indiacancer.org - Bladder Cancer

Bladder Cancer

		What is Urinary Bladder?
		What is Bladder Cancer?
		How does Bladder Cancer present?
		How is Bladder Cancer detected?
		What are staging and grading?
		How is Bladder Cancer treated?
		What are the side effects of Bladder Cancer treatment?
		What are the possible causes of Bladder Cancer?
		What is the importance of follow up?
		Can you prevent Bladder Cancer?
		How do Bladder Cancer patients return to normal life?

What is Urinary Bladder?

The kidneys filter blood and the waste which is produced known as urine, passes into a reservoir placed centrally in the lower abdomen known as the Bladder. This pouch like structure is muscular and has an ability to expand depending upon the volume of urine it contains. The connection between the Bladder and the kidneys is established with the help of two hollow, muscular tubes known as the ureters.

The Urinary Bladder (Cut open and seen from the front)

	What is Bladder Cancer?

The Urinary Bladder with the Prostate Gland below.
(3-D View)

The inner lining of the Bladder is made up of a special type of cells known as transitional cells. Cancer of the Bladder starts from these cells and is therefore known as transitional cell carcinoma.

If the cancer involves only the mucosa (which comprises the transitional cell layer), then it is known as superficial Bladder Cancer.

If the cancer penetrates to the mucosa into the muscular layers of the Bladder wall or beyond, then it is known as invasive Bladder Cancer.

From the Bladder, invasive cancer can spread locally and involve adjacent organs and structures. The cancer can also spread via small lymph channels (which carry lymph, a clear fluid ) to neighboring or distant lymph nodes or even lodge as cancerous deposits (spreading via the blood stream) in other organs such as lungs. The cancer is now known as metastatic Bladder Cancer, and the cancerous deposits in the lung are still transitional cell cancers and not lung cancers.

	How does Bladder Cancer present?

	The usual ways in which Bladder Cancer presents (otherwise known as symptoms of Bladder Cancers) are as follows:
		Bloody urine (a bloody tinge in the urine or even frank blood).
		Requency and Urgency - there is an urgent need to pass urine and more often than usual but many times without actually passing urine.
		Pain in the lower abdomen of a dull, aching variety.

	How is Bladder Cancer detected?

	There are several steps to establishing the presence of a Bladder Cancer.
		The doctor takes a history of the patient's symptoms.
		The doctor examines the patient physically - including an internal examination (i.e., a rectal or vaginal examination), in order to check whether the mass (if present) is palpable.
		A series of investigations are performed. Those specific for Bladder Cancer include:
	Urine examination A sample of the patient's urine is checked under the microscope for cancer. A procedure called cystoscopy is performed in which an instrument called the cystoscope is introduced into the patient's Bladder in order to allow the clinician to visualize the tumor, its location, size and take a biopsy (a small piece) from it for histopathology (tissue examination under microscope to confirm the cancer and its type). This is usually done under cover of some form of anaesthesia, either general or local. Sometimes, treatment may be effected during the biopsy itself, if the lesion is small and the whole tumor can be removed at one go.

	What are staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs

The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive.

Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome. Staging may require additional imaging tests such as CT Scan, MRI, Sonography, IVU, Bone scan or chest X-ray.

	How is Bladder Cancer treated?

A lot depends on the patient's constitution, the grade of his disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes a urologist, an oncosurgeon and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy or biological therapy may become add ons.

Treatment strategies.
The bastion of Bladder Cancer treatment is surgery.

The easiest form of treatment is of course, when the entire tumor is resected at the time of biopsy. This procedure goes by the name of Trans Urethral Resection (TUR). The procedure involves burning of the tumor cells using an electrical diathermy in the form of a wire loop called resectoscope.

Radical cystectomy is the most popular method of resection preferred by many oncosurgeons. The indications are either invasive transitional cell carcinoma or massive superficial transitional cell carcinoma. The extent of resection encompasses the entire urinary Bladder, the associated chains of lymph nodes and any adjacent involved organ.

Routine resection margins in women includes the uterus and adenexae and part of the vagina. In men, the corresponding organs sacrificed are the seminal vesicles and the prostate.

