Bladder Cancer

Bladder Cancer

What is Bladder Cancer?

Urinary bladder is a reservoir which stores urine coming from kidneys temporarily. Cancer arising from the cellular lining of the bladder would be called as carcinoma bladder or bladder cancer.  

Does bladder cancer spread fast?

Bladder cancer arises from the inner layer of the wall and slowly goes deeper involving muscular layer of the bladder and eventually comes out locally from the outer layer to invade local organs. This type of spread is called contagious spread and apart from this, it can spread through lymphatic channels as well as blood channels (hematogenous) to involve other body parts leading to metastasis. Overall, it is relatively fast growing cancer as compared to prostate cancer but individual cancer in different person behaves differently due to variable biology or aggressiveness of the cancer.

What kind of pain does bladder cancer cause?

In the initial stages, it may manifest with blood in urine or symptoms of frequency or night time urination or rarely recurrent infections. Vague pain in the lower abdomen may happen but majority of the times it is painless blood in urine as a presenting symptom. In late stages in stage IV, it may manifest with bony pains or pain related to the site of spread or metastasis.

What are the types of bladder cancer?

Most common bladder cancer is transitional cell carcinoma (TCC) of urinary bladder. Apart from that, there are some variations e.g. squamous cell carcinoma, adenocarcinoma. Histology wise there may be some variations of urothelial carcinoma which may behave differently due to variation in the biology of disease e.g. lymphoepithelioma like, micropapillary, sarcomatoid and plasmacytoid.

What are the different stages of bladder cancer?

For common understanding, bladder cancer management is based upon whether it is muscle invasive type (MIBC) or non-muscle invasive type (NMIBC). Stage-wise it goes from inner to outer layer and stage IV would be in case of distant spread. NMIBC would be less than or equal to T1 and MIBC would be at least T2 or more.

What are the odds of bladder cancer returning?

If we understand that the cellular lining of bladder is prone to have cancer formation due to genetic susceptibility, we can easily correlate that, the chance of bladder cancer coming back is very high. This stands true for non-muscle invasive bladder cancer (NMIBC), as the treatment in initial stage is bladder conservative modality. In clinical terms it would be labelled as recurrence. The biology of the cancer would be correlating with percentage risk for recurrence as well as increase in the stage which is called progression. ‘Recurrence’ and ‘progression’ are the two main determinants for the management of NMIBC. Depending upon the stage and the grade of the cancer the chance of recurrence varies between 31% and 78% at five years and the chance of progression varies between 1% and 45% at five years.  

What are the signs and symptoms of bladder cancer?

Bladder cancer would usually present as painless hematuria (blood in urine). In the initial stages, it may manifest with either blood in urine or symptoms of frequency or night time urination or rarely recurrent infections. Blood in pee can be either visible to naked eye (gross) or microscopic (picked up on microscopic examination on urine test).

Where does bladder cancer spread first?

Locally it does spread to adjacent organs and distant spread may happen either by lymphatic origin or hematogenous origin. Lymphatic spread will be happening to the lymph gland (lymph nodes) in the pelvis or the abdomen and hematogenous spread can involve solid organs like liver, lung etc.

What are the causes of bladder cancer?

Genetic susceptibility is indeed an important factor for causal association. In addition, certain modifiable factors do account for the pathogenesis. Smoking is one of the most important association and nearly half (50%) of the bladder cancers would be smokers. The reason for the same being aromatic amines and polycyclic aromatic hydrocarbons which are toxic to the bladder cell which are excreted in the urine of a person who smokes. Even low tar cigarettes are responsible for this after long term exposure. Environmental exposure to the toxic agents is second most important factor accounting to nearly 10% of the bladder cancer cases. These chemicals can be associated with petroleum, dye, paint, metal or rubber industries. A rare variant of squamous bladder cancer is seen in countries which have high incidence of Schistosomiasis, a parasitic disease involving bladder also called as bilharziasis.

Who is at high risk for bladder cancer?

Chronic smokers and industrial workers are the two most vulnerable groups for bladder cancer and family association is another small risk factor.

How can we diagnose a bladder cancer?

