- What is the bladder?
- What is bladder cancer?
- What are bladder cancer causes and risk factors?
- What are bladder cancer symptoms and signs?
- How is bladder cancer diagnosed?
- How is bladder cancer staging determined?
- What is the treatment for bladder cancer?
- Biological therapy
- Radiation therapy
- How does a person get a second opinion after a bladder cancer diagnosis?
- What happens after treatment for bladder cancer?
- What follow-up care is needed after bladder cancer treatment?
- What support can bladder cancer patients seek?
- What does the future hold for bladder cancer?
- Bladder Cancer At A Glance
The wall of the bladder has layers of tissue:
- Inner layer: The inner layer of tissue is also called the lining. As your bladder fills up with urine, the transitional cells on the surface stretch. When you empty your bladder, these cells shrink.
- Middle layer: The middle layer is muscle tissue. When you empty your bladder, the muscle layer in the bladder wall squeezes the urine out of your body.
- Outer layer: The outer layer covers the bladder. It has fat, fibrous tissue, and blood vessels.
Cancer begins in cells, the building blocks that make up tissues. Tissues make up the bladder and the other organs of the body.
Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place.
Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor.
Tumors in the bladder can be benign (not cancer) or malignant (cancer). Benign tumors are not as harmful as malignant tumors:
- Benign tumors:
- are usually not a threat to life
- can be treated or removed and usually don't grow back
- don't invade the tissues around them
- don't spread to other parts of the body.
- Malignant growths:
- may be a threat to life.
- usually can be removed but can grow back
- can invade and damage nearby tissues and organs (such as the prostate in a man, or the uterus or vagina in a woman)
- can spread to other parts of the body
Bladder cancer cells can spread by breaking away from the original tumor. They can spread through the blood vessels to the liver, lungs, and bones. In addition, bladder cancer cells can spread through lymph vessels to nearby lymph nodes. After spreading, the cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues. See the Staging section for information about bladder cancer that has spread.
When you get a diagnosis of bladder cancer, it's natural to wonder what may have caused the disease. Doctors can't always explain why one person gets bladder cancer and another doesn't.
However, we do know that people with certain risk factors may be more likely than others to develop bladder cancer. A risk factor is something that may increase the chance of getting a disease.
Studies have found the following risk factors for bladder cancer:
- Smoking: Smoking tobacco is the most important risk factor for bladder cancer. Smoking causes most of the cases of bladder cancer. People who smoke for many years have a higher risk than nonsmokers or those who smoke for a short time.
How to Quit Tobacco
Quitting is important for anyone who uses tobacco. Quitting at any time is good for your health.
For people who already have bladder cancer, quitting may reduce the chance of getting another type of cancer (such as lung, esophagus, or oral cancer), lung disease, or heart disease caused by tobacco. Quitting can also help cancer treatments work better.
There are many ways to get help:
- Chemicals in the workplace: Some people have a higher risk of bladder cancer because of cancer-causing chemicals in their workplace. Workers in the dye, rubber, chemical, metal, textile, and leather industries may be at risk of bladder cancer. Also at risk are hairdressers, machinists, printers, painters, and truck drivers.
- Personal history of bladder cancer: People who have had bladder cancer have an increased risk of getting the disease again.
- Certain cancer treatments: People with cancer who have been treated with certain drugs (such as cyclophosphamide) may be at increased risk of bladder cancer. Also, people who have had radiation therapy to the abdomen or pelvis may be at increased risk.
- Arsenic: Arsenic is a poison that increases the risk of bladder cancer. In some areas of the world, arsenic may be found at high levels in drinking water. However, the United States has safety measures limiting the arsenic level in public drinking water.
- Family history of bladder cancer: People with family members who have bladder cancer have a slightly increased risk of the disease.
Many people who get bladder cancer have none of these risk factors, and many people who have known risk factors don't develop the disease.
Bladder cancer may cause these common symptoms:
- Finding blood in your urine (which may make the urine look rusty or darker red)
- Feeling an urgent need to empty your bladder
- Having to empty your bladder more often than you used to
- Feeling the need to empty your bladder without results
- Needing to strain (bear down) when you empty your bladder
- Feeling pain when you empty your bladder
These symptoms may be caused by bladder cancer or by other health problems, such as an infection. People with these symptoms should tell their doctor so that problems can be diagnosed and treated as early as possible.
