About Bladder Cancer Everything You Need To Know
Bladder Cancer Overview
The bladder is an expandable, hollow organ in the pelvis that stores urine before it leaves the body during urination. This function makes the bladder an important part of the urinary tract. The urinary tract is also made up of the kidneys, ureters, and urethra.
The bladder, like other parts of the urinary tract, is lined with a layer of cells called the urothelium. This layer of cells is separated from the bladder wall muscles, called the muscularis propria, by a thin, fibrous band called the lamina propria.
Bladder cancer begins when healthy cells in the bladder lining, most commonly urothelial cells, change and grow uncontrollably, forming a mass called a tumour. A tumour can be cancerous or benign. A cancerous tumour is malignant, meaning it can grow and spread to other parts of the body. A benign tumour means a tumour can grow but will not spread.
The bladder and urinary system
The bladder is part of the body system that filters waste products out of the blood and makes urine.
This is called the urinary system (or urinary tract). It is made up of the:
- 1. Kidneys
- 2. Ureters
- 3. Bladder
- 4. Urethra
In men, the prostate gland surrounds the lower part of the bladder.
Normally, there are two kidneys, one on each side of the body. The kidneys filter your blood and make urine. The urine is carried to the bladder by two tubes called the ureters. The bladder is like a balloon which stores urine. It is a stretchy bag, made of muscle tissue, and can hold about 500mls (about 3 cups) of urine.
When we empty our bladder, the urine passes down a tube called the urethra and out of the body. The urethra in men passes through the prostate gland and down the penis. In women, the urethra is much shorter and passes from the bladder down to an opening just in front of the vagina.
The urine collecting tubes within the kidney, the ureters, the bladder, and the urethra are all lined with transitional cells.
The Layers Of The Bladder
The bladder is made up of a number of layers. Bladder cancer starts in the innermost lining. How your specialist treats your bladder cancer will depend on how far cancer has grown into these layers. This tells your doctor the stage of your bladder cancer.
The inside of the bladder has a special type of lining that stretches as the bladder fills up. This lining is called transitional epithelium. It stops the urine being absorbed back into the body. Below this first layer is a thin layer of connective tissue called the lamina propria. Underneath this layer is muscle tissue called the muscularis propria. Around the muscle tissue is a layer of fatty connective tissue, which separates the bladder from other body organs such as the prostate and kidneys.
Types Of Bladder Cancer
The type of bladder cancer depends on how it looks under the microscope. The three main types of bladder cancer are:
Urothelial carcinoma. Urothelial carcinoma accounts for about 90% of all bladder cancers. It begins in the urothelial cells found in the lining of the bladder. Urothelial carcinoma is the common term for this type of bladder cancer; however, it was previously called transitional cell carcinoma or TCC.
Squamous cell carcinoma. Squamous cells develop in the bladder lining in response to irritation and inflammation. Over time these cells may become cancerous. Squamous cell carcinoma accounts for about 4% of all bladder cancers.
Adenocarcinoma. This type accounts for about 2% of all bladder cancers and develops from glandular cells.
There are other less common types of bladder cancer, including sarcoma and small cell anaplastic cancer. Sarcoma begins in the fat or muscle layers of the bladder. Small cell anaplastic cancer is a rare type of bladder cancer that is likely to spread to other parts of the body.
Ways of describing bladder cancer
In addition to its cell type, bladder cancer may be described as noninvasive, non-muscle-invasive, or muscle-invasive.
Noninvasive. This type of bladder cancer usually does not extend through the lamina propria. Noninvasive cancer may also be called superficial cancer, although this term is being used less often because it may incorrectly imply that this type of cancer is not serious. Noninvasive bladder cancer is less likely to spread to other parts of the body than other types of bladder cancer.
Non-muscle-invasive. Non-muscle-invasive bladder cancer typically has only grown into the lamina propria. It is called invasive, but it is not the deeply invasive type that can spread to the muscle layer (see below).
Muscle-invasive. Muscle-invasive bladder cancer has grown into the bladder's wall muscle and sometimes into the fatty layers or surrounding tissue outside the bladder.
It is important to note that both noninvasive and non-muscle-invasive bladder cancers have the possibility of spreading into the bladder muscle or to other parts of the body. Additionally, all cell types of bladder cancer can spread beyond the bladder through a process known as metastasis.
