Brief overview
- Symptoms: No specific symptoms, usually none at all for a long time, discoloration of the urine due to blood admixture, disturbances in emptying the bladder such as frequent urination, pain when urinating
- Course of disease and prognosis: The earlier the diagnosis, the better the prognosis; if the bladder cancer is not in the muscle tissue, the chances of cure are better, usually treatable with therapy depending on the stage.
- Causes and risk factors: Main risk factor is smoking, besides contact with hazardous substances (e.g. occupational), chronic bladder infections, certain medications
- Diagnosis: Medical interview, physical examination, urine tests, cystoscopy, biopsy, imaging procedures such as computer tomography (CT), magnetic resonance imaging (MRI), X-ray
- Treatment: Depending on the type of tumor and stage: tumor removal via cystoscopy, open surgery, bladder instillations, chemotherapy and/or radiotherapy, as well as immunotherapy possible
What is bladder cancer?
Bladder cancer (bladder carcinoma) is a malignant tumor of the wall of the urinary bladder. In the vast majority of cases, it originates from the mucous membrane of the urinary bladder (urothelium). Doctors then speak of urothelial tumors.
In bladder cancer, altered cells form that divide faster than normal, healthy cells. If these altered cells reach other organs and other tissues, it is possible that they will form daughter tumors (metastases) there.
Worldwide, bladder cancer is the seventh most common cancer. Until the age of 25, bladder cancer is very rare in both sexes and occurs with equal frequency. The risk of bladder tumor increases with age and more so in men. On average, men are 75 years old at diagnosis and women are about 76 years old.
How does bladder cancer manifest itself?
As with most malignant tumors, bladder cancer has no specific symptoms. For this reason, it is possible that bladder cancer is behind the symptoms as well as many other diseases of the urinary tract.
Nevertheless, if you experience these bladder cancer symptoms, it is always advisable to consult a doctor.
The following symptoms sometimes indicate bladder cancer:
- Blood in the urine: The most common warning sign of a tumor in the bladder is a reddish to brown discoloration of the urine, not necessarily permanent and usually painless. This is caused by a small amount of blood in the urine. If this is visible to the naked eye, the bladder cancer is usually at a more advanced stage than if the blood has not yet discolored the urine.
- Frequent urination: Urinary symptoms such as an increased urge to urinate with frequent voiding of only small amounts of urine (pollakiuria) require clarification. In some cases, they are an indication of a tumor in the bladder.
- Bladder emptying disorders:Called dysuria by doctors. Urination is difficult and often only works in dribs and drabs. Sometimes this is associated with pain. Many misinterpret these symptoms as cystitis.
- Pain: If there is pain in the flanks for no apparent reason, caution is advised, here it is necessary to consult a doctor. This is because pain often occurs only in very advanced stages of bladder cancer. Then the bladder tumor already narrows the ureters or urethra.
- Inflammations:Chronic bladder inflammations may indicate bladder cancer, especially if treatment with antibiotics is unsuccessful.
Is bladder cancer curable?
The chance of curing bladder cancer depends on several factors. These include:
- How advanced is the tumor? Is it superficial or does it originate from deeper tissue structures? Has it already spread to other structures or organs?
- Is it an aggressively growing bladder cancer?
- Are lymph nodes affected or are there already metastases?
Most bladder cancer patients are in an early stage at the time of diagnosis. The prospects of recovery are then favorable, because the tumors at this stage relatively rarely form daughter tumors (metastases) and the cancer can usually be removed completely by surgery.
If the tumor cells have already grown beyond the urinary bladder or if there are distant metastases in the lungs, liver or skeleton, the chances of survival from bladder cancer decrease further. Therefore, it is important to have bladder cancer diagnosed and treated by a physician as early as possible.
Because bladder cancer sometimes recurs after removal, regular follow-up appointments are necessary. This allows for early detection and treatment of possible recurrences (relapses).
If left untreated, nothing prevents bladder cancer from spreading. For this reason, the malignant tumor leads to metastases in the body as it progresses, and sooner or later to death.
What causes bladder cancer?
In 90 percent of cases, bladder cancer originates from the urothelium. These are certain tissue layers of the mucosa that line the urinary bladder as well as other urinary tracts such as the ureter or urethra. However, there are some factors that increase the risk of bladder cancer – often external influences.