If you have symptoms that suggest bladder cancer, your doctor will try to find out what's causing the problems.
You may have a physical exam. Also, you may have one or more of the following tests:
- Urine tests: The lab checks your urine for blood, cancer cells, and other signs of disease.
- Cystoscopy: Your doctor uses a thin, lighted tube (a cystoscope) to look directly into your bladder. It may be done at your doctor's office. This test can be uncomfortable because the doctor will insert the cystoscope into the bladder through your urethra. You may need local anesthesia for this test.
- Biopsy: Your doctor can
remove samples of tissue with the cystoscope. A pathologist then examines the
tissue under a microscope. The removal of tissue to look for cancer cells is
called a biopsy. In most cases, a biopsy is the only sure way to tell whether
cancer is present.
For a small number of patients, the doctor removes the entire area with cancer during the biopsy. For these patients, bladder cancer is diagnosed and treated at the same time.
If cancer cells are found in the tissue sample from the bladder, the pathologist studies the sample under a microscope to learn the grade of the tumor. The grade tells how much the tumor tissue differs from normal bladder tissue. It may suggest how fast the tumor is likely to grow.
Tumors with higher grades tend to grow faster than those with lower grades. They are also more likely to spread. Doctors use tumor grade along with other factors to suggest treatment options.
You may want to ask the doctor these questions before having a biopsy:
If bladder cancer is diagnosed, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment.
Staging is a careful attempt to find out the following:
- Whether the tumor has invaded the muscle layer of the bladder
- Whether the tumor has invaded nearby tissues
- Whether the cancer has spread, and if so, to what parts of the body
Your doctor may order these tests:
- Blood tests: Blood tests can show how well the liver and kidneys are working.
- Chest x-ray: An x-ray of the chest can show a tumor in the lung.
- IVP: A dye that shows up on x-rays is injected into your blood vessel. The dye collects in your urine, which makes the bladder and the rest of the urinary tract show up on x-rays.
- CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your abdomen. You may receive an injection of contrast material so your urinary tract and lymph nodes show up clearly in the pictures. The CT scan can show cancer in the bladder, lymph nodes, or elsewhere in the abdomen.
- MRI: A large machine with a strong magnet linked to a computer is used to make detailed pictures of your urinary tract and lymph nodes. You may receive an injection of contrast material. MRI can show cancer in the bladder, lymph nodes, or other tissues in the abdomen.
- Ultrasound: The ultrasound device uses sound waves that can't be heard by humans. The sound waves make a pattern of echoes as they bounce off internal organs. The echoes create a picture of your kidneys and other organs in the abdomen. The picture can show a tumor or blockage in the urinary tract.
When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the original (primary) tumor. For example, if bladder cancer spreads to the liver, the cancer cells in the liver are actually bladder cancer cells. The disease is metastatic bladder cancer, not liver cancer. It's treated as bladder cancer, not as liver cancer. Doctors sometimes call the new tumor in the liver "distant" disease.
These are the stages of bladder cancer:
- Stage 0: The cancer cells are found only on the surface of the inner lining of the bladder. The doctor may call this carcinoma in situ.
- Stage I: The tumor has grown deeper into the inner lining of the bladder. But it hasn't invaded the muscle layer of the bladder.
- Stage II: The tumor has invaded the muscle layer of the bladder.
- Stage III: The tumor has grown through the muscle layer to reach tissues near the bladder, such as the prostate, uterus, or vagina.
- Stage IV: The tumor has invaded the wall of the pelvis or abdomen, but cancer is not found in any lymph nodes. Or, the cancer cells have spread to at least one lymph node or to parts of the body far away from the bladder, such as the liver, lungs, or bones.
The treatment that's right for you depends mainly on the following:
- The location of the tumor in the bladder
- Whether the tumor has invaded the muscle layer or tissues outside the bladder
- Whether the tumor has spread to other parts of the body
- The grade of the tumor
- Your age and general health
You may have a team of specialists to help plan your treatment. Your doctor may refer you to a specialist, or you may ask for a referral. You may want to see a urologist, a surgeon who specializes in treating problems in the urinary tract. Other specialists who treat bladder cancer include urologic oncologists (surgeons who specialize in cancers of the urinary tract), medical oncologists, and radiation oncologists.
