Treatment Plan

Best Hospitals for Bladder Cancer treatment in India- Urinary cancer

Treatment Plan

A cancer originating in the urinary bladder is called bladder cancer. Bladder cancer starts when the cells in the bladder start to grow abnormally and grow into a tumour.  With time, it can spread to other parts of the body as well. Almost 75% of the sufferers are males. It is more commonly found in those above 55 years of age. In most cases, an early diagnosis is possible because of the tell-tale symptoms of the disease. An early diagnosis helps to increase the survival rate as well. Modern surgical and non-surgical treatments are available for the disease with very good prognosis.

Bladder cancer can be sometimes detected early, when it hasn’t yet spread to the other parts of the body. Detecting it early can help improve the chances of the treatment working.

In most cases the presence of blood in the urine is the first indication of bladder cancer. Sometimes the blood can be so much that it changes the colour of the urine to pink or dark red.
Other symptoms of bladder cancer are:

The early symptoms are:

• Blood in urine (Haematuria)

• Pain during urination (Dysuria)

• Frequent urge to urinate

• Frequent urinary tract infections (UTIs)

Symptoms indicating more advanced bladder cancer include:

• Pain in the lower back 

• Swelling in the lower legs

• Anaemia

• A growth in the pelvis near the bladder

• Weight loss

• Pain in the anal, rectal or pelvic area or bone pain

TESTS FOR BLADDER CANCER

The common methods of bladder cancer diagnosis are:

Urine Analysis: A sample of the patient’s urine is examined under the microscope to find the presence of any cancerous cells. This process is known as urine cytology.

Cystoscopy: During a cystoscopy, the doctor inserts a long narrow tube that has a small camera, through the urethra, to see inside the bladder. Through the lens, the doctor can check for the presence of any signs of the disease. Sometimes a fluorescence cystoscopy is also performed along with a standard cystoscopy. Medicines known as porphyrins are inserted into the bladder and these are readily absorbed by the cancer cells. This causes the cancer cells to glow under a blue light and can help detect cancer cells even if they were missed during a routine cystoscopy.

Biopsy: During a cystoscopy, a thin instrument is sometimes introduced through the tube which collects possible cancerous cells from inside the bladder. This procedure is also known as transurethral resection of bladder tumour (TURBT). The cells collected are then tested for cancer.

CT Scan: A CT Scan, or in this case, a CT Urogram is sometimes conducted for the ureters, bladder and kidney. Images collected during the test provide a clear view of the urinary tract and helps the doctor determine if any areas might be cancerous.

Pyelogram: A retrograde pyelogram is a test for bladder cancer where a dye is used to refine the view of the bladder area. The dye is injected through a catheter and into the bladder or ureter.

If the doctor determines that the patient has cancer, then further tests may be conducted to verify if the cancer has spread to other parts of the body. Some of these tests include:

       X-ray

       Bone Scan

       MRI

       CT Scan

Bladder cancer can be divided into different types depending on where it forms along with other factors. Mainly, there are three main types of bladder cancer:

Transitional Cell Carcinoma (TCC):
95 percent of bladder cancers falls in this category. They occur in the urothelial cells that line the bladder. TCC has two subtypes:

Papillary carcinoma: Often called “non-invasive papillary cancers”, this type TCC is very low grade and have low-malignant potential.

Flat carcinomas:  If the cancer is confined to the urothelium, it is called “non-invasive flat carcinoma” or “flat carcinoma in situ”.

Squamous Cell Carcinoma:
Long term infection or inflammation in the bladder can cause squamous cells to develop in the bladder lining. Overtime, these squamous cells may become cancerous. Accounting for about 1 percent to 2 percent of bladder cancers, all squamous cell carcinomas of the bladder are invasive.

Adenocarcinoma:
Adenocarcinoma is also a rare form of bladder cancer. In this case as well, long term infection in the bladder causes glandular cells to form, which can become cancerous cells. It accounts for about 2% of all bladder cancers.

Bladder cancer like all other cancers, can be divided into five stages.

The five stages of bladder cancer are:

Stage 0 bladder cancer is confined to the superficial lining of the bladder.

