More than 90 percent of bladder cancers begin in the cells that make up the inner lining of the bladder wall. Bladder cancer can be treated with surgery, chemotherapy, intravesical chemotherapy, immunotherapy, or radiation therapy.
Each year in the United States, bladder cancer affects about 56,000 men and 17,500 women, and about 12,000 men and 4,700 women die from the disease.
Smoking is not only the main culprit in lung cancer, but it also plays a role in urinary tract cancers, most notably bladder cancer.
What is bladder cancer?
The bladder, a hollow organ in the lower abdomen, acts as a reservoir for urine until it leaves the body through the urethra.
There are different types of bladder cancer. Each type is named according to the type of cancer cells that cause it: transitional cell carcinoma, squamous cell carcinoma, or adenocarcinoma – depending on the types of cells that line the bladder wall where the cancer originates.
Most bladder cancers (more than 90 percent) begin in the transitional cells that occupy the inner lining of the bladder wall. Cancers that originate from these bladder-lining cells can, in some cases, invade the deeper layers of the bladder (called the lamina propria), the thick muscle layer of the bladder, or the bladder wall into the fatty tissue that surrounds the bladder.
Squamous cells are thin, flat cells that line the urethra and can form in the bladder after long bouts of bladder inflammation or irritation. Squamous cell carcinoma makes up about 5 percent of bladder cancers.
Adenocarcinoma is a very rare type of bladder cancer that begins in the glandular (secretory) cells in the lining of the bladder. Only 1 percent to 2 percent of bladder cancers are adenocarcinomas.
What are the causes and risk factors for bladder cancer?
Some factors increase the risk of bladder cancer:
- Cigarette smoking is the most significant risk factor. It doubles the risk. Pipe and cigar smoking and exposure to second-hand smoke may also increase the risk of
- Previous exposure to radiation is the next most common risk factor (for example, as a treatment for cervical cancer, prostate cancer, or rectal cancer)
- Some chemotherapy drugs (such as cyclophosphamide) also increase the risk of bladder cancer
- Environmental exposure increases the risk of bladder cancer. People who handle carcinogenic chemicals, such as aromatic amines (chemicals used in dyes), are at risk. Extensive exposure to rubber, leather, certain textiles, paint, and hairdressing supplies, typically associated with occupational exposure, also appears to increase the risk.
- Infection with a parasite known as schistosomiasis haematobium, which is more common in developing countries and the Middle East
- People who have frequent urinary tract infections, bladder stones, or other urinary tract diseases or who have a chronic need for a bladder catheter may be at higher risk for squamous cell carcinoma.
- Patients with previous bladder cancer are at increased risk of developing new or recurrent bladder tumors.
- Other risk factors include diets high in fried meats and animal fats, and older age. In addition, men are at three times higher risk than women.
What are the symptoms of bladder cancer?
In general, bladder cancer symptoms are nonspecific. Some symptoms of bladder cancer are also symptoms of other conditions and should prompt you to see a doctor.
The presence of blood in the urine is the most important warning sign. Other symptoms include pain during urination and frequent or difficult urination.
What are the stages of bladder cancer?
Bladder cancer can be either early-stage (confined to the bladder lining) or invasive (penetrating the bladder wall and possibly spreading to nearby organs or lymph nodes).
The stages range from T1 (confined to the inner lining of the bladder) to T4 (advanced, more invasive). In early stages (TA, T1, or CIS), the cancer is confined to the bladder’s lining or the connective tissue just below it but has not invaded the main wall of the bladder (muscle).
Stages two through four refer to invasive cancer:
- In stage 2, the cancer spreads to the muscular wall of the bladder.
- In stage 3, the cancer has spread to the fatty tissue outside the bladder muscle.
- In stage 4, the cancer has spread from the bladder to the lymph nodes, neighboring organs, or bones.
The most advanced and preferred staging system is TNM, which stands for tumor stage, lymph node involvement, and metastases. In this system:
Invasive bladder tumors can range from T2 (spread to the main muscle wall of the bladder below the lining) all the way up to T4 (the tumor spreads beyond the bladder to nearby organs or the lateral pelvic wall).
Lymph node involvement ranges from N0 (no lymph node involvement) to N3 (cancer in many lymph nodes or in one or more large lymph nodes greater than 5 cm).
M0 means there is no metastasis outside the pelvis. M1 means it has spread beyond the pelvis.
What tests will I have if my doctor suspects bladder cancer or another urinary problem?
Your doctor will order a urinalysis to determine if a urinary tract infection could be causing your symptoms. A microscopic examination of your urine, called cytology, will look for cancer cells.
A cystoscopy test plays a key role in identifying and diagnosing bladder cancer. In this procedure, a lighted telescope (cystoscope) is inserted into the bladder from the urethra to see inside, and when performed under anesthesia, tissue samples (biopsy) are taken, which are later examined under a microscope for signs of cancer.
When this procedure is performed in the doctor’s office, a local anesthetic gel is placed in the urethra before the procedure to minimize discomfort.
If bladder cancer is diagnosed, the next step is to remove the tumor for detailed staging and diagnosis.
Transurethral resection (TURBT) is a leading urology procedure performed under general or spinal anesthesia in the operating room.
A telescope is inserted into the bladder, and the tumor is removed by scraping it from the bladder wall (part of the bladder wall is removed with it) using a special cystoscope (called a resectoscope). This procedure is diagnostic as well as therapeutic.
