4urology

The bladder is a hollow sac in the lower abdomen. It stores urine, the liquid waste produced by the kidneys, prior to urination. Cancer is uncontrolled growth of cells and can effect any part of the body. All cancers begin in cells, the body's basic unit of life. Cells make up tissues, and tissues make up the organs of the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old and die, new cells take their place.
Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumour.

Tumours can be benign or malignant:

• Benign tumours are not cancer. Usually, doctors can remove them. Cells from benign tumours do not spread to other parts of the body. In most cases, benign tumours do not come back after they are removed. Most important, benign tumours are rarely a threat to life.
• Malignant tumours are cancer. They are generally more serious. Cancer cells can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumour and enter the bloodstream or the lymphatic system. That is how cancer cells spread from the original (primary) tumour to form new tumours in other organs. The spread of cancer is called metastasis.

The wall of the bladder is lined with cells called transitional cells and squamous cells. More than 90 percent of bladder cancers begin in the transitional cells. This type of bladder cancer is called transitional cell carcinoma. About 8 percent of bladder cancer patients have squamous cell carcinomas.

Cancer that is only in cells in the lining of the bladder is called superficial bladder cancer. This type of bladder cancer often comes back after treatment. If this happens, the disease most often recurs as another superficial cancer in the bladder. It is important that patients with superficial bladder cancer receive regular check ups to make sure that the cancer is not progressing to a more dangerous type of cancer.

Cancer that begins as a superficial tumour may grow through the lining and into the muscular wall of the bladder. This is known as invasive cancer. Invasive cancer may extend through the bladder wall. It may grow into a nearby organ such as the uterus or vagina (in women) or the prostate gland (in men). It also may invade the wall of the abdomen.

When bladder cancer spreads outside the bladder, cancer cells are often found in nearby lymph nodes. If the cancer has reached these nodes, cancer cells may have spread to other lymph nodes or other organs, such as the lungs, liver, or bones.

When cancer spreads (metastasizes) from its original place to another part of the body, the new tumour has the same kind of abnormal cells and the same name as the primary tumour. For example, if bladder cancer spreads to the lungs, the cancer cells in the lungs are actually bladder cancer cells. The disease is metastatic bladder cancer, not lung cancer. It is treated as bladder cancer, not as lung cancer. Doctors sometimes call the new tumour "distant" disease.
 

No one knows the exact causes of bladder cancer. However, it is clear that this disease is not contagious. No one can "catch" cancer from another person.

People who get bladder cancer are more likely than other people to have certain risk factors. A risk factor is something that increases a person's chance of developing the disease.

Still, most people with known risk factors do not get bladder cancer, and many who do get this disease have none of these factors. Doctors can seldom explain why one person gets this cancer and another does not.

Studies have found the following risk factors for bladder cancer:

• Age. The chance of getting bladder cancer goes up as people get older. People under 40 rarely get this disease.
• Tobacco. The use of tobacco is a major risk factor. Cigarette smokers are two to three times more likely than non-smokers to get bladder cancer. Pipe and cigar smokers are also at increased risk. Any smoker who has bladder cancer should stop immediately as this is the best way for them to help prevent recurrences.
• Occupation. Some workers have a higher risk of getting bladder cancer because of carcinogens in the workplace. Workers in the rubber, chemical, and leather industries are at risk. So are hairdressers, machinists, metal workers, printers, painters, textile workers, and truck drivers.
• Infections. Being infected with certain parasites increases the risk of bladder cancer. These parasites are common in tropical areas but not in the United States.
• Treatment with cyclophosphamide or arsenic. These drugs are used to treat cancer and some other conditions. They raise the risk of bladder cancer.
• Race. Whites get bladder cancer twice as often as African Americans and Hispanics. The lowest rates are among Asians.
• Being a man. Men are two to three times more likely than women to get bladder cancer.
• Family history. People with family members who have bladder cancer are more likely to get the disease. Researchers are studying changes in certain genes that may increase the risk of bladder cancer.
• Personal history of bladder cancer. People who have had bladder cancer have an increased chance of getting the disease again.

People who think they may be at risk for bladder cancer should discuss this concern with their doctor. The doctor may suggest ways to reduce the risk and can plan an appropriate schedule for checkups.
 

Common symptoms of bladder cancer include:

• Blood in the urine (making the urine slightly rusty to deep red or with clots),
• Pain during urination, and
• Frequent urination, or feeling the need to urinate without results.

