Bladder Cancer

Definition of Bladder Cancer

Cancer that forms in tissues of the bladder (the organ that stores urine). Most bladder cancers are transitional cell carcinomas (cancer that begins in cells that normally make up the inner lining of the bladder). Other types include squamous cell carcinoma (cancer that begins in thin, flat cells) and adenocarcinoma (cancer that begins in cells that make and release mucus and other fluids). The cells that form squamous cell carcinoma and adenocarcinoma develop in the inner lining of the bladder as a result of chronic irritation and inflammation.

The Bladder:

Your bladder is a hollow organ in the lower abdomen. It stores urine, the liquid waste made by the kidneys.

Your bladder is part of the urinary tract. Urine passes from each kidney into the bladder through a long tube called a ureter. Urine leaves the bladder through a shorter tube (the urethra).

The wall of the bladder has layers of tissue:

• Inner Layer: The inner layer of tissue is also called the lining. As your bladder fills up with urine, the transitional cells on the surface stretch. When you empty your bladder, these cells shrink.
• Middle Layer: The middle layer is muscle tissue. When you empty your bladder, the muscle layer in the bladder wall squeezes the urine out of your body.
• Outer Layer: The outer layer covers the bladder. It has fat, fibrous tissue, and blood vessels.

Cancer Cells

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the bladder and the other organs of the body.

Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place.

Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor.

Tumors in the bladder can be benign (not cancer) or malignant (cancer). Benign tumors are not as harmful as malignant tumors:

Benign Tumors:

• are usually not a threat to life
• can be treated or removed and usually don't grow back
• don't invade the tissues around them
• don't spread to other parts of the body

Malignant Growths:

• may be a threat to life
• usually can be removed but can grow back
• can invade and damage nearby tissues and organs (such as the prostate in a man, or the uterus or vagina in a woman)
• can spread to other parts of the body

Bladder cancer cells can spread by breaking away from the original tumor. They can spread through the blood vessels to the liver, lungs, and bones. In addition, bladder cancer cells can spread through lymph vessels to nearby lymph nodes. After spreading, the cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues. See the Staging section for information about bladder cancer that has spread.

Risk Factors of Bladder Cancer

When you get a diagnosis of bladder cancer, it's natural to wonder what may have caused the disease. Doctors can't always explain why one person gets bladder cancer and another doesn't.

However, we do know that people with certain risk factors may be more likely than others to develop bladder cancer. A risk factor is something that may increase the chance of getting a disease.

Studies have found the following risk factors for bladder cancer:

Smoking: Smoking tobacco is the most important risk factor for bladder cancer. Smoking causes most of the cases of bladder cancer. People who smoke for many years have a higher risk than nonsmokers or those who smoke for a short time.

Chemicals in the workplace: Some people have a higher risk of bladder cancer because of cancer-causing chemicals in their workplace. Workers in the dye, rubber, chemical, metal, textile, and leather industries may be at risk of bladder cancer. Also at risk are hairdressers, machinists, printers, painters, and truck drivers.

Personal history of bladder cancer: People who have had bladder cancer have an increased risk of getting the disease again.

Certain cancer treatments: People with cancer who have been treated with certain drugs (such as cyclophosphamide) may be at increased risk of bladder cancer. Also, people who have had radiation therapy to the abdomen or pelvis may be at increased risk.

Arsenic: Arsenic is a poison that increases the risk of bladder cancer. In some areas of the world, arsenic may be found at high levels in drinking water. However, the United States has safety measures limiting the arsenic level in public drinking water.

Family history of bladder cancer: People with family members who have bladder cancer have a slightly increased risk of the disease.

Many people who get bladder cancer have none of these risk factors, and many people who have known risk factors don't develop the disease.

Symptoms of Bladder Cancer

Bladder cancer may cause these common symptoms:

• Finding blood in your urine (which may make the urine look rusty or darker red)
• Feeling an urgent need to empty your bladder
• Having to empty your bladder more often than you used to
• Feeling the need to empty your bladder without results
• Needing to strain (bear down) when you empty your bladder
• Feeling pain when you empty your bladder

These symptoms may be caused by bladder cancer or by other health problems, such as an infection. People with these symptoms should tell their doctor so that problems can be diagnosed and treated as early as possible.