As with lung cancer, smoking is a significant risk factor for bladder cancer. The harmful substances from cigarette smoke enter the blood, and the kidneys in turn filter them out of the blood. They enter the bladder with the urine, where they exert their harmful effects until the body excretes them again.
About 50 percent of all bladder cancers are due to smoking, medical experts estimate. The risk of bladder cancer is twice to six times higher in smokers compared to non-smokers, depending on how long and how much one smokes. So if you quit smoking, you lower your risk of bladder cancer.
Chemical substances
Exposure to certain chemical substances also increases the risk of bladder cancer. Particularly dangerous are aromatic amines, which are considered carcinogenic. They used to be used primarily in the chemical industry, the rubber, textile or leather industry, and in the painting trade.
This link between chemicals and bladder cancer has been known for some time. In the workplace, therefore, such chemicals are used today only under high safety precautions. Sometimes they are even banned altogether. However, this is not the case in all countries.
Bladder cancer also develops very slowly – up to 40 years may pass between exposure to the chemicals and the development of bladder cancer (latency period).
Therefore, it is possible for bladder cancer to occur in people who worked with such chemicals a long time ago. In addition to aromatic amines, there are other chemicals that are likely to play a role in the development of bladder cancer.
Chronic bladder infections
Chronic bladder infections are also thought to be a risk factor for bladder cancer. For example, frequent bladder infections occur in people with urinary catheters.
Drugs that increase bladder cancer risk
Other infectious diseases
Some long-standing infectious diseases are associated with bladder cancer. One example is infection with schistosomes (couple flukes), which are found in the tropics and subtropics. They cause the disease schistosomiasis, which sometimes affects the urinary bladder and urethra (urogenital schistosomiasis).
How is bladder cancer diagnosed?
Bladder cancer usually causes little or no symptoms. Moreover, the symptoms of bladder cancer are so unspecific at the beginning that other diseases can also be considered.
However, if there is blood in the urine or if symptoms of bladder irritation persist, it is advisable to consult a doctor – preferably a family doctor or urologist. This is because the earlier bladder cancer is diagnosed, the better it can be treated.
Consultation with the doctor
The doctor will first ask you about your observations and complaints (medical history). This includes, for example, information about the following aspects:
- Discoloration of the urine
- Increased urge to urinate
- Occupational contact with chemicals
- Smoking
- Other existing diseases
Examinations
The doctor will then perform a physical examination. Only very large bladder tumors can be palpated through the abdominal wall, the rectum or the vagina. He also examines a urine sample, which usually reveals blood in the urine. In addition, a more detailed laboratory examination of the urine for malignant cells (urine cytology) is performed.
There are certain markers in the urine. Based on the determination of these markers, the physician estimates whether or not bladder cancer is present. However, these tests, which are also available as rapid tests, are not yet sufficiently accurate in their results. For this reason, many doctors do not use them for diagnosis or early detection, as the result is not sufficiently conclusive.
If the suspicion of bladder cancer is confirmed, the doctor usually suggests a cystoscopy. For this purpose, the patient is given a local anesthetic, or if necessary something to calm him down, or a general anesthetic.
During cystoscopy, the doctor inserts a special instrument (cystoscope) through the urethra, which allows the inside of the bladder to be examined. This examination allows the doctor to assess how deep the tumor has penetrated the bladder lining.
The diagnosis of bladder cancer can be confirmed by taking a tissue sample (biopsy) from the suspicious tissue. During a cystoscopy, the physician removes the tissue sample using an electric snare (transurethral electroresection of the bladder, TUR-B). Small, superficially growing tumors can sometimes be completely removed in this way. A pathologist then examines the cells under the microscope.
Examples are:
- Ultrasound of the liver
- X-ray of the chest
- Computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen
- Bone scintigraphy for suspected bone metastases
How is bladder cancer treated?
As a rule, specialists from different disciplines work closely together in cancer therapy, for example surgeons, urologists, oncologists and psychologists. It is important that you are well informed about the cancer and the treatment options so that you can make the decisions that are right for you. Be sure to ask questions if there is something you do not understand.
Usually, the treatment of bladder cancer is based on whether the tumor is in the muscle tissue or only superficial.
Endoscopic surgery (TUR) – removing the tumor
In about 75 percent of those affected, the tumor is superficial. This means that the bladder cancer is only in the bladder mucosa and has not yet reached the bladder muscles. It can then be removed during cystoscopy with the aid of a cystoscope. The surgeon removes the tumor layer by layer with an electric loop. An abdominal incision is not necessary here.