If a bladder tumour has spread into the surrounding organs, such as the uterus and vagina in women, the prostate in men, and/or nearby muscles, it is called locally advanced disease. Bladder cancer also often spreads to the lymph nodes in the pelvis. If it has spread into the liver, bones, lungs, lymph nodes outside the pelvis or other parts of the body, the cancer is called metastatic disease.
Signs & Symptoms To Look For
Blood in the urine
Blood in pee is the most common symptom of bladder cancer. 4 out of 5 people with bladder cancer (80%) have some blood in their urine. You may actually see the blood. It usually looks bright red but, rarely, may be dark brown. Or it might be there in such small amounts that you can't see it. Even if it cannot be seen, a urine test will show if blood is present. Doctors call blood in pee 'haematuria' (pronounced heem-at-you-ree-ah).
The blood may not be there all the time. It can come and go. So if you ever see blood in your pee, you should go to your GP.
People with bladder cancer may experience the following symptoms or signs. Sometimes, people with bladder cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer.
1. Blood or blood clots in the urine
2. Pain or burning during urination
3. Frequent urination
4. Feeling the need to urinate many times throughout the night
5. Feeling the need to urinate, but not being able to pass urine
6. Lower back pain on one side of the body
Most often, bladder cancer is diagnosed when a person tells his or her doctor about blood in the urine, also called hematuria. Gross hematuria means that enough blood is present in the urine to be visible to the patient. It is also possible there are small amounts of blood in the urine that are unable to be seen. This is called microscopic hematuria, and it can only be detected with a urine test.
General urine tests are not used to make a specific diagnosis of bladder cancer because hematuria can be a sign of several other conditions that are not cancer, such as an infection or kidney stones. One type of urine test that can indicate the presence of cancer is cytology, a test in which the urine is studied under a microscope to look for cancer cells.
Sometimes when the first symptoms of bladder cancer appear, cancer has already spread to another part of the body. In this situation, the symptoms depend on where cancer has spread. For example, cancer that has spread to the lungs may cause a cough or shortness of breath, spread to the liver may cause abdominal pain or jaundice (yellowing of the skin and whites of the eyes), and spread to the bone may cause bone pain or a fracture (bone break). Other symptoms of advanced bladder cancer may include pain, unexplained appetite loss, and weight loss.
If you are concerned about one or more of the symptoms or signs listed in this section, please talk with your doctor. Your doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.
If cancer is diagnosed, relieving symptoms remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.
Stages Of Bladder Cancer
Bladder Cancer: Stages and Grades
ON THIS PAGE: You will learn about how doctors describe cancer’s growth or spread, as well as the way the tumour cells look when viewed under a microscope. This is called the stage and grade. To see other pages, use the menu on the side of your screen.
Staging is a way of describing where the cancer is located, if or where it has invaded or spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to find out cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.
TNM staging system
One tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:
Tumour (T): How large is the primary tumour? Where is it located?
Node (N): Has the tumour spread to the lymph nodes? If so, where and how many?
Metastasis (M): Has cancer metastasized to other parts of the body? If so, where and how much?
The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing cancer, so doctors can work together to plan the best treatments.
Here are more details on each part of the TNM system for bladder cancer.
Using the TNM system, the "T" plus a letter and/or number (0 to 4) is used to describe the size and location of a tumour. Some stages are also divided into smaller groups that help describe a tumour in even more detail. If there is more than one tumour, the lowercase letter "m" (multiple) is added to the "T" stage category. Specific tumour stage information is listed below.
TX: A primary tumour cannot be evaluated.
T0: There is no evidence of a primary tumour in the bladder.
Ta: This refers to noninvasive papillary carcinoma. This type of growth often is found on a small section of tissue that easily can be removed with TURBT. However, it tends to come back after treatment.
Tis: This stage is carcinoma (cancer) in situ or a "flat tumour." This means that the cancer is only found on or near the surface of the bladder. The doctor may also call it non-muscle-invasive/superficial bladder cancer or noninvasive flat carcinoma. This type of bladder cancer often comes back after treatment, usually as another noninvasive cancer in the bladder.
T1: A tumour has spread to the subepithelial connective tissue but does not involve the bladder wall muscle (lamina propria, the tissue below the inside lining of the bladder).
T2: A tumour has spread to the muscle of the bladder wall.
T2a: A tumour has spread to the inner half of the muscle of the bladder wall, which may be called the superficial muscle.