These symptoms are not sure signs of bladder cancer. Infections, benign tumours, bladder stones, interstitial cystitis or other problems can also cause these symptoms. Anyone with these symptoms should see a doctor so that the doctor can diagnose and treat any problem as early as possible. People with symptoms like these may see their family doctor or a urologist, who specializes in diseases of the urinary system.
 

If you have any of the above symptoms and especially if you are over 50 then you should seek immediate medical attention. If your GP feels that you are at risk of bladder cancer then you should be seen by a specialist within 2 weeks of presenting to your doctor.

If a patient has symptoms that suggest bladder cancer, the doctor may check general signs of health and may order lab tests. The person may have one or more of the following procedures:

• Physical exam -- The doctor feels the abdomen and pelvis for tumours. The physical exam may include a rectal or vaginal exam.
• Urine tests -- The laboratory checks the urine for blood, cancer cells, and other signs of disease.
• Intravenous urogram -- The doctor injects dye into a blood vessel. The dye collects in the urine, making the bladder show up on x-rays.
• Ultrasound scan – using a scanner and gel on the skin images of the kidneys and bladder can be seen.
• Cystoscopy -- The doctor uses a thin, lighted tube (cystoscope) to look directly into the bladder. The doctor inserts the cystoscope into the bladder through the urethra to examine the lining of the bladder. This procedure is usually done as an outpatient procedure using local anaesthetic. Link to flexi cystoscopy info.
   

If bladder cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out whether the cancer has invaded the bladder wall, whether the disease has spread, and if so, to what parts of the body.

The doctor may determine the stage of bladder cancer at the time of diagnosis, or may need to give the patient more tests. Such tests may include imaging tests -- CT scan, magnetic resonance imaging (MRI), ultrasound scan, intravenous pyelogram, bone scan, or chest x-ray. Sometimes staging is not complete until the patient has surgery.

TNM staging
These are the main features of each stage of the disease:

Normal layers of the bladder

The bladder has several layers of tissue and more aggressive tumours will invade the deeper tissues.

Bladder TCC can be staged according to the 1997 TNM system:

• Ta Non-invasive papillary tumour
• T1 Invasive but not as far as the muscular bladder layer
• T2 Invasive into the muscular layer
• T3 Invasive beyond the muscle into the fat outside the bladder
• T4 Invasive into surrounding structures like the prostate (in men), uterus (in women) or pelvic wall.

The nomenclature "G1", "G2" and "G3" refers to the degree of differentiation, or histopathological grade. "G1" superficial tumour is well differentiated, while a "G3" tumour is poorly differentiated.

An alternative staging system for bladder cancer is as below. The most important thing about staging systems in this context is that they help you, the patient, understand, so please do not get overly anxious which system is best.

• Stage 0 -- The cancer cells are found only on the surface of the inner lining of the bladder. The doctor may call this superficial cancer or carcinoma in situ.
• Stage I -- The cancer cells are found deep in the inner lining of the bladder. They have not spread to the muscle of the bladder.
• Stage II -- The cancer cells have spread to the muscle of the bladder.
• Stage III -- The cancer cells have spread through the muscular wall of the bladder to the layer of tissue surrounding the bladder. The cancer cells may have spread to the prostate (in men) or to the uterus or vagina (in women).
• Stage IV -- The cancer extends to the wall of the abdomen or to the wall of the pelvis. The cancer cells may have spread to lymph nodes and other parts of the body far away from the bladder, such as the lungs.

Discussing treatment
Many people with bladder cancer want to take an active part in decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress that people often feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some patients also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

Treatment generally begins within a few weeks after the diagnosis. There will be time for patients to talk with the doctor about treatment choices, and learn more about bladder cancer.

Preparing for Treatment
The doctor develops a treatment plan to fit each patient's needs. Treatment depends on the type of bladder cancer, the stage of the disease, and the grade of the tumour. (The grade tells how closely the cancer cells resemble normal cells. It suggests how fast the cancer is likely to grow. Low-grade cancers usually grow and spread more slowly than high-grade cancers.) The doctor also considers other factors, including the patient's age and general health.
 

People do not need to ask all of their questions or understand all of the answers at once. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.

Because cancer treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. These side effects depend on many factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Doctors and nurses will explain the possible side effects of treatment and how they will help the patient manage them.

Follow up will depend on the type of bladder cancer and the type of treatment you have received. As bladder cancer can return, it is important that patients who still have their bladders get regular check ups including further flexible cystoscopies to look inside the bladder every 6 months or so.

If you have had your bladder removed then you will still need regular check ups with scans to make sure that all the cancer has been removed at the time of surgery. In a small percentage of patients some of the cancer will have already spread outside the bladder before your operation. If this is the case then you may require further treatments.
 

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