Your health care team may also include an oncology nurse and a registered dietitian. If your treatment involves surgery to remove the bladder, a wound, ostomy and continence nurse may also be part of your team.
Your health care team can describe your treatment choices, the expected results of each, and the possible side effects. Because cancer therapy often damages healthy cells and tissues, side effects are common. These side effects depend on many factors, including the type and extent of treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. You and your health care team can work together to develop a treatment plan that meets your needs.
At any stage of disease, supportive care is available to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns. Information about such care is available on NCI's Web site at http://www.cancer.gov/cancertopics/coping and from NCI's Cancer Information Service at 1–800–4–CANCER (1–800–422–6237) or at LiveHelp (http://www.cancer.gov/help).
You may want to talk with your doctor about taking part in a clinical trial. Clinical trials are research studies testing new treatments. They are an important option for people with all stages of bladder cancer. See the Taking Part in Cancer Research section.
You may want to ask your doctor these questions before you begin treatment:
Surgery is an option for most people with bladder cancer. You and your surgeon can talk about the types of surgery and which may be right for you:
- Transurethral resection (TUR): The doctor uses a cystoscope to treat
early bladder cancer (Stage 0 or Stage I). No incision (cut) into your body
is needed, but general anesthesia or spinal anesthesia is usually given.
The doctor inserts the cystoscope into the bladder through your urethra. The cutting tool is slipped through the cystoscope. A small wire loop at the end of the tool removes the cancer and burns away remaining cancer cells with an electric current.
TUR may need to be repeated. Also, chemotherapy or biological therapy may be given after this type of surgery.
For a few days after TUR, you may have some blood in your urine and difficulty or pain when passing urine. Otherwise, TUR generally causes few problems.
- Open surgery: The surgeon makes an incision into your body to remove the cancer from your bladder.
- Part of the bladder (called a partial cystectomy):
For some people with a single, small tumor in the bladder, the surgeon does
not remove the entire bladder. The surgeon removes the tumor, the part of
the bladder containing the tumor, and nearby lymph nodes.
After part of the bladder is removed, you may not be able to hold as much urine in your bladder as before surgery. You may need to empty your bladder more often. This problem usually gets better with time.
- All of the bladder (called a radical cystectomy): For bladder cancer that
has invaded the muscle layer (Stage II or some Stage III), the most common
type of surgery is radical cystectomy. The surgeon removes the entire
bladder, nearby lymph nodes, and part of the urethra. In addition, the
surgeon usually removes the prostate from a man and may remove the uterus
from a woman. Other nearby tissues may also be removed.
When the entire bladder is removed, the surgeon makes another way for urine to be collected from the kidneys and stored. You may wear a flat bag outside the body under your clothes, or the surgeon may use part of your intestine to create a pouch inside the body. The Rehabilitation section on page 23 has more information.
When the prostate or uterus is removed, a man can no longer father a child and a woman can no longer get pregnant. Also, a man may be unable to have sex after surgery. If the surgeon removes part of a woman's vagina, sex may be difficult.
Because bladder cancer surgery may affect your sex life, it may help you and your partner to talk about your feelings and help one another find ways to share intimacy during and after treatment. See Sources of Support on page 26 for more information.
It takes time to heal after surgery, and the time needed to recover is different for each person. It's common to feel weak or tired for a while.
Also, you may have pain or discomfort for the first few days. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain control.
After TUR or partial cystectomy, the urethra needs time to heal. You'll have a catheter. A catheter is a tube put through the urethra into the bladder to drain urine. You'll have the catheter for 5 days to 3 weeks. Your nurse or doctor will show you how to care for it.
You may want to ask your doctor these questions before having surgery:
Chemotherapy uses drugs to kill cancer cells. It may be used to treat bladder cancer before or after surgery. You may receive chemotherapy in different ways:
- Into the bladder: After TUR for early bladder cancer, the doctor inserts a tube (catheter) through your urethra to put a liquid drug in the bladder. The drug remains in your bladder for several hours. This treatment may be given once a week for six weeks.
- By mouth: Some drugs are pills that you can swallow. They may be given before or after surgery.
- Into a vein: For cancer that has invaded the muscle of the bladder or spread to other tissues, drugs are usually given by vein (intravenous). The drugs enter the bloodstream and travel throughout your body. Chemotherapy may be given before or after surgery.