Stage 1 bladder cancer has grown and spread past the lining of the bladder; however, it hasn’t reached the layer of muscle in the bladder.

Stage 2 where the cancer has spread to the muscle layers inside the bladder.

Stage 3 bladder cancer has reached the tissues surrounding the bladder.

Stage 4 bladder cancer has spread past the bladder to the neighbouring areas and tissues of the body.

Treatment by stages:
Treatment for stage 0 and stage 1: The treatment modality for stage 0 and stage 1 bladder cancer may include chemotherapy, surgery to remove the tumour from the bladder, or immunotherapy. Immunotherapy involves supervised administration of medicines that causes your immune system to attack the cancer cells.

Treatment for stage 2 and stage 3: Treatment for stage 2 and stage 3 bladder cancer may include:

• removal of the whole bladder or radical cystectomy, reconstructive surgery to create a new opening for the urine to exit the body

• chemotherapy, radiation therapy or immunotherapy  

Treatment for stage 4 bladder cancer includes:

• chemotherapy 

• radical cystectomy 

• radiation therapy

• immunotherapy 

A five-year survival rate for those with stage 0,1,2,3 and 4 is 98%, 88%, 63%, 46% and 15% respectively.

Treatment of bladder cancer is based on when it's first diagnosed. Bladder cancer has five stages and based on the stage the cancer is detected, the treatment varies. The sooner the cancer is detected, the better the chances of survival. Other factors, such as the tumour size, the rate at which the cancer cells are multiplying, and a person’s overall health also affect treatment options.

Surgery is a part of the treatment plan for most bladder cancers. The stage and extent of the cancer determines the type of surgery done.

A Transurethral Resection of Bladder Tumour (TURBT) is the most common surgical treatment for early-stage or superficial bladder cancers.  Though the surgery is a minimally invasive one, it is usually done under general or local anaesthesia. This is to reduce the unpleasant effects that one may feel. In this procedure, a thin wired instrument called a resectoscope or cystoscope is inserted into the bladder through the urethra. It contains a camera for viewing and a wire loop for cutting the tumour. The surgeon can identify the tumour tissues through the camera and removes it by using the loop. Fulguration, a procedure where the base of the tumour is burnt is also done to remove any remnants of the tumour.

Cystectomy is a procedure where the bladder is removed partially or completely. The procedure is done by open, laparoscopic or robotic methods depending on the discretion of the surgeon. Laparoscopic and robotic techniques have the advantage of lesser complications and faster recovery. The average hospital stay is about 5 to 7 days. A person can return to normal activities within in a month of the procedure. Partial cystectomy is rarely done because of the extent of cancer into the muscle layers. Adjacent lymph nodes are also removed. The main advantage of this surgery is that the bladder is not removed completely which helps to avoid reconstruction surgery

Radical cystectomy operation removes the entire bladder and nearby lymph nodes. Also, the prostate and seminal vesicles are also removed in men. In women, the ovaries, fallopian tubes, the uterus (womb), cervix, and a small portion of the vagina are often removed along with the bladder. A bladder reconstruction surgery is usually done after radical cystectomy.

Reconstructive surgery after radical cystectomy:

In reconstructive surgery, an artificial bladder is made using a part of the small intestine. There are three main types of reconstruction surgery.

Incontinent diversion:  In this, a passage called an ileal conduit is made for the urine to pass from the kidneys to the outside of the body. The urine passes from the kidneys to the ileal conduit through the ureters. It is then passed outside through an opening called stoma that is made in the skin of the abdomen. This is called urostomy. A small bag is placed over the stoma to collect the urine that comes out continuously in small amounts. The bag is emptied from time to time or when it is full. This approach is called an incontinent diversion because the patient is no longer in control of the flow of urine.

Continent diversion: Another way for urine to drain is called a continent diversion. In this approach, a pouch is made from the piece of intestine and is attached to the ureters. This pouch serves as a bladder where the urine is collected. The pouch also has a valve that opens only inwards. The other end of the pouch is connected to an opening (stoma) in the skin on the front of the abdomen. The pouch is emptied several times a day by putting a catheter into the stoma through the valve. The advantage is that there is no bag on the outside to collect urine.

