What is bladder cancer?

Non-invasive tumours

The cancer cells are found only in the inner lining of the bladder (urotheliaum) and haven’t grown into the deeper layers of the bladder wall. One type of non-invasive cancer is carcinoma in-situ. Most bladder cancers are non-invasive.

Invasive tumours

The cancer has spread beyond the lining of the bladder into the muscle wall, either into the lamina propria or the muscle, or right through the bladder wall.

What types are there

Urothelial carcinoma

About 90% of all bladder cancer start from the innermost urothelial layer of the bladder wall. This used to be called transitional cell carcinoma.

Squamous cell carcinoma/Adenocarcinoma

Accounts for the rest of bladder cancers. They are rare and can be very invasive.

How common is it?

Each year, more than 2400 Australians are diagnosed with bladder cancer. Most people diagnosed with bladder cancer are 60 or older. Men are about three times more likely than women to be diagnosed with bladder cancer.

What are the symptoms

Blood in the urine

This is the most common symptoms of bladder cancer. It often occurs suddenly, but is usually not painful. There may only be a small amount of blood in the urine and it may look red or brown.

Changes in bladder habits

A burning felling when passing urine, needing to pass urine more often or urgently, not being able to urinate when you feel the urge and pain during urination can also be symptoms.

Pain
Less commonly, people have pain in one side of their lower abdomen or back.

What are the risk factors

• Smoking – cigarette smokers are about six times more likely than non-smokers to develop bladder cancer
• Chemical exposure – chemicals called aromatic amines and aniline dyes, which are used in rubber and plastics manufacturing, have been linked to bladder cancer.
• Diabetes
• Chronic urinary tract infection
• Previous radiotherapy and chemotherapy with cyclophosphamide to the pelvic area.

Diagnosis

Blood test and urine test
A blood sample will be taken regularly to check your general health. You will be asked to give urine samples to check for blood, bacteria and any cancer cells.

Cystoscopy and biopsy Under sedation
The cystoscope is inserted through your urethra and into the bladder to examine the whole of the inside lining. This is usually done as day surgery. If the test finds abnormal tissue, a biopsy can be taken, but you will be asked to come back for a cystoscopy under general anaesthetic.

Under general anaesthesia
To take a tissue sample (biopsy) or to remove a tumour. Small pieces of tissue can be removed from suspicious areas or growths. These will be examined by a pathologist to check for cancer cells.

Scans – MRI, Bone scan
These scans are designed to check the local extent of bladder cancer and wether there is any spread of bladder cancer into bones.

Staging of Bladder cancer

Grading of Bladder cancer

Low Grade
The cancer cells look similar to normal bladder cells, are usually slow growing and are less likely to spread. Most bladder tumours are low grade, especially if they are superficial.

High grade
The cancer cells look very abnormal and grow quickly. They are more likely to spread into the bladder muscle
Treatment for Non-Invasive Bladder Cancer.

Surgery
Most people with non-invasvie bladder cancer have a type of surgery called transurethral resection of bladder tumour (TURBT). The operation takes 15-40 minutes. During the operation, the urologist may use other techniques to kill the cancer cells. These could include burning the base of the tumour (fulguration) with the cystoscope or using a high energy laser to damage or kill the cancer cells.

Intra-vesical chemotherapy
Chemotherapy treats cancer by damaging cancer cells as they are growing and dividing. Unlike normal cells, cancer cells are unable to repair this damage and die.

Chemotherapy drugs are usually given by mouth or injected into a vein. However, intravesical chemotherapy, the drugs are put directly into the bladder using a urinary catheter.

Intravesical chemotherapy is only used for non-invasive bladder cancer. Each treatment is called an instillation. The chemotherapy treatment may be given as one instillation at the time of surgery, or as weekly instillations for six weeks.

Immunotherapy
Immunotherapy uses substances that encourage the body’s own natural defences to fight disease. Bacillus Calmette – Guerin (BCG) is a vaccine originally developed to prevent tuberculosis, but it can also stimulate the immune system to stop or delay bladder cancer coming back.

BCG, in combination with TURBT, is the most effective treatment for high grade cancers or carcinoma in-situ. It can also be used to treat invasive cancer that has grown into the lamina propria.
BCG is usually given once a week for six weeks, starting 2-4 weeks are TURBT surgery. It is put directly into the bladder through a catheter.
Some people may have long-term BCG therapy – up to two years. This is called maintenance treatment. It has been shown to reduce the risk of bladder cancer progressing and invading deeper into the bladder wall.

Treatment for invasive bladder cancer

Surgery

Cystectomy
Surgery is the preferred treatment for muscle invasive disease. A radical cystectomy is the most common operation for invasive bladder cancer. In this operation, the whole bladder and nearby lymph nodes are removed. In men, the prostate and seminal vesicles may be removed. In women, the uterus, ovaries, a small portion of the vagina and the Fallopian tubes are often removed.

Replacing the bladder
With the bladder removed, you will need to store urine in another way. This is called a urinary diversion. Before any operation, we will discuss the risks and possible complications, and what is suitable for you. There are two options.

Ileal conduit
This is the most common procedure performed in Australia. It means that urine will drain into a bag attached to the outside of the abdomen.
A piece of your small bowel is used to create a passageway (conduit) that connects the ureters to an opening on the outside of your body. The hole created on the surface of the abdomen is called a stoma.
A watertight bag is placed over the stoma to collect urine. This small bag, worn under clothing, fills continuously and needs to be emptied throughout the day through the tap on the bag. The small bag will be connected to a larger drainage bag at night.

Neo-bladder
This is a common procedure performed internationally. A 60cm length of bowel is used to form into a pouch (artificial bladder or neo-bladder). The surgeon connects the pouch to the ureters, which drain urine into it from the kidneys. The pouch is joined to the urethra. The pouch or the new bladder store the urine and can provide good continence. The patient will need to learn techniques to keep the new bladder drained on a regular basis.

Preserving the bladder
In patients who are unfit for bladder removal surgery, a combination of systemic chemotherapy and radiotherapy can be effective in controlling the bladder cancer.

Chemotherapy
Chemotherapy is the treatment of cancer with anti-cancer drugs through the vein. For invasive bladder cancer, drugs are given by injection. As the drugs circulate in the blood they travel throughout the body. This is called systemic chemotherapy.

Before cystectomy
For invasive bladder cancer, systemic chemotherapy may be given before surgery to shrink the cancer and make it easier to remove.

After cystectomy
Systemic chemotherapy may also be indicated after bladder removal if there is a high risk of the cancer coming back.