What is Bladder Cancer?
A cancer originating in the urinary bladder is called bladder cancer. 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 symptoms and causes:
The early symptoms are:
• Blood in urine (Hematuria)
• 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
• A growth in the pelvis near the bladder (pelvic mass)
• Weight loss
• Pain in the anal, rectal or pelvic area or bone pain
Causes and risk factors of Bladder cancer:
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 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
• severe bladder infections
• low fluid consumption
• age- majority of bladder cancers occur in people over the age of 55
• a high fat diets
• family history of bladder cancer
• previous use of a chemotherapy drug called Cytoxan
• previous radiation therapy to treat cancer in the pelvic area
Diagnosis of bladder cancer:
The common methods of diagnosis are:
• urine analysis
• internal examination of the vagina or rectum to feel for lumps that may indicate a cancerous growth
• cystoscopy- a narrow tube that has a small camera is inserted through the urethra to see inside the bladder
• CT scan to view the bladder
• Intravenous pyelogram (IVP)
Types of bladder cancer:
Transitional cell (urothelial) 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”.
Rarer forms of bladder cancer include:
• Squamous cell carcinoma- accounting for about 1 percent to 2 percent of bladder cancers, all squamous cell carcinomas of the bladder are invasive
• Adenocarcinoma- accounts for about 1 percent of bladder cancers
• Small-cell carcinoma - extremely rare and accounts for fewer than 1 percent of all bladder cancers
• Sarcoma - another very rare type of bladder cancer
• Stages of bladder cancer:
There are four stages of bladder cancer:
• Stage 0 bladder cancer is confined to the superficial lining of the bladder.
• Stage 1 bladder cancer has spread past the lining of the bladder, but 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 for stage 0 and stage 1: The treatment modality for stage 0 and stage 1 bladder cancer may include chemotherapy, surgery to remove the tumor 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:
• radical cystectomy
• radiation therapy
A five-year survival rate for those with stage 0,1,2,3 and 4 is 98, 88, 63, 46 and 15% respectively.
Bladder cancer treatment in India:
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 Tumor (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 tumor. 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 cystecomy 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: This 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:
• Urine leaks
• Pouch stones
• Blockage of urine flow
• 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 noninvasive (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.
Intravesical Chemotherapy- Drugs are directly introduced to the bladder with the help of a catheter.
Cost of bladder cancer treatment in India:
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 are available at a much affordable price in India