Neobladder: In this method, a part of intestine is redesigned as a proper urinary bladder. One end of it is connected to the ureters and the other end to the urethra. This helps in normal urination.

The usual risks are bleeding, infection, and damages to the nearby organs.

Specific risks of cystectomy are:

• Infections

• Urine leaks

• Pouch stones

• Blockage of urine flow

• Incontinence 

• Sexual dysfunction

Chemotherapy uses drugs to destroy cancer cells. The drugs are given orally or intravenously. Chemotherapy is done before surgery to shrink the tumour or after surgery to prevent the return of cancer. It is also given in combination with radiotherapy. Chemotherapy is also given as a palliative measure to relieve symptoms when a cure is not possible. Chemotherapy is usually done in cycles with appropriate intervals in between.

Intravesical therapy is usually an option for people with non-invasive (stage 0) or minimally invasive (stage I) bladder cancer. In intravesical therapy for bladder cancer, drugs are put directly into the bladder through a catheter. Both immunotherapy and chemotherapy drugs can be given this way. This approach is useful only in early stage cancers where the cancer is limited to the lining. Intravesical therapy does not reach the deeper layers of the bladder wall, the kidneys, ureters or urethra. 

There are two types of intravesical immunotherapy:

Bacillus Calmette Guerin (BCG) therapy: BCG is a type of intravesical immunotherapy, used to treat early-stage bladder cancer. In this treatment, BCG is inserted into the bladder through a catheter activating the natural immune system. BCG is usually given for one to six weeks and may be given alongside transurethral resection. Less commonly, BCG is given as a long-term maintenance treatment.

Interferon therapy: Intravesical Chemotherapy- Drugs are directly introduced to the bladder with the help of a catheter.

The cost of bladder cancer treatment in India is highly affordable as compared to many other developed countries. On an average the treatment in India costs 35 to 50 percent less than what it costs in any other country including US, UK or Singapore. The most beneficial fact is that the best quality treatment of international standards is available at a much affordable price in India.

Cost of an evaluation is usually around 1500 USD.
Cost of surgery and Hormonal therapy is usually 10,200 USD approximately for a multi-bed ward.
Cost of Chemotherapy is 1300 – 1500 USD per cycle.

Apart from these patients will also need to factor in expenses such as travelling costs, hotel stay for the patient and their fellow traveller(s), food and miscellaneous expenses.

The exact cause of bladder cancer is unknown. It is a condition where the abnormal or defective cells grow and multiply rapidly and uncontrollably and invade other cells and tissues.

Smoking: Smoking puts a person in high risk of getting bladder cancer. Smoking is the main cause for half of all bladder cancers in men and women. The following are some of the risk factors that increase the possibility of developing a bladder cancer:

Exposure to cancerous chemicals: Chemicals used in a lot of industries such as rubber, leather, paint etc. can increase the risk of bladder cancer. Exposure to these chemicals on a long-term basis can cause bladder cancer.

Severe bladder infections: Chronic and continuous infections in the bladder can contribute to the growth of cancerous cells. Urinary infections, kidney and bladder stones and Schistosomiasis (a parasitic infection), is associated with increased bladder cancer risks.

Low fluid consumption: It has been inferred that an increased intake of fluids helps lower bladder cancer risks. Individuals should drink a required amount of fluid every day, in order to clear the bladder of any harmful chemicals.

Age: Majority of bladder cancers occur in people over the age of 55. Bladder cancer also affects men more than women. Race, geography, age and sex play a role increasing or decreasing the risk of getting bladder cancer.

Family history of bladder cancer: If any closely related family members has or has had bladder cancer, then the chances of others getting the disease is high. Close relatives include parents, sibling or child. Additionally, a genetic condition, known as hereditary non-polyposis colorectal cancer(HNPCC) also known as Lynch Syndrome, is usually tied to colon cancer.

Cyclophosphamide: Previous use of a chemotherapy drug called Cyclophosphamide can increase the risk of getting bladder cancer. If patients are taking this drug, then they need to drink a lot of fluids along with it, to reduce the risk. Also, previous radiation therapy to treat cancer in the pelvic area has also been associated with causing bladder cancer.