Bladder cancer is diagnosed on imaging (ultrasonoraphy / CT scan) plus direct visualisation of the lesion by a camera test called cystoscopy. Biopsy needs to be taken during the cystoscopy for pathological confirmation. Main aim for diagnosis is first to confirm the cancer on pathological examination of biopsy sample and second to stage the disease for ruling out local or distant spread. CT scan of the abdomen with contrast and chest is required for the same.

Is bladder cancer curable if caught early?

Depending upon the stage of diagnosis, bladder cancer prognosis would vary. In the stage before metastasis, intention of treatment would be for cure. Approximate 5 year overall and cancer specific survival would be nearly 66-7-% after definitive treatment of bladder cancer in muscle invasive stage. In non-muscle invasive stage, prognosis is better and hence the aim would be to diagnose it in earlier stage.

What are the available treatment options of bladder cancer?

Bladder cancer management would revolve around the stage at which it is picked up. In any case, distant spread is ruled out before definitively treating patient. In non-muscle invasive stage bladder cancer (NMIBC), bladder conservative modalities would be preferred. This involves transurethral resection of bladder tumor (TURBT) which is a procedure done per urethra (scar less) to resect the tumor from inner side of the bladder under the guidance of camera. At this stage patient may need addition of intravesical chemotherapy (Mitomycin D) or immunotherapy (BCG) in the bladder on regular intervals in addition to strict surveillance camera tests (cystoscopy) of the bladder as a part of follow up. In a very high risk NMIBC, complete removal of the bladder is also an alternative depending upon the patient preference.

In case of muscle invasive bladder cancer (MIBC), the choice varies between surgical removal of bladder completely (radical cystectomy) versus bladder conservative modalities (combined modality treatment CMT). Complete removal of bladder would need a surgery which essentially has two components. First part deals with removal of the bladder and prostate in men and bladder and uterus and ovaries in females (anterior exenteration). Organ sparing (ovary and uterus) radical cystectomy in females is also an alternative in case of younger age of onset. Second part involves reconstruction to create a channel for passing urine. This is called as urinary diversion which can be either conduit or neobladder. Ileal conduit will be a small segment of bowel which opens on the abdomen and drains urine in the collecting bag. Neobladder is another way of diverting the urine in which the bowel segment is used to create a new bladder inside the abdomen and it is joined with the water pipe (urethra) for passing urine in natural manner. Both these operations have pros and cons of itself and a thorough counselling is necessary before subjecting an individual for the respective procedure. Chemotherapy either before the surgery (neoadjuvant) or after the surgery (adjuvant) may be required based upon the indications after the radical cystectomy.

Combined modality of treatment is directed towards conserving the bladder by combination of transurethral resection (maximal TURBT) plus chemotherapy plus radiation therapy. Radical cystectomy versus CMT has variable outcomes in different age groups and both the approaches would need at length discussion for the complete process for final decision making.

A rare variant of adenocarcinoma of bladder needs different type of surgery named partial cystectomy which can be done either open or laparoscopic or robotic assistance.

How does Robotic Surgery for bladder cancer work? 

Radical cystectomy can be done by either open manner or minimally invasive manner (laparoscopic or robotic). Robot assisted radical cystectomy is one of the operations adapted by many centres across the globe due to distinct advantage of having better precision, magnified vision, lesser blood loss without requirement of blood transfusion, painless recovery. Overall hospital stay is lesser (1-1.5 days) in robotic cystectomy than open cystectomy. Requirement of ICU in post-operative phase is also lesser and certain complications (grade 3) are lesser with robotic cystectomy at 90 days. The complete robotic approach for radical cystectomy as well as for urinary diversion is a scar-less surgery in the purest form and has advantages of fastest recovery in post operative phase. Cancer control point of view, there is level 1 evidence now that robotic approach is equal to conventional approach and needless to say that robotic approach scores over open approach in postoperative recovery phase for fastest recovery. Overall, it is very safe and effective way of performing a radical cystectomy with a very bright future in years to come.

Prevention of bladder cancer

Key step in preventing bladder cancer is to cut down upon the risk factors. Two most important would be smoking and exposure to chemicals. Apart from this, healthy dietary habits and adequate water intake would be desirable.