Bladder Cancer: Every year, an estimated 50,000 Americans develop bladder cancer and 11,000 die from this disease. It is the fifth common cancer in American men. It is more frequent in men than in women with a ratio of 3:1. Average age at the time of diagnosis if 65 years. Fortunately, most patients are diagnosed in early stages, when cure is possible.

Cause: Cigarette smoking is responsible factor in up to 50% of the patients who develop this condition. Chronic bladder infections and Certain medications, if taken for many years (Phenacetin).

Signs and symptoms: Painless bleeding in the urine is the most common sign of this disease. The cancer tissue in the bladder has a tendency to break and bleed.  Bleeding may be microscopic and very minimal initially, when it can be only detected in an analysis of urine.  with progression of the disease, the bleeding may become noticeable to the patients, and may be even associated with passing blood clots in the Urine.

Diagnosis: When suspected, an endoscopy study of bladder (cystoscopy) should be performed. This procedure will allow for direct visual examination of the bladder as well as obtaining a biopsy at the same time. CT scan , MRI and Ultrasound examination of the abdomen and pelvis may be used to establish the extent of this cancer.

Staging: Endoscopic ultrasound is a very sensitive study that should be done to determine the depth of invasion of the cancer into the tissues around bladder, as well as evaluation of the local lymph glands.CT Scan of abdomen, as well as bone scans may have to be done to complete the staging work up.

• Stage 0, In situ cancer

• Stage A, Disease that is limited to the inside surface of bladder

• Stage B, Disease that extends though the thickness of bladder

• Stage C, Disease that extends to the outside of bladder

• Stage D, Disease spread to other organs, like bowels, rectum, lungs, liver, etc.

Information obtained from the cystoscopy examination, along with X rays, CT Scan, etc. will help in determining the stage of the disease as well as the best treatment option.

Treatment: Stages 0 and A: Management of the disease at these stages primarily relies on surgery, attempting to remove most or all of the cancer form bladder. This is done at the time of cystoscopy, whereby, the physician is able to see the sites of the disease and can practically scrape and remove the superficial tumors from the bladder. This procedure is known as Transurethral bladder resection. Additional use of topical chemotherapy to the cancer site, in form of administering the drugs directly into the bladder cavity has become an important part of treating very early cancers.  Chemotherapy drugs (Thiotepa, Adriamycin) are introduced into the bladder by way of using a bladder catheter (which is plastic rubbery tube that is inserted into the penis and further up into the bladder). This method of chemotherapy is done by placing a plastic tube (Foley catheter) into the bladder and administering the drugs directly into the bladder cavity via this catheter.  The drugs will then go to the inside of bladder cavity.  The Foley catheter is then locked (clamped) and the medicine is allowed to stay in the bladder for a length of time.  Thereafter, the catheter is unclamped and the urine that contains the drugs is drained.

BCG (the tuberculosis vaccine), is another drug that is used for local treatment of early stages of bladder cancer. It is administered the same way as described above by using a Foley catheter. The mechanism action of BCG is rather unclear, but it seems it may have a stimulating effect on the immune cells in the bladder wall and cause indirect damage to the cancerous tissue. BCG contains bacterial particles.  In order to destroy them, bladder tissue will react to these particles. The response to bacteria may also damage and destroy the superficial cancer cells.

Stage B: The treatment of choice for these patients is aggressive surgery and complete removal of the bladder. In certain patients, in whom the disease is limited to one site in the bladder, a partial removal of bladder may be feasible and appropriate.

Stage C: This stage of bladder cancer is mostly diagnosed after the surgery is performed and the removed bladder is studied under microscope by the pathologist. Such patients should be best treated with radiation and chemotherapy.

Stage D: When the disease is widely spread to different places, patients are best treated with radiation and chemotherapy.

Radiation has two roles in treatment of this cancer. Help with the local control of the cancer and to increase the cure rate. At times, this is achieved by combining it with chemotherapy. Help with control of the symptoms of the advanced disease, for example in treatment of metastasis to bones, etc.

Chemotherapy is used in a variety of situations: Topical chemotherapy to the cancer site, in form of administering the drugs directly into the bladder for stage 0-A. Prior to surgery, and combined with radiation. After the surgery, and combined with radiation.For patients, in whom the disease is not cured with surgery or has reoccurred, and patients with stage D disease.

Methotrexate, Vinblastine, Adriamycin, Cytoxan, Cisplatinum, Ifosfamide, Taxol, Thiotepa, 5-FU and Leucovorin are among the most commonly used drugs for bladder cancer. These drugs are used in combination and can have moderate to severe toxic effects.

Pattern of Spread: Normally, bladder cancer progresses slowly.  It many cases, it may be managed for years with simple cystoscopy and resection of the tumors from bladder.  This cancer has a tendency to re-occur, even if diagnosed at very early stages.  Therefore frequent cystoscopy are mandatory for evaluation and management of this condition.

If left untreated, or if it fails to respond to treatment, bladder cancer can spread to other organs such  liver, Lymph glands in the abdomen, lungs and other areas of the body.

Prognosis: When diagnosed early, which is the case in majority of situations, bladder cancer is highly curable, otherwise, it carries a poor prognosis. Patients with advanced stages, do respond to treatments, however cure may not be possible.

Special Situations: Patients with advanced bladder cancer may develop many complications, among which are: Bone metastasis, Lung metastasis, Pain, Urinary obstruction, Kidney failure.

Survival: Survival of patients with this cancer depends on the type and extent of the cancer at the time of initial diagnosis. Majority of patients with early stages can be cured with surgery alone. In patients, in whom cure is not possible, survival could vary from months to years, depending on the extent of cancer and overall condition of the patient as well as their response to treatments and the duration of their response.

Follow up: After completion of treatment, in any combination that might have taken place, patients need to remain under surveillance for possibility of recurrence of cancer. Follow up shall be scheduled on a regular basis and initially every 1-3 months for 1-2 years. The frequency of follow up will depend on the condition of the patients and their disease. In follow up visit, patients are examined and blood tests are obtained. Cystoscopy as well as a CT scan of abdomen may be obtained at regular intervals.

Treatment of advanced or recurrent disease will depend on the stage and extent of the reoccurred disease. Most patients are treated with chemotherapy, using the same drugs as mentioned above. Radiation therapy may be helpful in managing painful or symptomatic areas where the cancer has spread to. If patients experience pain, different pain medications could be used to alleviate the pain.  

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