A cancer originating in the urinary bladder is called bladder cancer. Bladder cancer starts when the cells in the bladder start to grow abnormally and grow into a tumour.  With time, it can spread to other parts of the body as well. Almost 75% of the sufferers are males. It is more commonly found in those above 55 years of age. In most cases, an early diagnosis is possible because of the tell-tale symptoms of the disease. An early diagnosis helps to increase the survival rate as well. Modern surgical and non-surgical treatments are available for the disease with very good prognosis.

Bladder cancer can be sometimes detected early, when it hasn’t yet spread to the other parts of the body. Detecting it early can help improve the chances of the treatment working.

In most cases the presence of blood in the urine is the first indication of bladder cancer. Sometimes the blood can be so much that it changes the colour of the urine to pink or dark red.
Other symptoms of bladder cancer are:

The early symptoms are:

• Blood in urine (Haematuria)

• Pain during urination (Dysuria)

• Frequent urge to urinate

• Frequent urinary tract infections (UTIs)

Symptoms indicating more advanced bladder cancer include:

• Pain in the lower back 

• Swelling in the lower legs

• Anaemia

• A growth in the pelvis near the bladder

• Weight loss

• Pain in the anal, rectal or pelvic area or bone pain

TESTS FOR BLADDER CANCER

The common methods of bladder cancer diagnosis are:

Urine Analysis: A sample of the patient’s urine is examined under the microscope to find the presence of any cancerous cells. This process is known as urine cytology.

Cystoscopy: During a cystoscopy, the doctor inserts a long narrow tube that has a small camera, through the urethra, to see inside the bladder. Through the lens, the doctor can check for the presence of any signs of the disease. Sometimes a fluorescence cystoscopy is also performed along with a standard cystoscopy. Medicines known as porphyrins are inserted into the bladder and these are readily absorbed by the cancer cells. This causes the cancer cells to glow under a blue light and can help detect cancer cells even if they were missed during a routine cystoscopy.

Biopsy: During a cystoscopy, a thin instrument is sometimes introduced through the tube which collects possible cancerous cells from inside the bladder. This procedure is also known as transurethral resection of bladder tumour (TURBT). The cells collected are then tested for cancer.

CT Scan: A CT Scan, or in this case, a CT Urogram is sometimes conducted for the ureters, bladder and kidney. Images collected during the test provide a clear view of the urinary tract and helps the doctor determine if any areas might be cancerous.

Pyelogram: A retrograde pyelogram is a test for bladder cancer where a dye is used to refine the view of the bladder area. The dye is injected through a catheter and into the bladder or ureter.

If the doctor determines that the patient has cancer, then further tests may be conducted to verify if the cancer has spread to other parts of the body. Some of these tests include:

       X-ray

       Bone Scan

       MRI

       CT Scan

Bladder cancer can be divided into different types depending on where it forms along with other factors. Mainly, there are three main types of bladder cancer:

Transitional Cell Carcinoma (TCC):
95 percent of bladder cancers falls in this category. They occur in the urothelial cells that line the bladder. TCC has two subtypes:

Papillary carcinoma: Often called “non-invasive papillary cancers”, this type TCC is very low grade and have low-malignant potential.

Flat carcinomas:  If the cancer is confined to the urothelium, it is called “non-invasive flat carcinoma” or “flat carcinoma in situ”.

Squamous Cell Carcinoma:
Long term infection or inflammation in the bladder can cause squamous cells to develop in the bladder lining. Overtime, these squamous cells may become cancerous. Accounting for about 1 percent to 2 percent of bladder cancers, all squamous cell carcinomas of the bladder are invasive.

Adenocarcinoma:
Adenocarcinoma is also a rare form of bladder cancer. In this case as well, long term infection in the bladder causes glandular cells to form, which can become cancerous cells. It accounts for about 2% of all bladder cancers.

Bladder cancer like all other cancers, can be divided into five stages.

The five stages of bladder cancer are:

Stage 0 bladder cancer is confined to the superficial lining of the bladder.

Stage 1 bladder cancer has grown and spread past the lining of the bladder; however, it hasn’t reached the layer of muscle in the bladder.