Treatment of Bladder Cancer

Treatment options for people with bladder cancer are surgery, chemotherapy, biological therapy, and radiation therapy. You may receive more than one type of treatment.

The treatment that’s right for you depends mainly on the following:

• The location of the tumor in the bladder
• Whether the tumor has invaded the muscle layer or tissues outside the bladder
• Whether the tumor has spread to other parts of the body
• The grade of the tumor
• Your age and general health

You may have a team of specialists to help plan your treatment. Your doctor may refer you to a specialist, or you may ask for a referral. You may want to see a urologist, a surgeon who specializes in treating problems in the urinary tract. Other specialists who treat bladder cancer include urologic oncologists (surgeons who specialize in cancers of the urinary tract), medical oncologists, and radiation oncologists.

Your health care team may also include an oncology nurse and a registered dietitian. If your treatment involves surgery to remove the bladder, a wound, ostomy and continence nurse may also be part of your team.

Your health care team can describe your treatment choices, the expected results of each, and the possible side effects. Because cancer therapy often damages healthy cells and tissues, side effects are common. These side effects depend on many factors, including the type and extent of treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. You and your health care team can work together to develop a treatment plan that meets your needs.

You may want to ask your doctor these questions before you begin treatment:

• What is the stage of the disease? Has the tumor invaded the muscle layer of the bladder or spread to other organs?
• What are my treatment choices? Which do you suggest for me? Why?
• What are the expected benefits of each kind of treatment?
• What can I do to prepare for treatment?
• Will I need to stay in the hospital? If so, for how long?
• What are the risks and possible side effects of each treatment? How can side effects be managed?
• What is the treatment likely to cost? Will my insurance cover it?
• How will treatment affect my normal activities?
• Would a research study (clinical trial) be a good choice for me?
• Can you recommend other doctors who could give me a second opinion about my treatment options?
• How often should I have checkups?

Surgery

Surgery is an option for most people with bladder cancer. You and your surgeon can talk about the types of surgery and which may be right for you:

• Transurethral resection (TUR): The doctor uses a cystoscope to treat early bladder cancer (Stage 0 or Stage I). No incision (cut) into your body is needed, but general anesthesia or spinal anesthesia is usually given. The doctor inserts the cystoscope into the bladder through your urethra. The cutting tool is slipped through the cystoscope. A small wire loop at the end of the tool removes the cancer and burns away remaining cancer cells with an electric current. TUR may need to be repeated. Also, chemotherapy or biological therapy may be given after this type of surgery. For a few days after TUR, you may have some blood in your urine and difficulty or pain when passing urine. Otherwise, TUR generally causes few problems.
• Open surgery: The surgeon makes an incision into your body to remove the cancer from your bladder. Part of the bladder (called a partial cystectomy): For some people with a single, small tumor in the bladder, the surgeon does not remove the entire bladder. The surgeon removes the tumor, the part of the bladder containing the tumor, and nearby lymph nodes.After part of the bladder is removed, you may not be able to hold as much urine in your bladder as before surgery. You may need to empty your bladder more often. This problem usually gets better with time.
• Removal of all of the bladder (called a radical cystectomy): For bladder cancer that has invaded the muscle layer (Stage II or some Stage III), the most common type of surgery is radical cystectomy. The surgeon removes the entire bladder, nearby lymph nodes, and part of the urethra. In addition, the surgeon usually removes the prostate from a man and may remove the uterus from a woman. Other nearby tissues may also be removed. When the entire bladder is removed, the surgeon makes another way for urine to be collected from the kidneys and stored. You may wear a flat bag outside the body under your clothes, or the surgeon may use part of your intestine to create a pouch inside the body. The Rehabilitation section has more information.

When the prostate or uterus is removed, a man can no longer father a child and a woman can no longer get pregnant. Also, a man may be unable to have sex after surgery. If the surgeon removes part of a woman’s vagina, sex may be difficult.

Because bladder cancer surgery may affect your sex life, it may help you and your partner to talk about your feelings and help one another find ways to share intimacy during and after treatment.