T2b: A tumour has spread to the deep muscle of the bladder (the outer half of the muscle).
T3: A tumour has grown into the perivesical tissue (the fatty tissue that surrounds the bladder).
T3a: A tumour has grown into the perivesical tissue, as seen through a microscope.
T3b: A tumour has grown into the perivesical tissue macroscopically, meaning that a tumour(s) is large enough to be seen during imaging tests or to be seen or felt by the doctor.
T4: A tumour has spread to any of the following: the abdominal wall, the pelvic wall, a man’s prostate or seminal vesicle (the tube(s) that carry semen), or a woman’s uterus or vagina.
T4a: A tumour has spread to the prostate, uterus, or vagina.
T4b: A tumour has spread to the pelvic wall or the abdominal wall.
The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near where cancer started, within the true pelvis (called hypogastric, obturator, iliac, perivesical, pelvic, sacral, and presacral lymph nodes), are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.
NX: The regional lymph nodes cannot be evaluated.
N0: Cancer has not spread to the regional lymph nodes.
N1: Cancer has spread to a single regional lymph node in the pelvis.
N2: Cancer has spread to more than one regional lymph node in the pelvis.
N3: Cancer has spread to the common iliac lymph nodes, which are located behind the major arteries in the pelvis, above the bladder.
The "M" in the TNM system indicates whether cancer has spread to other parts of the body called distant metastasis.
M0: The disease has not metastasized.
M1: There isa distant metastasis.
Cancer stage grouping
Doctors assign the stage of the bladder cancer by combining the T, N, and M classifications.
Stage 0a: This is early cancer that is only found on the surface of the inner lining of the bladder. Cancer cells are grouped together and can often be easily removed. Cancer has not invaded the muscle or connective tissue of the bladder wall. This type of bladder cancer is also called noninvasive papillary urothelial carcinoma (Ta, N0, M0).
Stage 0is: This stage of cancer, also known as flat or carcinoma in situ, is found only on the inner lining of the bladder. It has not grown in toward the hollow part of the bladder, and it has not spread to the thick layer of muscle or connective tissue of the bladder (Tis, N0, M0). This is always high-grade cancer (see Grades, below).
Stage I: Cancer has grown through the inner lining of the bladder into the lamina propria. It has not spread to the thick layer of muscle in the bladder wall or to lymph nodes or other organs (T1, N0, M0).
Stage II: Cancer has spread into the thick muscle wall of the bladder. It is also called invasive cancer or muscle-invasive cancer. A tumour has not reached the fatty tissue surrounding the bladder and has not spread to the lymph nodes or other organs (T2, N0, M0).
Stage III: Cancer has spread throughout the muscle wall to the fatty layer of tissue surrounding the bladder. It may also have spread to the prostate in a man or the uterus and vagina in a woman. It has not spread to the lymph nodes or other organs (T3 or T4a, N0, M0).
Stage IV: Any of these conditions:
A tumour has spread to the pelvic wall or the abdominal wall but not to the lymph nodes or other parts of the body (T4b, N0, M0).
A tumour has spread to one or more regional lymph nodes but not to other parts of the body (any T, N1-3, M0).
A tumour may or may not have spread to the lymph nodes but has spread to other parts of the body (any T, any N, M1).
Recurrent cancer: Recurrent cancer is cancer that has come back after treatment. If cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.
Doctors also describe this type of cancer by its grade (G), which describes how much cancer cells look like healthy cells when viewed under a microscope. The doctor compares the cancerous tissue with healthy tissue. Healthy tissue usually contains many different types of cells grouped together. If cancer looks similar to healthy tissue and contains different cell groupings, it is called differentiated or a low-grade tumour. If the cancerous tissue looks very different from healthy tissue, it is called poorly differentiated or a high-grade tumour.
Many urologic surgeons classify a tumour’s grade based on the chance that cancer will recur or progress (grow and spread). They often plan treatment based on the grade, using the following categories:
Papilloma. This is also called benign papillary urothelial neoplasm of low malignant potential (PUNLMP). This type of cancer may recur but has a low risk of progressing.
Low grade. This type of cancer is more likely to recur and progress compared with PUNLMP.
High grade. This type of cancer is the most likely to recur and progress.