You may have your treatment in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, you may need to stay in the hospital.
Chemotherapy is usually given in cycles. Each cycle has a treatment period followed by a rest period.
The side effects depend mainly on how the drug is given. If the drugs are given into the bladder, the side effects are usually mild. For a few days after treatment, you may need to empty your bladder more often. You may have blood in your urine. Also, you may have pain when emptying your bladder. Some people get a rash. These problems usually go away after treatment.
If the drugs are given by vein or taken by mouth, the side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:
- Blood cells: When drugs lower the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
- Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment, but the color and texture may be changed.
- Cells that line the digestive system: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems. They usually go away when treatment ends.
Some drugs used for bladder cancer may also cause tingling or numbness in your hands and feet. Your health care team can suggest ways to control many of these side effects.
People with early bladder cancer may receive a treatment called biological therapy. The treatment is BCG solution, which is a liquid containing weakened bacteria. The bacteria help your body's natural defenses (the immune system) to kill cancer cells in the bladder.
Several weeks after TUR, the doctor inserts a tube through your urethra to put a liquid treatment in your bladder. You'll be asked to hold the liquid treatment in your bladder for about two hours.
BCG solution is usually given once a week for six weeks. This treatment helps keep the cancer from coming back.
You may feel unusually tired during the treatment period. Also, BCG solution can irritate the bladder. You may feel an urgent need to empty your bladder, and you may need to empty your bladder more often. Also, you may have pain, especially when emptying your bladder. You may have blood in your urine, nausea, a fever, or chills. Tell your health care team about any problems that you have during the treatment period.
It may help to know that the side effects usually go away when treatment is over.
You may want to ask your doctor these questions about chemotherapy or biological therapy:
Radiation therapy uses high-energy rays to kill cancer cells. It may be given after surgery. Usually it's given along with chemotherapy for cancer that has invaded the muscle layer of the bladder. However, it is sometimes given instead of surgery or chemotherapy.
The radiation comes from a large machine. The machine aims beams of radiation at the bladder area in the abdomen.
You'll go to a hospital or clinic 5 days a week for several weeks to receive radiation therapy. Each treatment session takes about 30 minutes.
Although radiation therapy is painless, it may cause other side effects. The side effects include nausea, vomiting, or diarrhea. Also, you may feel very tired during radiation therapy. Your health care team can suggest ways to treat or control these side effects.
You may want to ask your doctor these questions about radiation therapy:
Before starting treatment, you may want a second opinion about your diagnosis, the stage of cancer, and the treatment plan. Some people worry that the doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. Some companies require a second opinion.
If you get a second opinion, the second doctor may agree with your first doctor's diagnosis and treatment plan. Or the second doctor may suggest another approach. Either way, you have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at all of your options.
It may take some time and effort to gather your medical records and see another doctor. In most cases, it's not a problem to take several weeks to get a second opinion. The delay in starting treatment usually will not make treatment less effective. To make sure, you should discuss this delay with your doctor.
There are many ways to find a doctor for a second opinion. You can ask your doctor, a local or state medical society, or a nearby hospital or medical school for names of specialists.
Also, you can get information about treatment centers near you from NCI's Cancer Information Service at 1–800–4–CANCER (1–800–422–6237) or LiveHelp (http://www.cancer.gov/livehelp).
Your health care team will help you return to normal activities as soon as possible. The goals of rehabilitation depend on the extent of disease and surgery.
If the surgeon removes your bladder, you'll need a new way to store urine. After your bladder is removed, the surgeon uses a piece of your small intestine or large intestine to make a new path for urine to exit the body or be stored. With this piece of intestine, the surgeon can either make a tube that carries urine from the ureters to the outside of the body or create a new bladder that holds urine inside the body.
Your health care team can tell you more about the following options:
- Bag worn outside your body under your clothing: The surgeon can attach a small piece of intestine to the ureters and to a stoma (an opening in the wall of the abdomen). Urine drains from the ureters through the piece of intestine to the stoma. A flat bag fits over the stoma to collect urine, and special glue holds the bag in place. The bag is emptied several times a day.
