Bladder Cancer
Every year, an estimated 50,000 Americans develop bladder cancer and 11,000 die from it. It is the fifth common cancer in American men. It is more frequent in men than in women with a ratio of 3:1. Average age at the time of diagnosis if 65 years. Fortunately, most patients are diagnosed in early stages, when cure is possible.
Cause
Cigarette smoking is responsible factor in up to 50% of the patients who develop this condition.
Chronic bladder infections
Certain medications, if taken for many years (Phenacetin).
Signs and symptoms
Painless bleeding in the urine is the most common sign of this disease. The cancer tissue in the bladder has a tendency to break and bleed.
Diagnosis
When suspected, an endoscopy study of bladder (Cystoscopy) should be performed. This procedure will allow for obtaining a biopsy at the same time. CT scan or Ultrasound examination of the abdomen and pelvis may establish the extent of the cancer.
Staging
Endoscopic ultrasound is a very sensitive study that should be done to determine the depth of invasion of the cancer into the tissues around bladder, as well as evaluation of the local lymph glands. CT Scan of abdomen, as well as bone scans may have to be done to complete the staging work up.
- Stage 0, In situ cancer
- Stage A, Disease that is limited to the inside surface of bladder
- Stage B, Disease that extends though the thickness of bladder
- Stage C, Disease that extends to the outside of bladder
- Stage D, Disease spread to other organs, like bowels, rectum, lungs, liver, etc.
Information obtained from the Cystoscopy examination, along with X rays, CT Scan, etc. will help in determining the best treatment option.
Treatment
Stages 0 and A: Management of the disease relies on surgery, attempting to remove most or all of the cancer form bladder. This is done at the time of Cystoscopy, whereby, the physician is able to see the sites of the disease and can remove them. This procedure is known as Transurethral bladder resection. Additional use of topical chemotherapy to the cancer site, in form of infusing the drugs directly into the bladder, has become an important part of treating very early cancers.
BCG, the tuberculosis vaccine, is another method of local treatment of early stages of bladder cancer. The mechanism action of BCG is rather unclear, but it seems it may have a stimulating effect on the immune cells in the bladder wall and cause indirect damage to the cancerous tissue. BCG contains bacterial particles and the bladder tissue reacts to these particles, in order to destroy them. This response to bacteria may also damage and destroy the superficial cancer cells.
Chemotherapy drugs (Thiotepa, Adriamycin) are introduced into the bladder by way of using a bladder catheter (which is plastic rubbery tube that is inserted into the penis and further up into the bladder.)
Stage B: The treatment of choice for these patients is aggressive surgery and complete removal of the bladder. In certain patients, in whom the disease is limited to one site in the bladder, a partial removal of bladder may be appropriate.
Stage C: This stage bladder cancer is mostly diagnosed after the surgery, when the removed bladder is studied by the pathologist. Such patients should be best treated with radiation and chemotherapy.
Stage D: When the disease is widely spread to different places, patients are best treated with radiation and chemotherapy.
Radiation has two roles in treatment of this cancer.
- Help with the local control of the cancer and to increase the cure rate. At times, this is achieved by combining it with chemotherapy a.
- It is also used to control the symptoms of the advanced disease, for treatment of metastasis to bones, etc.
Chemotherapy is used in a variety of situations:
- Topical chemotherapy to the cancer site, in form of infusing the drugs directly into the bladder for stage 0-A.
- Prior to surgery, and combined with radiation
- After the surgery, and combined with radiation
- For patients, in whom the disease is not cured with surgery or has reoccurred, and patients with stage D.
Methotrexate, Vinblastine, Adriamycin, Cytoxan, Cisplatinum, Ifosfamide, Taxol, Thiotepa, 5-FU and Leucovorin are among the most commonly used drugs for bladder cancer. These drugs are used in combination and can have moderate to severe toxic effects.
Pattern of Spread
If left untreated, or if it fails to respond to treatment, bladder cancer can spread to the liver, Lymph glands in the abdomen, lungs and almost anywhere else.
Prognosis
When diagnosed early, bladder cancer is highly curable, otherwise, it carries a poor prognosis. Patients with advanced stages, do respond to treatments, however cure is not possible.
Special Situations
Patients with advanced bladder cancer may develop any of the following complications.
- Bone metastasis
- Lung metastasis
- Pain
- Urinary obstruction
- Kidney failure
Survival
Survival of patients with this cancer depends on the type and extent of the cancer at the time of initial diagnosis. Majority of patients with early stages can be cured with surgery alone. In patients, in whom cure is not possible, survival could vary from months to years, depending on the extent of cancer and overall condition of the patient as well as their response to treatments and the duration of their response.
Follow up
After completion of treatment, in any combination that might have taken place, patients need to remain under surveillance for possibility of recurrence of cancer. Follow up shall be scheduled on a regular basis and initially every 1-3 months for 1-2 years. The frequency of follow up will depend on the condition of the patients and their disease. In follow up visit, patients are examined and blood tests are obtained. Cystoscopy as well as a CT scan of abdomen are obtained at intervals.
Treatment of advanced or recurrent disease will depend on the stage and extent of the reoccurred disease. Most patients are treated with chemotherapy, using the same drugs as mentioned above. Radiation therapy may be helpful in managing painful or symptomatic areas where the cancer has spread to. If patients experience pain, different pain medications could be used to alleviate the pain. For patients with advanced disease, where most treatments have failed, one could consider assistance from hospice.