More recently, the World Health Organization (WHO) has recommended changing bladder cancer grading to only two categories: 1) well-differentiated or low grade, and 2) poorly differentiated or high grade. This is the system that is used in the latest version of the American Joint Committee on Cancer (AJCC) Staging System.
Used with permission of the AJCC, Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition, published by Springer-Verlag New York, www.cancerstaging.org. Please note that AJCC’s Eighth Edition (2017) has been released; related changes to the information provided above are underway. Please check back soon for updated staging definitions or talk with your doctor about whether these changes affect your diagnosis.
What Increases The Risk Of Developing Bladder Cancer?
A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.
The following factors may raise a person’s risk of developing bladder cancer:
Tobacco use. The most common risk factor is cigarette smoking, although smoking cigars and pipes can also raise the risk of developing bladder cancer. Smokers are four to seven times more likely to develop bladder cancer than nonsmokers. Learn more about tobacco’s link to cancer and how to quit smoking.
Age. The likelihood of being diagnosed with bladder cancer increases with age. More than 70% of people with bladder cancer are older than 65 years old.
Gender. Men are three to four times more likely to develop bladder cancer than women, but women are more likely to die from bladder cancer than men. Before smoking rates for women increased, men were five to six times more likely to develop bladder cancer than women.
Race. White people are more than twice as likely to be diagnosed with bladder cancer as black people, but black people are twice as likely to die from the disease.
Chemicals. Chemicals used in the textile, rubber, leather, dye, paint, and print industries; some naturally occurring chemicals; and chemicals called aromatic amines can increase the risk of bladder cancer.
Chronic bladder problems. Bladder stones and infections may increase the risk of bladder cancer. Bladder cancer may be more common for people who are paralyzed from the waist down and have had many urinary infections.
Cyclophosphamide (Cytoxan, Clafen, Neosar) use. People who have taken the chemotherapy drug cyclophosphamide have a higher risk of developing bladder cancer.
Pioglitazone hydrochloride (Actos) use. In 2011, the U.S. Food and Drug Administration (FDA) warned that people who have taken the diabetes drug pioglitazone hydrochloride for more than one year may have a higher risk of developing bladder cancer. However, published studies have shown contradictory results.
Personal history. People who have already had bladder cancer once are more likely to develop bladder cancer again.
Schistosomiasis. People who have some forms of this parasitic disease, which is found particularly in parts of Africa and the Mediterranean region, are more likely to develop bladder cancer.
Arsenic exposure. Arsenic is a naturally occurring substance that can cause health problems if consumed in large amounts. When found in drinking water, it has been associated with an increased risk of bladder cancer. The chance of being exposed to arsenic depends on where you live and whether you get your water from a well or from a system that meets the standards for acceptable arsenic levels.
Statistics And Facts About Bladder Cancer
- Bladder cancer is the tenth most common cancer in the UK (2014).
- Bladder cancer accounts for 3% of all new cases in the UK (2014).
- In males in the UK, bladder cancer is the eight most common cancer, with around 7,300 cases diagnosed in 2014.
- In females in the UK, bladder cancer is the 14th most common cancer, with around 2,800 cases diagnosed in 2014.
- More than half (55%) of bladder cancer cases in the UK each year are diagnosed in people aged 75 and over (2012-2014).
- Incidence rates for bladder cancer in the UK are highest in people aged 90+ (2012-2014).
- Since the late 1970s, bladder cancer incidence rates have decreased by more than a quarter (27%) in Great Britain. The decrease is larger in males where rates have decreased by almost a third (30%), than in females where rates have decreased by around a fifth (19%).
- Over the last decade, bladder cancer incidence rates have decreased by a tenth (10%) in the UK, with a similar decrease in males (13%) and females (10%).
- Most bladder cancer cases are diagnosed at an early stage.
- Incidence rates for bladder cancer are projected to fall by 34% in the UK between 2014 and 2035, to 13 cases per 100,000 people by 2035.
- 1 in 39 men and 1 in 110 women will be diagnosed with bladder cancer during their lifetime.
- Bladder cancer in England is more common in people living in the most deprived areas.
- Bladder cancer is more common in White people than in Asian or Black people.
- In the UK more than 46,500 people were still alive at the end of 2006,
- In Europe, more than 151,000 new cases of bladder cancer were estimated to have been diagnosed in 2012. The UK incidence rate is the lowest in Europe for males and the 13th lowest for females.
