Bladder cancer is very common. In fact, it is the 7th most common cancer in the United States and is diagnosed in about 80,000 patients every year.
The cancer arises from the cells of the lining of the bladder. Determining if your tumor is aggressive or non-aggressive and whether or not it is invading into the bladder are the most important factors in making your treatment plan. The primary distinction is whether the tumor invades into the muscle layer of the bladder wall. Non-muscle-invasive bladder cancer (NMIBC) represents about 75% of bladder cancers and muscle-invasive bladder cancer (MIBC) accounts for the remaining 25%. NMIBC have a recurrence rate around 50% after initial tumor treatment and therefore careful long-term surveillance is important. Although non-aggressive NMIBC progress only rarely, about 20% of aggressive NMIBC can become muscle invasive. Bladder cancer is often asymptomatic though it sometimes causes need to urinate frequently or blood in the urine.
Causes and Risk Factors
Tobacco smoking is the most important risk factor. It is strongly associated with development of bladder cancer as well as bladder cancer recurrences. Current smokers are 4 times more likely to develop bladder cancer than nonsmokers, and former smokers are twice as likely.
When to Speak with a Urologist about Bladder Cancer
You should talk to a Urologist about Bladder Cancer if you have noticed blood in your urine or if a bladder tumor has been identified on imaging.
What to Expect when Seeking Treatment
In addition to history and physical examination, initial assessment includes urine testing for culture to rule out infection and sometimes cytology to assess for high-grade cancer cells. Imaging, most commonly with CT urogram, must be obtained to examine the kidneys and ureters (the tubes that drain the ureters). There is a 5% risk of another cancer in these locations when bladder tumors are discovered. All bladder tumors should be completely removed using a cystoscope inserted through the urethra in a procedure called transurethral resection of bladder tumor (TURBT). Further management is based on the tumor pathology and risk category.
Treatment Options
Non-Muscle-Invasive Bladder Cancer
NMIBC can be managed with local therapies, and certain low-risk types require only close surveillance. Treatments are designed to lower the odds of recurrence and progression. For smokers, smoking cessation is important to limit risk of recurrence.
Mitomycin C is a chemotherapy agent that can be instilled into the bladder shortly following TURBT. Although it does not prevent progression, this medication has shown benefit for low-risk NMIBC, and a single dose decreases risk of recurrence to around 25%. Patients with tumors that appear high grade or with bladder perforation during TURBT are not candidates for Mitomycin C.
Any recurrent or high-grade NMIBC requires treatment with a medication instilled into the bladder called BCG. This is a weakened bacteria strain that stimulates your own immune system to attack cancer cells. BCG is administered into the bladder by brief catheterization weekly for six weeks to reduce recurrence by about 50% and to reduce progression. For those patients with a complete response that tolerated treatment, maintenance BCG with three-week courses can be considered every 3-6 months for 1-3 years.
Once cancer is removed, surveillance is conducted with regular cystoscopy using a small flexible telescope to examine the lining of the bladder. The first surveillance cystoscopy should be completed around 3 months after initial treatment. For patients with high-grade NMIBC, repeat surveillance should be completed every 3 months for 1 year, then every 6 months for the second year and then annually thereafter. Cytology testing is obtained regularly to check for microscopic cancer cells in the absence of visible tumor on cystoscopy. Upper tract imaging should be obtained every two years. Low-grade NMIBC requires less frequent surveillance.
Fortunately, your odds of surviving NMIBC are quite good with extremely high rates of cancer-specific survival at 10 years for non-aggressive disease and around 85% cancer-specific survival at 10 years for aggressive disease.
Muscle-invasive Bladder Cancer
If you have this type of bladder cancer, unfortunately Intravesical therapies with medications instilled into the bladder are not enough to control your tumor. The standard recommendation in these cases is for surgical removal of the entire bladder.
Following diagnosis with TURBT, you will need complete staging including a CT scan of the chest to check for spread of your cancer outside of the bladder.
Taking care of your overall health as much as possible is important in helping you get through your bladder cancer treatment. You should try to maintain good nutrition and, if you are a smoker, stop using tobacco. All of this can increase your chances of surviving your cancer.
The gold standard treatment is radical cystectomy with urinary diversion and pelvic lymph node dissection. Chemotherapy prior to cystectomy can provide additional survival benefit. In men, the surgery also involves removal of the prostate and seminal vesicles. In women, the surgery also involves removal of the uterus, ovaries and part of the vagina. The most common reconstructive technique involves routing urine to a stoma on the abdominal wall that continuously drains into an ostomy appliance. Although continent urinary diversions are possible, they dramatically increase both the complexity of the procedure and possible future complications.
The chances of your cancer coming back vary based on your stage and lymph node status. MIBC limited to the muscle has a 25% recurrence rate; MIBC extending beyond the bladder wall has a 40% recurrence rate; and, MIBC that has moved to lymph nodes has a 70% recurrence rate. Systemic recurrences typically cannot be cured with current chemotherapy treatments.
Cisplatin-based chemotherapy before cystectomy has been demonstrated in a large randomized trial to improve overall survival by about 5% (from 60% to 65%) at 9 years of follow-up. Although insufficiently studied, postoperative chemotherapy has not shown a similar benefit. Frailty, impaired kidney function, reduced hearing and heart failure can preclude patients from chemotherapy. Surgery should be performed shortly following chemotherapy.
If you are not healthy enough to undergo surgery, your doctor will discuss other options with you such as using chemotherapy and radiation. This requires very close surveillance with cystoscopy and CT scans every 3-6 months. About 40% of patients progress to cystectomy. Bladder sparing is typically reserved for patients with a single tumor that can be totally resected on TURBT. Bladder sparing has been shown to reduce 5-year survival relative to surgery (28% vs 47%).
It is important to understand that treatments can have a significant quality of life impact with changes in continence, sexual function, bowel function and metabolism. It is also important to understand that cystectomy entails a difficult postoperative period. About 60% of patients experience some complications within 90 days. 20% experience a serious complication and about 30% are readmitted to the hospital. The risk of death during this period is about 4%.