based on spread

• Non-invasive: Generally seen close to the surface of the bladder, and in a small portion of tissue.
• Non-muscle-invasive: In this case, the cancer has moved deep into the bladder but not yet spread to the bladder muscles
• Muscle-invasive: In this, the cancer has reached the muscles of the bladder wall and is now spreading into the external tissues of organs close to the bladder.

Stages of Bladder Cancer

• Stage I: also called Early-stage, TA, T1 or CIS: In this, the cancer is limited to the inner lining of the bladder, and just the connective tissue below this lining
• Stage II: In this, the cancer has spread to the wall of the bladder muscles
• Stage III: In this, the cancer has reached the fatty tissue which lies on the outside of organs close to the bladder
• Stage IV: In this, the cancer has spread to the inside of the organs, lymph nodes and bones near the bladder

Symptoms

• Haematuria: blood in the urine that is visible to the naked eye, and also shows up in lab analysis
• Dysuria: Pain or burning sensation before and after urinating. Men may also feel pain in the penis
• Pollakiuria: Urination that is more frequent than normal
• Trouble urinating: The flow may be weak or intermittent
• Frequent bladder infection that does not go away in-spite of taking antibiotics.

Diagnosis

General examinations

• This includes asking questions about the person’s and the family’s medical history
• Physical examinations which include Digital rectal exam (DRE)

Urine lab tests

• Urinalysis: This looks for blood and some other compounds in the urine sample.
• Urine cytology: This looks for cells that indicate cancer or pre-cancer in the urine sample.
• Urine culture: This looks for bacteria in the urine to determine if urine infection is the condition here (considering that bladder cancer and UTI have similar symptoms).
• Urine tumour marker tests: These look for tumour markers, which are specific compounds created by the cancer cells.

Other procedures

• Cystoscopy: This uses an endoscope with lens, video camera and light fitted at the end. This tube is inserted into the bladder through the urethra
• Fluorescence cystoscopy: In this, a drug that gets activated by light is used. This is inserted into the bladder during a regular cystoscopy. Then a blue light is shone inside the bladder. Cancer cells are known to absorb this light-activated drug, and will glow now.
• Transurethral resection of bladder tumour (TURBT): This enables a biopsy of the suspected cancerous tissue

Imaging tests

• Intravenous pyelogram (IVP): This is used to detect tumours of the urinary tract. This test uses a special dye that is visible in an X-ray. The dye is injected into the blood. The kidneys remove this dye, and as and when urine passes through the urinary tract, the dye lights up on the x-ray and shows any abnormalities in the tract.
• Retrograde pyelogram: In this, an endoscope is pushed into the bladder through the urethra and a special dye injected into the bladder. This shows up clearly in the X-ray and reveal abnormalities if any.
• CT scan: A CT scan of the organs in the urinary tract will reveal abnormalities in any of the organs
• MRI scan: Similar to CT scan, but this can reveal if the cancer has metastasized to other organs near the bladder.
• Ultrasound: Using sound waves, the doctor can simulate images of internal organs. This helps check if the cancer has metastasized or not.
• Chest x-ray: This will show if the cancer has spread beyond the diaphragm into the lungs
• Bone scan: This will show if the cancer has metastasized to the bones or not.

Biopsies

• CT-guided needle biopsy: A sample of the suspect tissue is biopsied using a needle. A CT scan helps guide the doctor’s movements.
• Ultrasound-guided needle biopsy: Similar to CT-guided needle biopsy, but uses ultrasound waves rather than CT.

Treatment options

Surgery

• TURBT: This procedure mentioned earlier under Diagnosis can also be used to treat bladder cancer. The tumour is removed using high-energy electric currents or burnt away. This method is called fulguration.
• Radical cystectomy: When the bladder cancer has spread to other organs and is in an advanced stage, then the affected organs must be removed along with the bladder. In men, the seminal vesicles and prostate may also have to be removed while in women, a part of the vagina, the ovaries and even uterus may also have to be removed.
• Urinary diversion: After the bladder is removed, a tube is created or carved out of the intestine and terminated in an external pouch that is worn outside on the body. The urine collects here and must be emptied regularly, similar to urination.

Chemotherapy

Cancer-killing drugs are injected directly into the bladder using a catheter that is inserted into the urethra and pushed all the way into the bladder. This is called an intravesical therapy.

Immunotherapy

This energizes or boost the immune system to help it fight the cancer cells better. This includes the BCG vaccination, PD-1 inhibitor therapy and PD-L1 inhibitor therapy:

Radiation therapy

Targeted therapy

These drugs target genes or genetic changes that are promoting the growth of cancer cells, thereby inhibiting such growth.

Adjuvant therapy

In this, the doctors will use a combination of surgery and either chemotherapy or radiation.

NOTE: Take medications only when prescribed by your doctors, self-medication must be avoided under any circumstances.

Reviewed by Dr Suresh S Venkita, Group Medical Director, Kauvery Hospitals

Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai, Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.

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