- Worldwide, an estimated 429,000 new cases of bladder cancer were diagnosed in 2012, with incidence rates varying across the world.
Treatment For Bladder Cancer
In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. This team is usually led by a urologist, a doctor who specializes in the genitourinary tract, which includes the kidneys, bladder, genitals, prostate, and testicles, or a urologic oncologist, a doctor who specializes in treating cancers of the urinary tract. Cancer care teams also include a variety of other health care professionals, including physician assistants, oncology nurses, social workers, pharmacists, counsellors, dietitians, and others.
Descriptions of the most common treatment options for bladder cancer are listed below, followed by an outline of general approaches to treatment according to the stage of cancer. Treatment options and recommendations depend on several factors, including the type, stage, and grade of bladder cancer; possible side effects; and the patient’s preferences and overall health. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.
Surgery is the removal of the tumour and some surrounding healthy tissue during an operation. There are different types of surgery for bladder cancer, and the most beneficial option usually depends on the stage and grade of the disease. Surgical options to treat bladder cancer include:
Transurethral bladder tumour resection (TURBT). This procedure is used for diagnosis and staging, as well as treatment. During TURBT, a surgeon inserts a cystoscope through the urethra into the bladder. The surgeon then removes a tumour using a tool with a small wire loop, a laser, or fulguration (high-energy electricity). The patient is given medication to block the awareness of pain, known as an anaesthetic before the procedure begins.
For people with non-muscle-invasive bladder cancer, TURBT may be able to eliminate cancer. However, the doctor may recommend additional treatments to prevent cancer recurrence, such as intravesical chemotherapy or immunotherapy (see below). For people with muscle-invasive bladder cancer, additional treatments involving surgery to remove the bladder or, less commonly, radiation therapy are usually recommended.
Cystectomy. A radical cystectomy is a removal of the whole bladder and possibly nearby tissues and organs. For men, the prostate and urethra also may be removed. For women, the uterus, fallopian tubes, ovaries, and part of the vagina may be removed. In addition, lymph nodes in the pelvis are removed for both men and women. This is called a pelvic lymph node dissection. A thorough pelvic lymph node dissection is the most accurate way to find cancer that has spread to the lymph nodes. Rarely, for some specific cancers, it may appropriate to remove only part of the bladder, which is called partial cystectomy.
During a laparoscopic or robotic cystectomy, the surgeon makes several small incisions (cuts) instead of the one larger incision used for traditional surgery. The surgeon then uses telescoping equipment with or without robotic assistance to remove the bladder. The surgeon must make an incision to remove the bladder and surrounding tissue. This type of operation requires a surgeon who is very experienced in minimally invasive surgery. Several studies are still in progress to determine whether laparoscopic or robotic cystectomy is as safe as the standard surgery and whether it is able to eliminate bladder cancer as successfully as standard surgery.
Urinary diversion. If the bladder is removed, the doctor will create a new way to pass urine out of the body. One way to do this is to use a section of the small intestine or colon to divert urine to a stoma or ostomy (an opening) on the outside of the body. The patient then must wear a bag attached to the stoma to collect and drain urine.
Increasingly, surgeons can use part of the small or large intestine to make a urinary reservoir, which is a storage pouch that sits inside the body. With these procedures, the patient does not need a urinary bag and can have a better quality of life. For some patients, the surgeon is able to connect the pouch to the urethra, creating what is called a neobladder, so the patient can pass urine out of the body normally. However, the patient may need to insert a thin tube called a catheter if urine does not empty through the neobladder. Also, patients with a neobladder will no longer have the urge to urinate and will need to learn to urinate on a consistent schedule.
For other patients, the pouch is connected to the skin on the abdomen or umbilicus through a small stoma, which creates a type of continent urinary reservoir. This means urine will stay in the reservoir until the patient drains the pouch and no urinary pad is needed. The pouch is drained by inserting a catheter through the small stoma and then removing the catheter.
Living without a bladder can affect a patient’s quality of life. Finding ways to keep all, or part, of the bladder, is an important treatment goal, as long as the patient’s prognosis isn’t affected. For some patients with muscle-invasive bladder cancer, certain treatment plans involving chemotherapy and radiation therapy (see below) may be used as an alternative to removing the bladder.