Stage 2 where the cancer has spread to the muscle layers inside the bladder.

Stage 3 bladder cancer has reached the tissues surrounding the bladder.

Stage 4 bladder cancer has spread past the bladder to the neighbouring areas and tissues of the body.

Treatment by stages:
Treatment for stage 0 and stage 1: The treatment modality for stage 0 and stage 1 bladder cancer may include chemotherapy, surgery to remove the tumour from the bladder, or immunotherapy. Immunotherapy involves supervised administration of medicines that causes your immune system to attack the cancer cells.

Treatment for stage 2 and stage 3: Treatment for stage 2 and stage 3 bladder cancer may include:

• removal of the whole bladder or radical cystectomy, reconstructive surgery to create a new opening for the urine to exit the body

• chemotherapy, radiation therapy or immunotherapy  

Treatment for stage 4 bladder cancer includes:

• chemotherapy 

• radical cystectomy 

• radiation therapy

• immunotherapy 

A five-year survival rate for those with stage 0,1,2,3 and 4 is 98%, 88%, 63%, 46% and 15% respectively.

Treatment of bladder cancer is based on when it's first diagnosed. Bladder cancer has five stages and based on the stage the cancer is detected, the treatment varies. The sooner the cancer is detected, the better the chances of survival. Other factors, such as the tumour size, the rate at which the cancer cells are multiplying, and a person’s overall health also affect treatment options.

Surgery is a part of the treatment plan for most bladder cancers. The stage and extent of the cancer determines the type of surgery done.

A Transurethral Resection of Bladder Tumour (TURBT) is the most common surgical treatment for early-stage or superficial bladder cancers.  Though the surgery is a minimally invasive one, it is usually done under general or local anaesthesia. This is to reduce the unpleasant effects that one may feel. In this procedure, a thin wired instrument called a resectoscope or cystoscope is inserted into the bladder through the urethra. It contains a camera for viewing and a wire loop for cutting the tumour. The surgeon can identify the tumour tissues through the camera and removes it by using the loop. Fulguration, a procedure where the base of the tumour is burnt is also done to remove any remnants of the tumour.

Cystectomy is a procedure where the bladder is removed partially or completely. The procedure is done by open, laparoscopic or robotic methods depending on the discretion of the surgeon. Laparoscopic and robotic techniques have the advantage of lesser complications and faster recovery. The average hospital stay is about 5 to 7 days. A person can return to normal activities within in a month of the procedure. Partial cystectomy is rarely done because of the extent of cancer into the muscle layers. Adjacent lymph nodes are also removed. The main advantage of this surgery is that the bladder is not removed completely which helps to avoid reconstruction surgery

Radical cystectomy operation removes the entire bladder and nearby lymph nodes. Also, the prostate and seminal vesicles are also removed in men. In women, the ovaries, fallopian tubes, the uterus (womb), cervix, and a small portion of the vagina are often removed along with the bladder. A bladder reconstruction surgery is usually done after radical cystectomy.

Reconstructive surgery after radical cystectomy:

In reconstructive surgery, an artificial bladder is made using a part of the small intestine. There are three main types of reconstruction surgery.

Incontinent diversion:  In this, a passage called an ileal conduit is made for the urine to pass from the kidneys to the outside of the body. The urine passes from the kidneys to the ileal conduit through the ureters. It is then passed outside through an opening called stoma that is made in the skin of the abdomen. This is called urostomy. A small bag is placed over the stoma to collect the urine that comes out continuously in small amounts. The bag is emptied from time to time or when it is full. This approach is called an incontinent diversion because the patient is no longer in control of the flow of urine.

Continent diversion: Another way for urine to drain is called a continent diversion. In this approach, a pouch is made from the piece of intestine and is attached to the ureters. This pouch serves as a bladder where the urine is collected. The pouch also has a valve that opens only inwards. The other end of the pouch is connected to an opening (stoma) in the skin on the front of the abdomen. The pouch is emptied several times a day by putting a catheter into the stoma through the valve. The advantage is that there is no bag on the outside to collect urine.