It takes time to heal after surgery, and the time needed to recover is different for each person. It’s common to feel weak or tired for a while.

Also, you may have pain or discomfort for the first few days. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain control.

You may want to ask your doctor these questions before having surgery:

• What type of surgery do you recommend for me? Why?
• Will lymph nodes and other tissues be removed? Why?
• How will I feel after surgery? If I have pain, how will you control it?
• How long will I be in the hospital?
• Will I have any long-term effects because of the surgery?
• If my bladder is removed, who will teach me how to store urine in a pouch or bag?
• If my bladder is removed, will I need to wear a medical alert bracelet for the rest of my life?

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. It may be used to treat bladder cancer before or after surgery. You may receive chemotherapy in different ways:

• Into the bladder: After TUR for early bladder cancer, the doctor inserts a tube (catheter) through your urethra to put a liquid drug in the bladder. The drug remains in your bladder for several hours. This treatment may be given once a week for six weeks.
• By mouth: Some drugs are pills that you can swallow. They may be given before or after surgery.
• Into a vein: For cancer that has invaded the muscle of the bladder or spread to other tissues, drugs are usually given by vein (intravenous). The drugs enter the bloodstream and travel throughout your body. Chemotherapy may be given before or after surgery. You may have your treatment in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, you may need to stay in the hospital.

Chemotherapy is usually given in cycles. Each cycle has a treatment period followed by a rest period.

The side effects depend mainly on how the drug is given. If the drugs are given into the bladder, the side effects are usually mild. For a few days after treatment, you may need to empty your bladder more often. You may have blood in your urine. Also, you may have pain when emptying your bladder. Some people get a rash. These problems usually go away after treatment.

If the drugs are given by vein or taken by mouth, the side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:

• Blood cells: When drugs lower the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
• Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment, but the color and texture may be changed.
• Cells that line the digestive system: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems. They usually go away when treatment ends.

Some drugs used for bladder cancer may also cause tingling or numbness in your hands and feet. Your health care team can suggest ways to control many of these side effects.

You may wish to read the NCI booklet Chemotherapy and You.

Biological Therapy

People with early bladder cancer may receive a treatment called biological therapy. The treatment is BCG solution, which is a liquid containing weakened bacteria. The bacteria help your body's natural defenses (the immune system) to kill cancer cells in the bladder.

Several weeks after TUR, the doctor inserts a tube through your urethra to put a liquid treatment in your bladder. You'll be asked to hold the liquid treatment in your bladder for about two hours.

BCG solution is usually given once a week for six weeks. This treatment helps keep the cancer from coming back.

You may feel unusually tired during the treatment period. Also, BCG solution can irritate the bladder. You may feel an urgent need to empty your bladder, and you may need to empty your bladder more often. Also, you may have pain, especially when emptying your bladder. You may have blood in your urine, nausea, a fever, or chills. Tell your health care team about any problems that you have during the treatment period.

It may help to know that the side effects usually go away when treatment is over.

You may want to ask your doctor these questions about chemotherapy or biological therapy:

• Why do I need this treatment?
• Which drug or drugs will I have?
• How do the drugs work?
• When will treatment start? When will it end?
• Will I have any long-term side effects?

Radiation Therapy

Radiation therapy uses high-energy rays to kill cancer cells. It may be given after surgery. Usually it’s given along with chemotherapy for cancer that has invaded the muscle layer of the bladder. However, it is sometimes given instead of surgery or chemotherapy.

The radiation comes from a large machine. The machine aims beams of radiation at the bladder area in the abdomen.

You’ll go to a hospital or clinic 5 days a week for several weeks to receive radiation therapy. Each treatment session takes about 30 minutes.

Although radiation therapy is painless, it may cause other side effects. The side effects include nausea, vomiting, or diarrhea. Also, you may feel very tired during radiation therapy. Your health care team can suggest ways to treat or control these side effects.

You may want to ask your doctor these questions about radiation therapy:

• Why do I need this treatment?
• When will the treatments begin? When will they end?
• How will I feel during treatment?
• How will we know if the radiation treatment is working?
• Will I have any long-term side effects?