The side effects of bladder cancer surgery depend on the procedure. Patients should talk with their doctor in detail to understand exactly what side effects may occur, including urinary and sexual side effects, and how they can be managed. In general, side effects may include:
1. Delayed healing
3. Mild bleeding and discomfort after surgery.
4. Infections or urine leaks after cystectomy or a urinary diversion. If a neobladder has been created, a patient may sometimes be unable to urinate or completely empty the bladder.
Men may be unable to have an erection, called impotence, after cystectomy. Sometimes, a nerve-sparing cystectomy can be performed. When this is done successfully, men may be able to have a normal erection.
Damage to the nerves in the pelvis and loss of sexual feeling and orgasm for both men and women. Often, these problems can be fixed.
Patients should talk to their doctor about any side effects they are experiencing.
Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. A chemotherapy regimen typically consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.
There are two types of chemotherapy that may be used to treat bladder cancer. The type the doctor recommends and when it is given depends on the stage of cancer. Patients should talk with their doctor about chemotherapy before surgery.
Intravesical chemotherapy. Intravesical (local) chemotherapy is usually given by a urologist. During this type of therapy, drugs are delivered into the bladder through a catheter that has been inserted through the urethra. Local treatment only destroys superficial tumour cells that come in contact with the solution. It cannot reach tumour cells in the bladder wall or tumour cells that have spread to other organs. Mitomycin (Mitozytrex, Mutamycin) and thiotepa (multiple brand names) are the drugs used most often for intravesical chemotherapy. Other drugs that are used include doxorubicin (Adriamycin), gemcitabine (Gemzar), and valrubicin (Valstar).
Systemic chemotherapy. Systemic (whole body) chemotherapy is usually prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication. Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).
A combination of drugs, called MVAC, has been the standard treatment for bladder cancer for many years. MVAC combines four drugs: methotrexate (multiple brand names), vinblastine (Velban, Velsar), doxorubicin, and cisplatin (Platinol). When given before surgery, MVAC can extend life and cure patients. For people with bladder cancer that has spread, known as metastatic disease, this combination can shrink cancer and potentially prolong life. In addition, depending on the situation, MVAC may help delay bladder cancer recurrence. However, it has severe side effects.
The combination of gemcitabine plus cisplatin may also be recommended. It provides similar benefits as MVAC for people with metastatic disease, but this combination has somewhat fewer side effects.
Many systemic chemotherapies continue to be tested in clinical trials to help find out which drugs or combinations of drugs work best to treat bladder cancer. Usually, a combination of drugs works better than one drug alone. Researchers are also studying when it is best to use chemotherapy, either before or after surgery.
Side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, the risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhoea. These side effects usually go away once treatment is finished.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications.
Immunotherapy (updated 05/2016)
Immunotherapy also called biologic therapy, is designed to boost the body’s natural defences to fight cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
The standard immunotherapy drug for bladder cancer is a weakened bacterium called bacillus Calmette-Guerin (BCG), which is similar to the bacteria that causes tuberculosis. BCG is placed directly into the bladder through a catheter. This is called intravesical therapy. BCG attaches to the inside lining of the bladder and stimulates the immune system to destroy a tumour. BCG can cause flu-like symptoms, chills, mild fever, fatigue, a burning sensation in the bladder, and bleeding from the bladder.
Interferon (Roferon-A, Intron A, Alferon) is another type of immunotherapy that can be given as intravesical therapy. It is sometimes combined with BCG if using BCG alone does not help treat cancer.
One active area of immunotherapy research is looking at drugs that block a protein called PD-1. PD-1 is found on the surface of T-cells, which are a type of white blood cell that directly helps the body’s immune system fight disease. Because PD-1 keeps the immune system from destroying cancer cells, stopping PD-1 from working allows the immune system to better eliminate the disease. One such drug, atezolizumab (Tecentriq), received FDA approval in May 2016 for use by patients with advanced or metastatic urothelial carcinoma and for whom platinum-containing chemotherapy was not effective.
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation therapy is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.
Radiation therapy is usually not used by itself as a primary treatment for bladder cancer, but it may be given in combination with chemotherapy. Some people who cannot receive chemotherapy might receive radiation therapy alone. The combination of radiation therapy and chemotherapy may be used to treat cancer that is located only in the bladder for the following reasons:
To destroy any cancer cells that may remain after TURBT to avoid removing all or part of the bladder
To relieve symptoms caused by a tumour, such as pain, bleeding, or blockage
To treat a metastasis located in one area, such as the brain or bone
Side effects from radiation therapy may include fatigue, mild skin reactions, and loose bowel movements. For bladder cancer, side effects most commonly occur in the pelvic or abdominal area and may include bladder irritation with the need to pass urine frequently during the treatment period and bleeding from the bladder or rectum. Most side effects go away soon after treatment is finished.