After the operation, a fine tissue examination of the removed tissue is performed. This makes it possible to determine whether it was possible to remove the tumor “in a healthy state,” i.e., completely.
Risk-dependent instillation treatment
Doctors introduce a solution directly into the bladder via a bladder catheter. This solution usually remains there for a certain period of time (usually two hours) and is then excreted through the bladder. Different solutions are used depending on the risk:
- Local chemotherapy after TUR: Patients receive preventive anti-cancer drugs, known as chemotherapeutic agents, directly after surgery. The physician flushes them directly into the bladder during cystoscopy (intravesical chemotherapy).
- Local immunotherapy after TUR: In addition, doctors often use the tuberculosis vaccine Bacillus Calmette-Guérin (BCG) and also introduce it directly into the bladder. The vaccine triggers an intense immune response in the body that sometimes fights tumor cells.
In some cases, this induction phase is followed by a so-called maintenance phase, which lasts several months to years.
Removal of the bladder (cystectomy)
In some patients, the bladder cancer has grown deeper into the wall and already into the muscle. In this case, a major surgical procedure is needed in which surgeons remove part or all of the bladder (cystectomy). This surgery is performed either open, by laparoscope (laparoscopy) or robot-assisted.
In addition, doctors remove the surrounding lymph nodes. This reduces the risk of the disease spreading again via lymph nodes that may have been affected.
In men, surgeons remove the prostate and seminal vesicles at the same time, and in the case of tumor involvement of the urethra, they also remove the urethra. In women with advanced bladder cancer, the uterus, ovaries, part of the vaginal wall and usually the urethra are removed.
The simplest form is the implantation of the two ureters into an eliminated piece of small or large intestine about 15 centimeters long. Doctors drain the open end of this piece of intestine through the abdominal skin (ileum conduit). Since some urine always runs out of the abdominal opening with this form of urinary diversion, the affected person wears a urine bag at all times.
Another option is to form a “new” bladder (neobladder). In this case, doctors form a collection bag from an eliminated part of the intestine and connect it to the urethra. The prerequisite for this is that the transition from the bladder to the urethra was free of malignant cells in the fine tissue examination. Otherwise, it is necessary to remove the urethra as well.
In addition, there is the possibility of connecting both ureters from the renal pelvises to the last part of the colon (ureterosigmoidostomy). The urine then drains during bowel movements.
Chemotherapy and immunotherapy
In addition to partial or total removal of the bladder for bladder cancer that has already invaded deeper tissues (muscle), many of these patients receive chemotherapy before and after surgery. The goal of this is to improve survival.
Sometimes removal of the bladder is not possible or the patient refuses surgery – in this case, chemotherapy is also an option, which affects the entire body and is intended to eliminate tumor cells (systemic therapy).
Chemotherapy also helps with bladder cancer if the tumor is already far advanced (for example, if it has spread to the lymph nodes of the abdominal cavity or to other organs). The therapy alleviates the symptoms and has a life-prolonging effect.
Radiotherapy
Bladder cancer is sensitive to radiation – the tumor cells can often be completely destroyed by radiation. Radiation treatment is an alternative to bladder removal – so the bladder can sometimes be preserved.
Usually there is a combination of radiation and chemotherapy. The drugs used (cytostatics) make the tumor even more sensitive to radiation. Doctors refer to this as radiochemotherapy. Radiation often lasts several weeks and is usually given daily for a few minutes.
Rehabilitation and aftercare
Especially for bladder cancer patients after a cystectomy and an alternative urinary diversion or with a neobladder, follow-up treatment is necessary in many cases. Here, those affected receive support with regard to urination, for example in the form of physiotherapy as well as in training courses on artificial urinary outlets.
It is also important for those affected to attend regular follow-up appointments. This enables doctors to detect at an early stage whether there is a relapse of the bladder cancer. But also to see if there are any complications, how well the affected person is doing with the therapy, and whether there may be any side effects. The rhythm of the control appointments depends on the risk.
Can bladder cancer be prevented?
To prevent bladder cancer, the most important thing is to minimize both active and passive tobacco use. Ideally, you should give up smoking completely, as this will lower your risk of developing the disease.
If you have a job where you come into contact with hazardous substances, it is important that you follow safety rules. Keep in mind that the time from contact with hazardous substances to the development of cancer may be very long (up to 40 years).