Neobladder: In this method, a part of intestine is redesigned as a proper urinary bladder. One end of it is connected to the ureters and the other end to the urethra. This helps in normal urination.

The usual risks are bleeding, infection, and damages to the nearby organs.

Specific risks of cystectomy are:

• Infections

• Urine leaks

• Pouch stones

• Blockage of urine flow

• Incontinence 

• Sexual dysfunction

Chemotherapy uses drugs to destroy cancer cells. The drugs are given orally or intravenously. Chemotherapy is done before surgery to shrink the tumour or after surgery to prevent the return of cancer. It is also given in combination with radiotherapy. Chemotherapy is also given as a palliative measure to relieve symptoms when a cure is not possible. Chemotherapy is usually done in cycles with appropriate intervals in between.

Intravesical therapy is usually an option for people with non-invasive (stage 0) or minimally invasive (stage I) bladder cancer. In intravesical therapy for bladder cancer, drugs are put directly into the bladder through a catheter. Both immunotherapy and chemotherapy drugs can be given this way. This approach is useful only in early stage cancers where the cancer is limited to the lining. Intravesical therapy does not reach the deeper layers of the bladder wall, the kidneys, ureters or urethra. 

There are two types of intravesical immunotherapy:

Bacillus Calmette Guerin (BCG) therapy: BCG is a type of intravesical immunotherapy, used to treat early-stage bladder cancer. In this treatment, BCG is inserted into the bladder through a catheter activating the natural immune system. BCG is usually given for one to six weeks and may be given alongside transurethral resection. Less commonly, BCG is given as a long-term maintenance treatment.

Interferon therapy: Intravesical Chemotherapy- Drugs are directly introduced to the bladder with the help of a catheter.

The cost of bladder cancer treatment in India is highly affordable as compared to many other developed countries. On an average the treatment in India costs 35 to 50 percent less than what it costs in any other country including US, UK or Singapore. The most beneficial fact is that the best quality treatment of international standards is available at a much affordable price in India.

Cost of an evaluation is usually around 1500 USD.
Cost of surgery and Hormonal therapy is usually 10,200 USD approximately for a multi-bed ward.
Cost of Chemotherapy is 1300 – 1500 USD per cycle.

Apart from these patients will also need to factor in expenses such as travelling costs, hotel stay for the patient and their fellow traveller(s), food and miscellaneous expenses.

The exact cause of bladder cancer is unknown. It is a condition where the abnormal or defective cells grow and multiply rapidly and uncontrollably and invade other cells and tissues.

Smoking: Smoking puts a person in high risk of getting bladder cancer. Smoking is the main cause for half of all bladder cancers in men and women. The following are some of the risk factors that increase the possibility of developing a bladder cancer:

Exposure to cancerous chemicals: Chemicals used in a lot of industries such as rubber, leather, paint etc. can increase the risk of bladder cancer. Exposure to these chemicals on a long-term basis can cause bladder cancer.

Severe bladder infections: Chronic and continuous infections in the bladder can contribute to the growth of cancerous cells. Urinary infections, kidney and bladder stones and Schistosomiasis (a parasitic infection), is associated with increased bladder cancer risks.

Low fluid consumption: It has been inferred that an increased intake of fluids helps lower bladder cancer risks. Individuals should drink a required amount of fluid every day, in order to clear the bladder of any harmful chemicals.

Age: Majority of bladder cancers occur in people over the age of 55. Bladder cancer also affects men more than women. Race, geography, age and sex play a role increasing or decreasing the risk of getting bladder cancer.

Family history of bladder cancer: If any closely related family members has or has had bladder cancer, then the chances of others getting the disease is high. Close relatives include parents, sibling or child. Additionally, a genetic condition, known as hereditary non-polyposis colorectal cancer(HNPCC) also known as Lynch Syndrome, is usually tied to colon cancer.

Cyclophosphamide: Previous use of a chemotherapy drug called Cyclophosphamide can increase the risk of getting bladder cancer. If patients are taking this drug, then they need to drink a lot of fluids along with it, to reduce the risk. Also, previous radiation therapy to treat cancer in the pelvic area has also been associated with causing bladder cancer.