Getting care for symptoms and side effects
Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.
Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process.
People often receive treatment for cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate cancer, such as chemotherapy, surgery, or radiation therapy. Talk to your doctor about the goals of each treatment in your treatment plan.
Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and palliative care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible.
Developing a treatment plan
The first treatment a person is given is called first-line therapy. If that treatment stops working, then a person receives second-line therapy. In some situations, third-line therapy may also be available.
Adjuvant therapy is a treatment that is given after the first treatment, which is usually surgery. Neoadjuvant therapy is a treatment that is given before the primary treatment, such as chemotherapy before surgery.
The treatment options your doctor recommends mainly depend on the stage of bladder cancer you have been diagnosed with. (See the Stages and Grades section above for detailed descriptions of each stage.) However, the tumour’s size and grade may also affect the recommended treatment options. Talk with your doctor about the risks and benefits of all the available treatment options and when treatment should begin.
Non-muscle-invasive bladder cancer
People with low-grade, non-muscle-invasive bladder cancer rarely develop aggressive or metastatic bladder cancer. However, they are at risk for developing additional low-grade cancers throughout their life. This requires life-long checkups, called surveillance, using cystoscopy. For people who develop frequent recurrences, the urologist may recommend having intravesical chemotherapy to prevent more recurrent tumours from developing.
People with high-grade, non-muscle-invasive bladder cancer are at risk for developing recurrent tumours. Sometimes these tumours come back at a more advanced stage with a risk of developing metastatic bladder cancer. To prevent this from happening, the urologist may recommend removing the whole bladder (radical cystectomy), especially if the person is young and/or has large tumours or a number of tumours at the time of diagnosis.
More often, people with high-grade, non-muscle-invasive bladder cancer receive intravesical immunotherapy using BCG after TURBT to prevent recurrence and the development of muscle-invasive disease. Before BCG treatment, these patients will need to have another TURBT to make sure that cancer has not spread to the muscle. The first round of BCG treatment is given weekly for six weeks. After that, the doctor will perform a cystoscopy and sometimes a bladder biopsy to see if the BCG has eliminated all of the cancer. If there is no evidence of cancer, the person will have maintenance therapy, which may be given once a week for three weeks or every six months, for three years, followed by lifelong surveillance. If recurrent tumours develop, the doctor may recommend having a cystectomy.
Muscle-invasive bladder cancer
Bladder cancer found at this stage has grown into the muscle layer of the bladder wall. As with other stages of cancer, surgery is often used as the initial treatment. However, instead of TURBT, a radical cystectomy is the standard treatment. Lymph nodes near the bladder are usually removed as well. A TURBT may still be done, but it usually is used to help the doctor figure out the extent of cancer rather than as a treatment option.
People with muscle-invasive bladder cancer are optimally treated with systemic chemotherapy followed by radical cystectomy and urinary diversion (see above). Research shows that having chemotherapy before a radical cystectomy reduces the risk of cancer spreading to other parts of the body and increases survival for men with muscle-invasive bladder cancer.
An important clinical trial showed that having MVAC chemotherapy before radical cystectomy helped patients with muscle-invasive bladder cancer live longer. Based on this research, this approach is considered a standard treatment for people whose overall health allows it, meaning they have adequate kidney and heart function and functional status. This type of initial chemotherapy, called neoadjuvant chemotherapy, may shrink the tumour in the bladder and may also destroy small areas of cancer that have spread beyond the bladder.
It is important to note that chemotherapy with one drug does not seem to help patients with locally advanced bladder cancer live longer, and some people may not be healthy enough to receive chemotherapy. Therefore, it is important for anyone who has been diagnosed with muscle-invasive bladder cancer to talk with a urologist and medical oncologist about their treatment options, including the risks and benefits of chemotherapy.
In very specific people with small muscle-invasive cancers, an approach using chemotherapy with radiation therapy may provide the same benefits as removing the bladder.
