Bladder Cancer

Bladder cancer is a disease in which malignant (cancer) cells form in the tissues of the bladder. Cancer that is confined to the lining of the bladder is called superficial bladder cancer. Cancer that begins in the transitional cells may spread through the lining of the bladder and invade the muscle wall of the bladder or spread to nearby organs and lymph nodes; this is called invasive bladder cancer. Smoking, gender, and diet can affect the risk of developing bladder cancer.

The prognosis depends on the stage of the cancer (whether it is superficial or invasive bladder cancer, and whether it has spread to other places in the body); the type of bladder cancer cells and how they look under a microscope; and the patient’s general health. Bladder cancer in the early stages can often be cured.

Our patients with bladder cancer are treated at the Moores Urologic Cancer Unit. See the Urologic Cancer Unit for more information. You can also review the tabs at top of this page for information on bladder cancer symptoms and risks, diagnosis, and treatment.

Symptoms

• Blood in the urine
• Urgent need to urinate
  
• Frequent urination in small amounts
  
• Back or abdominal pain
  
• Painful urination
  
• Loss of appetite and weight
  

Risks

• Smoking: Smokers are two to three times more likely to get bladder cancer than non-smokers
  
• Chemical exposure: People who work in the rubber, chemical and leather industry show an increased risk, as do printers, painters, textile workers, truck drivers and hairdressers
  
• Chronic bladder infections
  
• A diet high in fried meats and fat
  
• Being older, male, or white
  

Diagnosing Bladder Cancer

In addition to taking a thorough medical history and giving you a physical exam that includes urine and blood tests, your doctor may also use the following diagnostic tools:

• Computed tomography (CT) scan: This procedure uses x-rays to take detailed pictures of structures within the body.
• Transurethral resection (TUR) of the bladder: A surgical procedure that is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder. During TUR surgery, a cystoscope is passed into the bladder through the urethra. A tool called a resectoscope is used to remove the cancer for biopsy. For tumors that are confined to the surface of the bladder, this treatment can be curative. For tumors that are more extensive, additional treatment is required.
• Cystoscopy: A procedure to look inside the bladder and urethra to check for abnormal areas using a thin, tube-like instrument with a light and a lens for viewing.

Bladder Cancer Stages and Grades

The stages for bladder cancer depend on the size of the cancer, its growth in the bladder wall , any lymph node involvement, and any spread to other areas of the body (metastasis). The grade of bladder cancer refers to how the cancer cells look under a microscope. Stage and grade of bladder cancer has been classified by the American Joint Committee on Cancer (AJCC).

Stages

• Stages 0 and I bladder cancer are considered superficial, meaning cancer is found only in the lining of the bladder (urothelium) or in the connective tissue below the lining (lamina propria) but has not spread to the bladder muscle.
• Stages II, III, and IV bladder cancer are considered invasive, meaning cancer has spread to the bladder muscle, the fatty tissue outside the muscle, and to the pelvic or abdominal wall (peritoneum). Stage IV bladder cancer can include cancer that has spread (metastasized) from the bladder to other places in the body such as the lungs, liver, or bones.

The primary tumor (T) is staged in the following way:

Superficial bladder cancer

• TX: A primary tumor cannot be assessed.
• T0: No primary tumor seen.
• Ta: Superficial cancer is found only in polyps (papillary) on the surface of the inner lining of the bladder.
• Tis: Carcinoma in situ. Tumor is found only in flat lesions on the surface of the inner lining of the bladder.
• T1: Tumor is found in the connective tissue below the lining of the bladder, but has not spread to the bladder muscle.

Invasive bladder cancer

• T2a: Tumor has spread to the inner half of the smooth muscle layer (superficial layer) below the lining of the bladder.
• T2b: Tumor has spread to the outer half of the smooth muscle layer (deep layer) of the bladder.
• T3a: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer as identified under a microscope.
• T3b: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer and a mass is visible to the eye.
• T4a: Tumor has spread to the prostate in men and to the uterus or vagina in women.
• T4b: Tumor has spread to the pelvic or abdominal wall.

Lymph node involvement

After the tumor (T) is staged, the TNM system stages lymph node involvement (N) to help determine the treatment options at each stage. Lymph node involvement is staged in the following way:

• NX: Lymph nodes in the pelvis cannot be assessed.
• N0: No bladder cancer is found in lymph nodes.
• N1: Bladder cancer is found in one lymph node, 2 cm(0.8 in.) or less in size.
• N2: Bladder cancer is found in one lymph node and is more than 2 cm(0.8 in.) but less than 5 cm(2 in.) in size, or cancer is found in multiple lymph nodes but none are more than 5 cm(2 in.) in size.
• N3: Bladder cancer is found in one or more lymph nodes and is more than 5 cm(2 in.) in size.

