What is Bladder Cancer?

According to Cancer Research UK, there are around 10,300 new diagnoses of bladder cancer each year, which equates to 28 every day. With a survival rate of 46%, there are more than 5,500 deaths every year. However, just under half of bladder cancer cases are preventable. The Urology Foundation claims that this form of cancer is the 16^th most common cancer in females and the 8^th most common in males.

Overall, it is the 11^th most common cancer and accounts for 3% of new cancer cases. Thankfully, the incidence rates of this type of cancer are expected to fall by 34% by 2035. This article will tell you all about bladder cancer, the signs and symptoms, its causes and risk factors, and how it’s treated.

What is bladder cancer?

Bladder cancer occurs when abnormal cells within the lining of the bladder begin to multiply. As the bladder itself is hollow, the cancer will grow in the bladder’s layers. There are different layers within the bladder.

These are:

• The urothelium or the transitional epithelium (the first layer).
• The lamina propria, a layer of connective tissue (the second layer).
• The muscularis propria, muscle tissue (the third layer).
• Fatty connective tissue (the fourth layer).

Transitional cell/urothelial bladder cancer

Most cancers of the bladder will start in the first layer, the transitional epithelium or urothelium, and will begin in urothelial or transitional cells. You might hear these cancers being referred to as urothelial cancers or transitional cell bladder cancers.

Squamous cell bladder cancer

Around 5% of bladder cancer is an invasive type of cancer called squamous cell bladder cancer. A squamous cell is a flat cell that makes up the skin-like, moist tissues lining the organs of the body. When cancer starts in these cells, it’s called squamous cell bladder cancer.

This type of bladder cancer is more common in certain areas of the world like Asia and Africa due to a parasitic worm infection called bilharzia. The parasitic worms live in fresh water. It is rare to get this parasitic infection in the United Kingdom.

Adenocarcinoma

This type of bladder cancer is very rare and only 1% to 2% of bladder cancers have adenocarcinoma. It is typically invasive and develops from the mucus-producing gland cells in the tissues that line your organs, including the bladder.

Sarcoma

Another rare type of bladder cancer is one that starts in the structural tissues or bladder muscle. When a cancer starts in the muscle, it is called a sarcoma and will be treated differently to cancers that have started in the lining of the bladder.

What are the signs and symptoms of bladder cancer?

The first, main bladder cancer symptom is blood in your urine and is the same symptom for women and men. Bladder cancer also causes problems with the passing of urine.

Blood in urine

Around 80% of people with bladder cancer will experience blood in their urine. This is called haematuria. When blood is in the urine it will either look bright red like fresh blood or it could look darker. Even if it is not visible to the eye, it can be picked up on a urine test.

With bladder cancer, the blood might not be in the urine all of the time and it might come and go. It typically won’t hurt.

Seeing blood in your urine is a sign to go to the GP.

Difficulty passing urine

Another sign of bladder cancer is having problems passing urine. This might include urgency (passing urine suddenly), frequency (passing urine often), and a burning or painful sensation when passing urine.

It’s worth knowing that when you see these symptoms, it is much more likely that they are caused by another problem rather than cancer. One common cause of these problems is a urine infection, or an enlarged prostate gland in men.

Infections will clear up quickly with antibiotics.

Other symptoms of bladder cancer

Besides problems with urination, there are other symptoms of bladder cancer. These are more likely if the cancer has spread (metastatic bladder cancer) or if it is locally advanced.

These symptoms include:

• Feeling unwell and tired.
• Pain in the lower abdomen, bones or back.
• Unexplained weight loss.

What causes bladder cancer?

Bladder cancer starts when bladder cells mutate their DNA and multiply quickly. Abnormal cells will form tumours that invade normal cells and destroy them. Over time, the cells will break off from the original tumour site and spread throughout the body.

What are the risk factors of bladder cancer?

There are certain factors that increase a person’s risk of developing bladder cancer.

These include:

• Smoking
  Smoking tobacco (cigarettes, cigars and pipes) will increase a person’s risk of developing bladder cancer because harmful chemicals accumulate in their urine. Whenever someone smokes, their body will process the inhaled chemicals and excrete them in the urine. Over time, these damage the bladder lining, increasing the cancer risk. Around 45% of bladder cancers are caused by smoking, according to Cancer Research UK.
• Advancing age
  As a person ages, their risk of developing bladder cancer increases. Although you can have bladder cancer at any age, the majority of new diagnoses are in people above the age of 55.
• Biological sex
  Men are much more likely to develop cancer of the bladder than women.
• Chemical exposures
  The kidneys have an important role and will filter chemicals from the bloodstream, moving them to the bladder to be excreted. This exposure to the lining of the bladder increases the risk of cancer. There are lots of harmful chemicals that are linked to cancer of the bladder, and these include chemicals involved in the production of paints, textiles, leather, rubber and dyes. Arsenic is also on the list. Cancer Research UK estimates that 6% of UK bladder cancers are caused by workplace exposures.
• Past cancer treatment
  If you’ve used a drug to treat another cancer, like cyclophosphamide, you have an increased risk of bladder cancer. What’s more, anyone who has received radiotherapy on the pelvic area for cancer will have a greater risk of getting cancer of the bladder. According to Cancer Research UK, 2% of bladder cancers are caused by radiation.
• Chronic inflammation of the bladder
  Repeated urine infections, chronic infections and cystitis will increase the risk. This is more common among people who use a urinary catheter long term.
• Family history or personal history of cancer
  If you’ve had bladder cancer in the past, your risk of getting it again is higher. Also, if your direct relative (a child, sibling or parent) has had bladder cancer, you might be at an increased risk – even though it is rare for this cancer to have a family link.
  If there is a family history of HNPCC (hereditary nonpolyposis colorectal cancer) – otherwise known as Lynch syndrome – then there is an increased risk of urinary system cancer as well as colon cancer, uterine cancer, and ovarian cancer.

Can bladder cancer be prevented?

Though there are no guarantees when it comes to preventing bladder cancer, there are things you can do to reduce your risk. Around 49% of bladder cancers are thought to be preventable.

Here are some things you can do:

• Don’t smoke. Don’t take up smoking. If you already smoke, try to stop. A GP can help provide support to stop smoking.
• Take care when being exposed to chemicals. If you work with harsh chemicals, it’s important to always follow their safety instructions to prevent overexposure.
• Eat a healthy diet containing a range of fruits and vegetables. With a diet rich in different vegetables and fruits, you will be increasing your intake of antioxidants, which are important in the destruction of cancer-causing free radicals.

What are the stages of bladder cancer?

Doctors talk about bladder cancer depending on how far it has spread through the bladder’s different layers.

At diagnosis, patients are told they have:

• Non-muscle invasive bladder cancer – This is when the cancer is limited to the connective tissue beneath the lining of the bladder or the lining itself.
• Muscle invasive bladder cancer – This is when the cancer has spread into the muscle layer of the bladder or further.

Non-muscle invasive bladder cancer

This can be broken down into different types:

• Papillary bladder cancer – This appears as small, mushroom-shaped growths that grow out of the lining of the bladder. These growths can be removed and might not grow back.
• CIS – carcinoma in situ – This is a non-muscle invasive cancer that is flat. Unlike papillary bladder cancer, it doesn’t grow out of the wall of the bladder. The cells will look abnormal and tend to grow at a rapid rate. CIS is considered high grade. It is much more likely to return compared to other non-muscle invasive cancers.
• High grade T1 tumours – These are early bladder cancers that start in the bladder lining and grow into the lamina propria. They’re early cancers but grow quickly.

Muscle invasive bladder cancer

Urothelial cell or transitional cell bladder cancer can be invasive. It can grow into the bladder’s muscle layer and beyond.

This type of cancer will need treatment that’s more intensive compared to non-invasive bladder cancer as there is a real risk of it spreading to other areas in the body.

Metastatic bladder cancer

When a cancer is described as metastatic, it means it has spread to another area in the body. It might also be referred to as advanced bladder cancer. Some people are diagnosed with metastatic bladder cancer when they are first diagnosed. Others might be diagnosed later. It can also be called ‘recurrent’ cancer or ‘relapsed’ cancer.

Secondary cancer of the bladder

When cancer that has started in another part of the body spreads to the bladder, it is called secondary cancer. This might happen with rectum cancer, prostate cancer, ovarian cancer, cervical cancer, or uterine cancer, for instance.

It can even happen when the primary cancer is further away like with breast cancer. When this happens, the cancer will be treated in the same way as the primary cancer (the first cancer) because the cancer cells won’t have originated in the bladder.

Can bladder cancer be detected early?

Unfortunately, there isn’t a national screening programme for bladder cancer in the United Kingdom. This is due to the fact that there is no reliable screening test that will pick up early-stage bladder cancer.

Bladder cancer can be detected early if people are vigilant about their bodies and any unusual symptoms are investigated by a doctor.

How is bladder cancer diagnosed?

Usually, a person will start by seeing their GP for urinary problems like blood in the urine. The GP will decide whether further tests are required by a specialist.

Here are some tests you might undertake at a GP practice:

Usually, a person will start by seeing their GP for urinary problems like blood in the urine. The GP will decide whether further tests are required by a specialist.