Metastatic bladder cancer
If bladder cancer has spread to another part of the body, it is called metastatic bladder cancer. Patients with this diagnosis are encouraged to talk with doctors, usually medical oncologists, who are experienced in treating this stage of cancer because there can be different opinions about the best treatment plan.
Your health care team may recommend a combination of treatments to help manage cancer. There are no methods to permanently cure metastatic bladder cancer for most people. The goals of treatment are to slow the spread of cancer, shrink a tumour (called remission, see below), and extend life for as long as possible. Palliative care is also important to help relieve symptoms and side effects.
Since there are relatively few treatment options for metastatic bladder cancer, clinical trials are often the best option for treatment. Currently, the standard treatment options are MVAC and gemcitabine-cisplatin chemotherapy. There are other drugs and combinations that can be used for patients who for medical reasons are unable to receive gemcitabine-cisplatin or MVAC. Changes to these regimens or the use of new treatment regimens aimed at helping patients live longer and improve their quality of life are being studied in clinical trials.
For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the healthcare team. It may also be helpful to talk with other patients, including through a support group.
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission may be temporary or permanent. This uncertainty causes many people to worry that cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if cancer does return.
If cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence, also known as metastasis).
When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options.
In general, non-muscle-invasive bladder cancers that come back in the same location as the original tumour or somewhere else in the bladder are treated in the same way as first cancer. However, if cancer continues to return after treatment, a cystectomy may be recommended. Bladder cancers that recur outside the bladder are more difficult to eliminate with surgery and are often treated with chemotherapy and/or radiation therapy. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope.
If treatment fails
Recovery from bladder cancer is not always possible. If cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and advanced cancer is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The healthcare team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.
Patients who have advanced cancer and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.
The word survivorship means different things to different people. Two common definitions include:
Having no signs of cancer after finishing treatment.
The process of living with, through, and beyond cancer. According to this definition, cancer survivorship begins at diagnosis and includes people who continue to have treatment over the long term, to either reduce the risk of recurrence or to manage chronic disease.
In some ways, survivorship is one of the most complex aspects of the cancer experience because it is different for every person.
Survivors may experience a mixture of strong feelings, including joy, concern, relief, guilt, and fear. Some people say they appreciate life more after a cancer diagnosis and have gained a greater acceptance of themselves. Others become very anxious about their health and uncertain of how to cope with everyday life.
Survivors may feel some stress when frequent visits to the healthcare team end following treatment. Often, relationships built with the cancer care team provide a sense of security during treatment, and people miss this source of support. This may be especially true as new worries and challenges surface over time, such as any late effects of treatment, emotional challenges including fear of recurrence, sexuality and fertility concerns, and financial and workplace issues.
Every survivor has individual concerns and challenges. With any challenge, a good first step is being able to recognize your fears and talk about them. Effective coping requires:
Understanding the challenge you are facing,
Thinking through solutions,
Asking for and allowing the support of others, and
Feeling comfortable with the course of action you choose.
Many survivors find it helpful to join an in-person support group or an online community of survivors. This allows you to talk with people who have had similar first-hand experiences. Other options for finding support include talking with a friend or member of your health care team, individual counselling, or asking for assistance at the learning resource centre of the centre where you received treatment.
Changing role of caregivers
Family members and friends may also go through periods of transition. A caregiver plays a very important role in supporting a person diagnosed with cancer, providing physical, emotional, and practical care on a daily or as-needed basis. Many caregivers become focused on providing this support, especially if the treatment period lasts for many months or longer.
However, as treatment is completed, the caregiver's role often changes. Eventually, the need for caregiving related to the cancer diagnosis will become much less or come to an end.
A new perspective on your health
For many people, survivorship serves as a strong motivator to make positive lifestyle changes.
People recovering from bladder cancer are encouraged to follow established guidelines for good health, such as not smoking, limiting alcohol, eating well, and managing stress. Regular physical activity can help rebuild your strength and energy level. Your health care team can help you create an appropriate exercise plan based on your needs, physical abilities, and fitness level.
In addition, it is important to have recommended medical check-ups and tests to take care of your health. Cancer rehabilitation may also be recommended, and this could mean any of a wide range of services such as physical therapy, career counselling, pain management, nutritional planning, and/or emotional counselling. The goal of rehabilitation is to help people regain control over many aspects of their lives and remain as independent and productive as possible.
Talk with your doctor to develop a survivorship care plan that is best for your needs.
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