Sometimes, the disease found on table may be too extensive to warrant complete resection. under these circumstances, only the Bladder is removed to circumvent the urinary symptoms due to the cancer.

When the Bladder is no longer in situ, the doctor finds another way to divert the urine outside the body. Various alternatives are available The commonest method is to perform an ileal conduit, in which a new tube is made using a part of the patient's small intestine. The ureters are implanted to this intestinal segments. The intestinal segment opens to the wall of the abdomen and this opening is called a stoma. Sometimes, the intestinal segment may be refashioned to make it continent (i.e. able to store urine instead of just acting as a passive conduit). The urine which comes out is collected in a special bag called a stoma bag which is held in place by adhesive tapes.

When a patient has a low grade cancer with only a small area of the Bladder invaded, a partial cystectomy, which involves removal of only a segment of the Bladder may be performed. In this case, no urinary diversion is necessary.

The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It also affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced Bladder Cancer.

Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after.

Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used.

Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the Bladder is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy.

This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks.)

Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after.

Bladder Cancer also employs another form of treatment called biological therapy. But this option is restricted only to cancers which are superficial, again in combination or without conjunction with chemotherapy and surgery. The substance used is BCG a common vaccination used in tuberculosis. BCG is introduced directly into the Bladder cavity and allowed to act locally by asking the patient to hold his urine for 2-3 hours.

	What are the side effects of Bladder Cancer treatment?

	Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. TUR rarely causes any problems, although the patient may be disconcerted to see a little blood in the urine for a few days after surgery. There may also be a little discomfort while passing urine for a few days. After partial cystectomy, since the capacity of the Bladder is suddenly decreased, for a few days, most patients have to go more frequently to the toilet. This problem usually alleviates after some time, as the Bladder distends to almost normal size. But in some patients, this phenomenon may never occur and they may always have to compromise with frequent urination. Men who have had their Bladder, prostate and seminal vesicles removed experience dry orgasms and cannot produce semen or father children. Women likewise can never become mothers as their uteri have been removed during radical surgery. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. It is also not uncommon to see impotence develop in those patients who are subjected to external radiation. This is usually temporary. Vaginal dryness is also known to occur in women, thus sexual intercourse during radiation therapy is discouraged. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are.
		Skin rashes
		Loss of hair
		Diarrhea
		Vomiting
		Tingling and numbness in the fingers and toes
		Hearing loss
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient. BCG intravesical therapy may cause the following problems:
		Pain during urination
		Frequent and urgent need to urinate.
		Low grade fever.
		Nausea and vomiting (usually mild).
		Rashes and bruises.
	All these problems disappear on cessation of therapy.

	What are the possible causes of Bladder Cancer?

	The following factors have strong links with Bladder Cancer. Smoking is a major risk factor. The chances of developing Bladder Cancer is increased by almost threefold in smokers. People above the age of 55 years have greater chances of developing Bladder Cancer. The following occupations (due to exposure to cancer causing agents at the workplace) pose a higher risk for Bladder Cancer.
		Rubber, chemical and leather industries.
		Dye and metal industries.
		Truck drivers, hair dressers and mechanics.
		Printers, painters and textile workers.

	What is the importance of follow up?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination ), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.

	Can you prevent Bladder Cancer?

	Not always. But you can certainly reduce the risk by taking the following steps:
		Stop smoking altogether.
		Going for regular check ups if you are above 55 years of age or working in the above mentioned occupations.

	How do Bladder Cancer patients return to normal life?

Especially in those patients who have undergone a radical cystectomy and suffer from the potential social embarassment of using an external urine collection device such as a stoma bag (although this bag is well hidden, some patients always fear scandal in public in the form of the bag bursting, etecetra), it is vitally important that the doctor, nurses and relatives get together to make the patient feel as much at home as possible.

During rehabilitation, it is important for both clinicians and relatives to realise that physical recovery always outpaces emotional recovery and just the removal of the final stitch does not signify the end of the recovery phase. A significant part of the recovery process for the relatives is to be as positive as possible and to get the patient off his or her emotional crutches as early as possible.

Stoma care specialists are available in most cancer hospitals to teach the patient how to comfortably take care of his or her stoma.