Understanding Bladder Cancer: Types, Diagnosis and Treatment Options

A cancer diagnosis is a life-altering event that can bring up a lot of questions and uncertainty. Knowing what to expect is one of the most important things you can do to take control of your health. This guide is designed to provide a comprehensive overview of bladder cancer, from diagnosis to treatment, to help you feel more prepared for conversations with your medical team.

Overview of Bladder Cancer

Bladder cancer occurs when cells in the lining of the bladder, a hollow, muscular organ that stores urine, start to grow uncontrollably. The most common type is urothelial carcinoma, which accounts for over 90% of cases in industrialized nations. The disease can be classified into two main types based on how deeply it has invaded the bladder wall:

• Non-Muscle-Invasive Bladder Cancer (NMIBC): This is the most common form, accounting for about 70% to 75% of diagnoses. The cancer is confined to the inner layers of the bladder and has not yet grown into the muscle layer. NMIBC is considered early-stage and often has a very good prognosis, though it has a high rate of recurrence.
• Muscle-Invasive Bladder Cancer (MIBC): This type is more advanced, as the cancer has grown into the deeper muscle layers of the bladder wall and has a higher chance of spreading (metastasizing) to other parts of the body. Treatment for MIBC is more aggressive, and it represents a more serious health concern.

The primary risk factors for bladder cancer include smoking, which is the most significant risk factor, and exposure to certain industrial chemicals. Common symptoms include blood in the urine (hematuria), a frequent urge to urinate and painful urination. These symptoms can also be caused by less serious conditions like a urinary tract infection (UTI), so a proper diagnosis is crucial.

Diagnosis

The diagnostic process for bladder cancer is thorough and aims to not only confirm the presence of cancer but also to determine its type, stage and grade. This information is vital for creating an effective treatment plan.

• Cystoscopy and Biopsy: This is the most important diagnostic procedure. A urologist inserts a thin, flexible tube with a camera (a cystoscope) through the urethra into the bladder to visually inspect the lining for any abnormal growths or tumors. If a suspicious area is found, a small tissue sample (biopsy) is taken for a pathologist to examine under a microscope. This examination confirms the diagnosis and determines the cancer's grade (how aggressive the cells look) and type.
• Urine Cytology and Marker Tests: A urine sample is examined under a microscope for the presence of cancerous cells. While not as definitive as a biopsy, it can provide an initial indication. Some newer tests can also look for specific tumor markers in the urine to help with diagnosis and monitoring.
• Imaging Scans: To assess the extent of the cancer and check for any spread, your doctor may order imaging tests like a CT urogram or an MRI. These scans provide detailed pictures of the kidneys, ureters and bladder, helping to stage the cancer. A chest X-ray or bone scan may also be performed if there's a concern that the cancer has spread to other organs.

Treatment Options

Treatment for bladder cancer is highly individualized and depends on the type, stage, and grade of the cancer, as well as your overall health.

• Transurethral Resection of Bladder Tumor (TURBT): This is the initial and often curative treatment for most NMIBC cases. During this procedure, a surgeon removes the tumor from the bladder wall using an instrument inserted through the urethra. This is the same procedure often used for diagnosis and can be a complete treatment if the cancer is superficial.
• Intravesical Therapy: After a TURBT, medication may be delivered directly into the bladder via a catheter to prevent the cancer from coming back.
• Immunotherapy: The most common form is Bacillus Calmette-Guerin (BCG), a weakened bacterium that stimulates an immune response in the bladder to fight cancer cells.
• Chemotherapy: Chemotherapy drugs, such as mitomycin, are instilled directly into the bladder to kill any remaining cancer cells.
• Cystectomy: For more aggressive NMIBC or most MIBC cases, a cystectomy (surgical removal of the bladder) is often necessary.
• Partial Cystectomy: A small part of the bladder is removed. This is an option if the cancer is in a single, isolated area.
• Radical Cystectomy: The entire bladder is removed, along with nearby lymph nodes and, for men, the prostate and seminal vesicles; for women, the uterus, ovaries and part of the vagina. If you have a radical cystectomy, a surgeon will create a new way for your body to store and pass urine, a procedure known as urinary diversion.

CURE spoke with Dr. Janet Kukreja, the director of urologic oncology at the CU Cancer Center and UCHealth University of Colorado Hospital, about the patient experience of radical cystectomy.

“From a patient's perspective, getting ready for the surgery, having the surgery, and then recovering from the surgery are the main parts,” she said. “I generally recommend that patients recover from surgery at home but stay active, which is also the best way to get ready for surgery. I often have patients, even well into their 80s, do long walks multiple times a day and make sure they're eating high-protein diets and things like that so their bodies can recover.

“I generally like to perform bladder removal surgery with laparoscopic robot assistance. This means we make small incisions in the abdominal wall, put ports through them, and then insert the instruments through the ports and dock the robot. This allows me to get deep into the pelvis and see everything. When you do the surgeries open, it's very hard to get both hands into the pelvis and perform very fine surgery, at least for me. So, we remove the bladder, and often we remove lymph nodes with it as well to make sure that the cancer hasn't spread. Then we create some sort of urinary diversion, [which is] some way to reroute the urine to leave the body.”

• Systemic Therapies: These treatments use drugs that travel through the bloodstream to kill cancer cells throughout the body.
• Chemotherapy: Used to shrink tumors before surgery (neoadjuvant chemotherapy) or to kill any remaining cancer cells after surgery (adjuvant chemotherapy).
• Immunotherapy: Newer drugs, called checkpoint inhibitors, can help your immune system recognize and attack cancer cells.
• Targeted Therapy: These drugs specifically target cancer cells by interfering with their growth signals, causing less harm to healthy cells.
• Radiation Therapy: High-energy X-rays are used to kill cancer cells. It can be used alone or in combination with chemotherapy, particularly for patients who can't have or don't want surgery.

Side Effects of Treatment

It's important to be aware of the potential side effects of treatment, as managing them is a key part of your journey.

• Intravesical Therapy: Common side effects include bladder irritation, a frequent need to urinate, painful urination and flu-like symptoms, such as fever and fatigue. These are usually temporary.
• Surgery (Cystectomy): A radical cystectomy is a major surgery with significant side effects. You will need to adjust to a new way of urinating through a urinary diversion. Side effects can include urinary leakage, infections and changes in sexual function due to nerve damage.
• Chemotherapy and Immunotherapy: Systemic treatments can cause a range of side effects, including fatigue, nausea, vomiting, hair loss, loss of appetite and a higher risk of infection. Immunotherapy can also cause an overactive immune response, leading to inflammation in various organs.
• Radiation Therapy: Side effects can include skin changes in the treated area, fatigue and bladder or bowel symptoms like frequent urination or diarrhea.

This guide is designed to be a starting point. Your personal experience will be unique. By using this information as a foundation for your discussions, you can partner with your oncologist to make the best decisions for your health.

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