This can often be done as an outpatient procedure, with patients being discharged from the hospital on the same day. After removal, the tumor is analyzed by a pathologist, who will determine the type of tumor, tumor grade (aggressiveness), and depth of invasion. The purpose of the procedure is to remove the tumor and obtain important interim information (such as tumor grade and depth of invasion).
For some patients with invasive cancer, a CT scan of the abdomen and pelvis may be the next step to determine if there is any spread of the disease beyond the bladder.
An MRI, which uses magnets, radio waves, and a computer to create detailed images, can also be useful in planning further treatment.
A chest X-ray may also be performed to detect whether any cancer has spread to the lungs. Occasionally, bone imaging may be performed to look for malignant spread (metastasis) of the cancer to the bones. Most of these tests are used selectively, i.e., only in certain patients with relevant symptoms.
Once bladder cancer is diagnosed, the disease is staged using the above-mentioned tests. The stage of the disease will determine the course of treatment.
What are the treatment options for bladder cancer in Turkey?
There are four types of treatment for bladder cancer patients. These include:
- Surgery
- Chemotherapy
- Intravesical chemotherapy or immunotherapy for superficial cancer
- Radiation therapy
Sometimes, combinations of these treatments will be used.
Surgical options for bladder cancer treatment in Turkey
Surgery is a common treatment option for bladder cancer. The type of surgery chosen depends on the stage of the cancer.
Transurethral cystectomy is often used in the early stage of the disease (TA, T1, or CIS). It is performed under general anesthesia or lumbar anesthesia.
In this procedure, a special telescope called a resectoscope is inserted through the urethra into the bladder. The tumor is cut with it.
A partial cystectomy removes part of the bladder. It is sometimes used when a single tumor invades the bladder wall in only one area. This type of surgery preserves most of the bladder. Chemotherapy or radiation therapy is often used in combination. Only a minority of patients are suitable for this bladder-preserving procedure.
Radical cystectomy is the complete removal of the bladder. It is used to treat invasive cancers that have spread beyond the bladder (or multiple early-stage tumors over a large portion of the bladder).
This surgery is often performed in Turkey using a robot that removes the bladder and any other surrounding organs, such as the prostate and seminal vesicles in men and the ovaries, uterus, and part of the vagina in women. This includes the prostate and seminal vesicles in men and the ovaries, uterus, and part of the vagina in women.
Because the bladder has been removed, a procedure called a urinary diversion must be performed so that urine can exit the body. A bag made from the intestines can be made inside the body, or a sealing bag worn outside the body can be used to collect the urine. The procedure usually requires a hospital stay of five to six days.
Chemotherapy for bladder cancer
Chemotherapy tends to use combinations of drugs whose main effect is to either kill or slow down the growth and reproduction of rapidly multiplying cells. Cancer cells absorb chemotherapy drugs faster than normal cells (but all cells in the body are exposed to the chemotherapy drug).
Chemotherapy drugs are given intravenously or can be delivered by injection (directly into the bladder through a catheter passed through the ureter), depending on the stage of the cancer.
Some of the common chemotherapy drugs used to treat bladder cancer include:
- Methotrexate
- Vinblastin
- Doxorubicin
- Cyclophosphamide
- Paclitaxel
- Carboplatin
- Cisplatin
- Ifosfamide
- Gemcitabine
Many of these medications are used in combinations.
Side effects can occur with chemotherapy, and their severity depends on the type of drug used and the patient’s ability to tolerate the drugs. Common side effects of chemotherapy include the following:
- vomiting and nausea
- loss of appetite
- hair loss
- Fatigue due to anemia
- Exposure to infections
- Sores in the mouth
Chemotherapy can be used alone but is often used in combination with surgery or radiation therapy.
Intravesical therapy for bladder cancer
Bladder cancer can be treated with immunotherapy or chemotherapy inside the bladder (through a tube inserted into the urethra and bladder).
Immunotherapy refers to using the body’s immune system to attack cancer cells.
A vaccine called Bacillus Calmette-Guérin (BCG), a tuberculosis vaccine, is commonly used for this purpose in the intravesical treatment of Ta, T1, or carcinoma in situ (limited to the inner lining) of bladder cancer.
In this procedure, a solution containing BCG is kept in the bladder for a few hours before it is drained out.
Intravesical BCG is usually given once a week for six weeks, but sometimes long-term maintenance therapy is needed. Bladder irritation, pain or burning during urination, low-grade fever, and chills are possible side effects of intravesical BCG.
Intravesical chemotherapy with mitomycin C is another treatment option.
Because chemotherapy is given directly into the bladder, other cells in the body are not exposed to the chemotherapy, minimizing the chances of side effects. It is also often given as a single dose after the tumor is removed by cystoscopy.
Radiation therapy for bladder cancer
Radiation therapy destroys the DNA of cancer cells by exposing them to high-energy X-rays or other types of radiation. It may be an alternative to surgery or used in combination with surgery or chemotherapy. Radiation therapy can be delivered externally or internally.
In external beam radiation therapy, the radiation source is a machine outside the body that directs a focused beam of radiation at the tumor. With today’s modern imaging techniques, targeted radiation emitted from multiple angles minimizes radiation exposure to surrounding tissues and organs, limiting damage to these tissues.
External radiation may cause fatigue and skin irritation.
Internal radiation therapy isn’t often used to treat bladder cancer. In this type of treatment, radioactive pellets are inserted into the bladder through the urethra or an incision in the lower abdomen. Brachytherapy requires hospitalization during treatment, which can take several days, after which the pellets are removed.
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