Here are some tests you might undertake at a GP practice:

Urine sample

A urine sample will usually be requested and tested to see if the symptoms are caused by a simple urine infection or something else.

Internal examination

A GP might decide to conduct an internal examination. This is because the bladder is close to the bowels, the prostate (in men) and the uterus (in women).

The doctor will insert a finger into the vagina or rectum to see if it all feels normal. If they are worried about cancer, they will refer to a urologist, a bladder cancer specialist at the hospital. If bladder cancer is suspected, it might be processed as an urgent referral.

Bladder cancer tests

A urologist will carry out tests to see if bladder cancer is present and, if it is, how advanced it is.

Tests include:

• A cystoscopy – A test that looks inside the bladder.
• A CT urogram – A test that looks at the ureters, bladder and kidneys.
• An ultrasound – To look at the bladder.
• An MRI scan – To look at the bladder.
• A CT scan – To look at the bladder.
• A PET-CT scan – To look at the bladder.
• Blood tests.

Cystoscopy

During a cystoscopy, the urologist will look inside the bladder for signs of cancer. They might take biopsies of the bladder lining to test for the presence of cancer cells. There are different types of cystoscopy tests. These include flexible cystoscopy, rigid cystoscopy, narrow band imaging, PDD (photodynamic diagnosis), or blue light cystoscopy.

A cystoscopy can be done while awake using a local anaesthetic or while asleep under general anaesthetic.

A CT Urogram

This is a test that uses a contrast medium (a special dye) along with a CT scan to examine the kidneys, bladder and ureters (the tubes connecting the kidneys to the bladder).

The scan uses x-rays to take pictures of the body at different angles. These are then put together to form a 3D image. CT means ‘Computed Tomography’.

A CT scan might be performed to find out why there is blood in the urine and where it is coming from. It will also show whether there is cancer and what stage it is at.

MRI scan

MRI uses radio waves and magnetism to take images of the insides of your body. You might have an MRI to detect where the cancer has grown to and whether it has spread to other areas of the body.

PET-CT scan

This will combine a PET scan with a CT scan and will use a radioactive substance to highlight where cells in the body are abnormally active, which can be due to cancer.

Blood tests

These will check general health as well as how well the kidneys and liver are working.

How is bladder cancer treated?

In terms of statistics, around half of people who have bladder cancer will have surgery to remove their tumours. Around one in five patients will have radiotherapy and around one-third will have chemotherapy.

The treatment will depend on different factors, including the stage of the bladder cancer.

The specialist will decide which treatment is best for each patient and will discuss the benefits of it and any likely side effects it will cause. There might be other doctors or professionals involved in the treatment too. This might be a multidisciplinary team (MDT) involving a urologist, an oncologist, a radiologist, a urology nurse, and a pathologist.

The treatment of bladder cancer will depend on the size of the tumour (the stage), what the cells look like (the grade), the number of tumours, the type of tumour, and whether the patient has previously had treatment for early cancer of the bladder.

When surgery has taken place, biopsies of the tumour will be sent to a laboratory. This will look at the cells under a microscope to determine their type and grade. This will help doctors know what the risk is (low, intermediate or high). This then helps to determine how it is treated.

Non-muscle invasive bladder cancer treatments

The primary treatments for this type of bladder cancer are:

• Surgery to remove the tumour.
• Intravesical chemotherapy.
• A BCG vaccination.

Surgery

The surgery to remove the cancer from the lining of the bladder is called a trans urethral resection of bladder tumour or TURBT.

If the cancer is high-risk, a patient might have a different surgery called a cystectomy, which means the bladder is removed.

With a cystectomy, patients are left without a bladder. This means they will collect urine in a different way by wearing a bag outside of the abdomen that collects urine through a urostomy (an opening in the abdomen that’s a bit like a stoma).

Intravesical chemotherapy

This type of chemotherapy is given directly into the bladder to lower the risk of the cancer returning.

BCG vaccination

Another treatment is a vaccine into the bladder directly. The vaccine is the same one that is used to prevent TB (tuberculosis). It is an immunotherapy drug that encourages the immune system to fight off cancer cells. When this vaccine is given directly to the bladder it makes the immune system get rid of cancer cells.

The vaccine is given once per week for a period of six weeks. There might be further injections, called maintenance treatment, after this induction course, as it is often called.

Final thoughts

Bladder cancer occurs when there is abnormal tissue grown in the lining of the bladder, and its main symptom is blood in the urine. This is why it’s important to get any blood checked out.

There are lots of different treatments for bladder cancer and the five-year survival rate is 77%. The individual survival rate depends on the stage of the cancer. The five-year survival rate for Stage 0 cancer is 98% while Stage 4 cancer is 15%. Early diagnosis is key to improved treatment and survival chances.