- New bladder or pouch inside your body: The surgeon can create a new bladder or pouch made from a piece of your intestine. The surgeon connects the pouch to the ureters so that urine can flow from the ureters and can be stored in the pouch in the pelvis. The surgeon also connects the pouch either to your urethra or to a stoma in the wall of your abdomen:
- New bladder connected to your urethra: Because the pouch is joined to your urethra, you will be able to empty your new bladder much as you did before.
- New bladder connected to a stoma: The surgeon creates a new path for urine to leave your body. The pouch is joined to the stoma, and you will use a catheter (a soft tube) to empty your bladder several times a day. You will not need to wear a bag over the stoma.
A wound, ostomy and continence nurse or another member of your health care team will visit you before surgery to describe what to expect. The nurse or doctor will teach you how to care for yourself after surgery. If you need an ostomy, the nurse or doctor will help you decide where the opening should be on your abdomen and will teach you how to care for the stoma after surgery.
Ask your health care team about your physical, emotional, or sexual concerns. Often they can provide information about resources and support groups.
It's important for you to take very good care of yourself before, during, and after cancer treatment. Taking care of yourself includes eating well so you get the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy.
Sometimes, especially during or soon after treatment, you may not feel like eating. You may be uncomfortable or tired. You may find that foods don't taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth blisters) can make it hard to eat well.
Your doctor, a registered dietitian, or another health care provider can suggest ways to help you meet your nutrition needs.
You'll need regular checkups (such as every 3 to 6 months) after treatment for bladder cancer. Checkups help ensure that any changes in your health are noted and treated if needed.
If you have any health problems between checkups, you should contact your doctor.
Bladder cancer may come back after treatment. Your doctor will check for return of cancer. Checkups may include a physical exam, blood tests, urine tests, cystoscopy, or CT scans.
Sources of Support
Learning that you have bladder cancer can change your life and the lives of those close to you. These changes can be hard to handle. It's normal for you, your family, and your friends to need help coping with the feelings that a diagnosis of cancer can bring.
Concerns about treatments and managing side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, keeping your job, or continuing daily activities.
Here's where you can go for support:
- Doctors, nurses, and other members of your health care team can answer questions about treatment, working, or other activities.
- Social workers, counselors, or members of the clergy can be helpful if you want to talk about your feelings or concerns. Often, social workers can suggest resources for financial aid, transportation, home care, or emotional support.
- Support groups also can help. In these groups, patients or their family members meet with other patients or their families to share what they have learned about coping with the disease and the effects of treatment. Groups may offer support in person, over the telephone, or on the Internet. You may want to talk with a member of your health care team about finding a support group.
- NCI's Cancer Information Service at 1–800–4–CANCER (1–800–422–6237) and at LiveHelp (http://www.cancer.gov/livehelp) can help you locate programs, services, and NCI publications. They can send you a list of organizations that offer services to people with cancer.
- Your doctor or a sex counselor may be helpful if you and your partner are concerned about the effects of bladder cancer on your sex life. Ask your doctor about possible treatment of side effects and whether these effects are likely to last. Whatever the outlook, you and your partner may find it helps to discuss your concerns.
Taking Part in Cancer Research
Doctors all over the world are conducting many types of clinical trials (research studies in which people volunteer to take part). Clinical trials are designed to find out whether new treatments are safe and effective.
Even if the people in a trial do not benefit directly, they may still make an important contribution by helping doctors learn more about bladder cancer and how to control it. Although clinical trials may pose some risks, doctors do all they can to protect their patients.
Doctors are studying new drugs and drug combinations. If you're interested in being part of a clinical trial, talk with your doctor.
NCI's Web site includes a section on clinical trials at http://www.cancer.gov/clinicaltrials. It has general information about clinical trials as well as detailed information about specific ongoing studies of bladder cancer. NCI's Cancer Information Service at 1–800–4–CANCER (1–800–422–6237) and at LiveHelp at http://www.cancer.gov/livehelp can answer questions and provide information about clinical trials.
- While the exact cause(s) of bladder cancer is not known, risk factors have been identified.
- The most common warning sign of bladder cancer is blood in the urine.
- The diagnosis of bladder cancer is supported by findings of the medical history and examination, blood, urine, and x-ray tests, and confirmed with a biopsy (usually during a cystoscope exam).
- Treatment of bladder cancer depends on the growth, size, and location of the tumor as well as the age and health of the patient.
SOURCE: U.S. National Institutes of Health, National Cancer Institute (http://www.cancer.gov)