Metastasis stages

The last part of staging bladder cancer is to determine whether cancer has spread to other parts of the body (metastasized). The TNM system stages metastasis (M) in the following way:

• MX: Spread of cancer to other organs cannot be evaluated.
• M0: No evidence of bladder cancer exists elsewhere in the body.
• M1: Bladder cancer cells are found somewhere else in the body.

The TNM staging system allows a health professional to recommend the most effective treatment options and discuss the long-term outcome (prognosis) based on the type of tumor, the stage of the cancer, and the person's age and overall health condition.

TNM Classification of Bladder Cancer

• Stage 0(a): TaN0M0
• Stage 0(is): TisN0M0
• Stage I: T1N0M0
• Stage II: T2aN0M0, T2bN0M0
• Stage III: T3aN0M0, T3bN0M0, T4aN0M0
• Stage IV: T4bN0M0; Any T, N1, M0; Any T, N2, M0; Any T, N3, M0; Any T, any N, M1

Grades

The grade of bladder cancer refers to how the cancer cells look under a microscope. Bladder cancer cells are described as well differentiated, moderately differentiated, or poorly differentiated. Differentiation is a term used to describe how clearly the cancer cells can be distinguished from the surrounding normal tissues and how normal or abnormal the cells look.

• GX: Grade cannot be assessed.
• G1: Well-differentiated cancers have very clear boundaries and cells that look relatively normal. They usually do not grow and spread rapidly.
• G2: Moderately differentiated cancer has more abnormal looking cells and cell boundaries.
• G3-4: Poorly differentiated cancers have less-clearly defined boundaries and cells that look very abnormal. They often grow and spread rapidly.

Because bladder cancer can require a variety of treatments, UCSD Medical Center uses a multi-disciplinary approach involving urologic surgeons, medical oncologists, and radiation oncologists. This team of doctors utilizes state-of–the-art techniques and medical protocols to ensure you receive the best treatment for your particular condition.

At UCSD, we specialize in several treatments for bladder cancer, depending on the stage of the cancer and your individual case.

Superficial bladder cancer

For patients with superficial bladder cancer (cancer that has not invaded the muscle tissue), we can perform transurethral resection (TUR), also known as transurethal resection for bladder tumor (TURBT). We may also utilize intravesical therapy in addition to, or instead of, TUR.

Intravesical therapy is a type of chemotherapy or biologic therapy (also known as immunotherapy) infused directly into the bladder to decrease the progression of the disease. The most common type of immunotherapy for bladder cancer is BCG (Bacille Calmette-Guerin) solution, which contains live, weakened bacteria that stimulate the body's immune system to kill cancer cells. Intravesical therapy is often performed at the time of TUR and post-TUR to avoid future TUR procedures or radical cystectomy (removal of the bladder).

Transurethral resection for bladder tumor is a surgical procedure that is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder. During TURBT surgery, a cystoscope – a thin, tube-like instrument with a light and a lens for viewing - is passed into the bladder through the urethra. A tool called a resectoscope, which uses electric current to remove tissue is used to remove the cancerous tissue inside the bladder for biopsy and remove remaining cancer cells. Most patients will have a tube (catheter) placed in their bladder to drain urine after the operation and to help flush away any bleeding or blood clots that could make it difficult to pass urine after the procedure.

For tumors that are confined to the surface of the bladder, this treatment can be curative in itself. However, it’s important to realize that bladder cancer will occur approximately 50 percent of the time. Bladder cancer is a multi-focal disease, meaning that even if a tumor is removed, the cancer can reoccur in a different area of the bladder. For this reason, regular follow up care and monitoring is vital.

Post-TURBT surgery treatment can include chemotherapy or immunotherapy. Follow-up therapy includes a cystoscopic evaluation three months after the initial TURBT treatment and then every six months for an additional year.

Bladder cancer that may have spread

For patients with bladder cancer that appears to have spread to the muscle tissue, we may perform intravesical therapy prior to other treatments such as TUR or partial cystectomy (partial removal of the bladder). This treatment before surgery is known as neo-adjuvant treatment. When given prior to surgery, neo-adjuvant treatment can improve the outcome.

Muscle-invasive (advanced) bladder cancer

For patients with muscle-invasive bladder cancer whose bladders need to be removed, we perform radical cystectomy with urinary reconstruction. During the urinary reconstruction process, we use a portion of the ileum to create an orthotopic neobladder that allows a patient to urinate normally through the urethra rather than needing a urostomy bag worn on the outside of the body.