What is Bladder cancer?

Bladder cancer is a cancer that arises from the cells located in your bladder. The bladder is an organ which is responsible for holding urine, which is formed by the kidney, until you urinate. It is a common cancer of the urinary tract. The most common type of bladder cancer is the transitional cell carcinoma, which arises from the transitional cells in your bladder.

The clinical course of this condition varies according to the staging and extent of the disease. If the cancer is superficial, it is less likely to progress to death. However, if the cancer involves deeper layers of the bladder wall, it can be life-threatening. The most common symptom for this condition is blood in urine and is present in around 80-90% of people.

The American Cancer Society estimated that there will be around 81,400 people who will be diagnosed with bladder cancer in 2020 and that around 17,000 others will die from the disease. Bladder cancer becomes more common with increasing age. It is rare among people aged less than 40 years. It is a condition which is more common among men compared to women. Around the world, this cancer arises in around 275,000 people per year.

The treatment for bladder cancer depends on the extent and aggressiveness of the disease.

Causes and risk factors of Bladder Cancer

Bladder cancer is caused by abnormal proliferation of cells in your bladder. It can also be due to cancer cells which have migrated from another site to the bladder. Similarly, cancer cells from the bladder cancer can travel to other organs. When this happens, the cancer is said to have metastasized.

The majority of bladder cancer cases are due to environmental exposures. The following increase your risk of having bladder cancer:

• Tobacco smoking: This is the most common cause of bladder cancer. The more cigarettes and the longer timeframe you smoke, the higher your risk. People who smoke are 2-6 times more prone to have bladder cancer compared to those who don’t smoke.
• Certain occupations: If you are exposed to diesel exhaust, petroleum products and solvents in your workplace, you have a higher risk of having bladder cancer.
• Living in urban areas: Due to the increased likelihood of exposure to carcinogens in urban areas, this make the inhabitants more prone to bladder cancer.
• Exposure to arsenic: Arsenic is an element which is found in rocks, soil, water or air as well as in man made products such as pesticides. Excessive exposure to that element increases your risk of having bladder cancer.
• Radiation to pelvis: You are at risk if you had radiation therapy to your pelvis in the past.
• Chemotherapy: Similarly, chemotherapy can put you more at risk of having bladder cancer.

Signs and symptoms of Bladder cancer

The most common symptom of bladder cancer is blood in urine. Urination is usually painless and the blood is visible to naked eye. Your urine can appear dark or cola coloured. Other signs and symptoms include:

• With advanced disease, pain on urination can arise
• Frequent urination
• Urge to urinate
• If the cancer spreads to the pelvic or other bones of the body, back pain may be present

Making a diagnosis

After taking a good history from you, your doctor will examine you to look for any other signs and symptoms. Then, your doctor will request for other tests to confirm the diagnosis. These include:

• Urine cytology: A sample of your urine is taken to be analysed under a microscope to look for the presence of cancer cells.
• Cystoscopy: In this procedure, a tube with a camera on its end is inserted through your urethra up to your bladder. This will allow visualising the inside of your bladder to look for any abnormal mass or suspicious findings. If a mass is found, a sample of it can be taken during for procedure for further analysis. In some cases, the whole mass can be taken out.
• Ultrasonography: This involves using sound waves to visualize your bladder. It can also be used to identify the presence of any complications arising in the kidneys.
• Computed tomography (CT) scan: This gives a more detailed view of the bladder, the kidneys and other surrounding structures. It is also an important step in staging the cancer. A CT urogram is a procedure in which a dye is injected in your blood. It will travel to the kidneys and bladder and thus, X-ray images are taken to view the urinary tract.

Treatment of Bladder cancer

 The treatment of bladder cancer depends on the extent (grading), aggressiveness and type of the cancer. It will also depend on the general health and age of the patient.

Surgical options include:

• Transurethral resection of bladder tumour (TURBT): This is usually done during cystoscopy. An instrument is inserted through the cystoscope to reach the bladder. Electric current is passed through the instrument to excise the cancer.
• Cystectomy: This is the removal of all or part of the bladder. If partial removal is done, only the part which has the tumour is removed. When the whole bladder is removed, this is called radical cystectomy. In some cases, surrounding structures such as the uterus, ovaries and vagina (in females) or the prostate and seminal vesicles (in males) will have to be removed if the cancer reached these structures.
• Ileal conduit: After the removal of the bladder, a diversion pathway should be created in order to be able to collect urine coming from the kidneys. This is done by creating a channel from the ureters (tubes coming from the kidneys) to the outside of your abdomen into a collecting bag called the urostomy bag.

Other treatment options can be used together with surgical options or on their own depending on the cases. These include:

• Chemotherapy: In chemotherapy, certain drugs are used to kill cancer cells. These drugs can be delivered through your veins or directly into your bladder.

• Radiation therapy: In this procedure, beams of high energy are used to kill cancer cells. This is sometimes given together with chemotherapy in certain situations.
• Immunotherapy: In immunotherapy, drugs are used to boost your immune system to help it fight cancer. Similar to chemotherapy, the drugs can be delivered through your bloodstream or directly into your bladder.

Furthermore, apart from surgical and medical treatment, certain measures should be implemented in your lifestyle to promote a good recovery such as:

• Smoking cessation- decrease the chance of recurrence and progression of the cancer
• Increased water intake

Complications of Bladder cancer

If left untreated, several complications may ensue:

• Painful urination: This is due to invasion of the bladder cancer into deeper layers
• Urinary retention: This arises from inability to void
• Urinary incontinence: Involuntary leakage of urine
• Obstruction of the ureters: If the mass develops at the level of the opening of ureters in the bladder
• Metastasis: This is the spread of the cancer to distant structures

Prevention

There is no specific way to prevent the occurrence of bladder cancer. However, you can reduce your risk by taking the following steps:

• Avoid smoking or smoking cessation if you already are. If you are addicted to cigarette smoking, your doctor may refer you to a smoking cessation clinic. It is also important to avoid passive smoking as well.

• Avoid exposure to harmful chemicals or use protective equipments if you need to handle them.
• Maintain a healthy lifestyle by eating enough fruits and vegetables as well as being physically active.

Prognosis

The most common type of bladder cancer is the transitional cell carcinoma. It has a recurrence rate of about 80%. Grading and depth of invasion of the cancer highly impact the course of the disease. In cases of metastasis, the prognosis is poor.

Parveen, K. and Michael, C., 2017. Kumar & Clarks Clinical Medicine. 9th ed. The Netherlands: ELSEVIER.

Medscape. 2020. Bladder Cancer.