 | Bladder Cancer |
| Overview |
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A bladder tumor is a collection of malignant or cancerous cells within the bladder. Approximately 55,000 patients were diagnosed with bladder cancer in 1998. Approximately 80% of bladder cancers are "superficial" or confined to the lining of the bladder. Although many superficial bladder cancers may recur, the majority do not progress to the point of becoming a life threatening illness. Unfortunately, 15 - 20% of bladder cancers either invade the bladder wall at the time of diagnosis or progress from superficial disease to more invasive disease over time. Recent statistics show that 12,500 patients died of bladder cancer in 1998. Most malignant tumors of the lining of the urinary system are of the transitional cell type and called transitional cell carcinoma. These tumors, although most common in the bladder, can arise anywhere in the urinary system, from the level of the kidney all the way to the urethra.
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| Signs and Symptoms |
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The most common sign of a bladder tumor is blood in the urine - either blood that can be seen by the naked eye or blood that is detected by a physician on a urine sample. Most bladder tumors have no other symptoms unless they become invasive or there is an associated condition called carcinoma in situ. In theses cases, a patient may also experience frequent urination, painful urination, or difficulty controlling the urine stream. Since other conditions may also cause these symptoms, evaluation by a physician is mandatory. All cases of blood in the urine should be evaluated, since a bladder tumor can go unrecognized without other symptoms, blood may be the only sign of a bladder malignancy.
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| Diagnosis |
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Once a bladder tumor is suspected either due to blood in the urine or other symptoms, diagnostic tests need to be performed. Standard tests used to diagnose a bladder tumor include:
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| Staging |
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Once the diagnosis of malignancy is determined, the tumor must be staged. Staging enables the physician to determine the extent of the tumor a the time of diagnosis. For superficial tumors an IVP is the only study that is necessary to ensure that no other tumors are present within the remainder of the urinary system.
If a patient is diagnosed with invasive bladder cancer, then a CT scan of the abdomen and pelvis will usually be obtained to determine whether there is tumor present outside of the bladder. Common sites of tumor spread include the surrounding lymph nodes in the pelvis, the liver, lungs or bones. A chest x-ray and basic blood tests will also be performed. In certain cases, a bone scan may also be obtained to rule-out spread to the bones.
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| Treatment |
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Superficial Bladder Cancer If the tumor is confined to the superficial layer of the bladder, no additional treatment may be necessary after the tumor is removed. If the surgeon removes the tumor completely and the pathology reveals a low-grade and low-stage tumor, routine follow-up may be all that is necessary. After the initial tumor is removed, patients require a repeat cystoscopy every 3 months for 2 years. If no tumor recurrences are noted after 2 years, the schedule for follow-up cystoscopy may be decreased to twice yearly and eventually to an annual basis. Periodically, an IVP will be repeated to make sure that the "upper tracts" are free of tumor. If the tumor grade or stage is intermediate, intravesical (inside the bladder) medical therapy may be indicated. The most common medication used to treat bladder cancer is called BCG (Bacillus Camille Guerin). This treatment is usually performed weekly in the office for six weeks by administering the medication into the bladder with a catheter. Other similar treatments include Mitomycin-C, Thiotepa, and Adriamycin. Invasive Bladder Cancer Cases of invasive bladder cancer require more aggressive treatment than superficial bladder cancer. Once the tumor invades into the muscle layer of the bladder, the tumor cells may gain access to the blood vessels and spread to distant organs. Although it is believed by some that an aggressive transurethral resection may remove all of the tumor cells, the standard treatment for muscle invasive bladder cancer is a radical cystectomy - a procedure to entirely remove the bladder. Once the bladder is removed, the urinary system must be surgically reconstructed to drain the urine via a procedure called a urinary diversion. Different types of urinary diversion exist depending upon an individual patient's desires and his ability to undergo a longer and more complex surgery. The simplest urinary diversion is called an ileal conduit and allows the urine to drain to an external collection bag via a short segment of small bowel. A more complicated urinary reconstruction is called a continent urinary diversion whereby a pouch to collect the urine is constructed out of bowel and placed inside the body. The patient then drains the urine from this pouch with a catheter 4 to 6 times daily. The most complicated urinary diversion is called an orthotopic neobladder and creates a new bladder out of bowel which is then connected to the native urethra. Most of these patients will be able to urinate with a fairly normal pattern following surgery although some may need to perform self-catheterization for adequate "bladder" emptying. The best urinary reconstruction for an individual patient can only be decided upon after a discussion of the benefits and risks of each procedure. Patients who are not candidates for an aggressive surgical procedure, may be offered a combination of radiation therapy and chemotherapy to treat an invasive bladder tumor. Advanced Bladder Cancer When bladder cancer is found to involve either the pelvic lymph nodes or distant organs, removal of the primary tumor is unlikely to cure the patient. In these cases, the patient may be offered chemotherapy and/or radiation therapy after consultation with a medical oncologist. When standard chemotherapy is ineffective, patients may be offered experimental chemotherapy as a last effort to treat refractory tumor cells.
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