Bladder cancer is now one of the 10 most common cancers in the United States and the second most common urological cancer. Men are four times as likely as women to develop it, but women more frequently have advanced disease at the time of diagnosis. The mean age of development is about age 65 and can range from benign easily treated lesions to invasive cancer.
The urinary bladder, located in the pelvic area, has the main function of emptying and storing urine. The most common forms of bladder cancer are transitional cell carcinomas, and arise mainly from the lining of the bladder itself. Tumors of the bladder can vary from lesions that resemble polyps and have a slow recurring course over years, to deeply invasive growths when they are found that tend to be much more aggressive. The more differentiated the cells appear (the most like “normal” bladder cells), the better the prognosis is. The undifferentiated cell type predisposes to invasion and spread to nearby pelvic structures, lymph nodes, liver and bones.
Tobacco smoking is a clear risk factor in the development of this disease, and people who smoke have four times the risk of bladder cancer than those who don’t. There is a strong association between bladder cancer and work related exposure to certain chemicals, such as in the rubber, aluminum, dye and leather industries, and in painters, machinists and even hair stylists. Most industrial sites now have protection against these chemicals, but exposure earlier in life has still shown to elevate the risk in later years.
The most common sign of bladder cancer is hematuria, or blood in the urine. In many cases it is microscopic, and found in the course of a urinalysis done as part of a physical exam. Other times it can be visible blood, like small clots or a change in urine color with a pink or red hue. Cytology is then run to see if any cancer cells are present, and appropriate evaluation of hematuria involves a procedure called cystoscopy, which is the doctor’s view of the inside of the bladder with an instrument that has a thin, tube like camera. Sometimes a CT urogram is done to make sure that the source of bleeding is indeed the bladder and not a trickle-down effect from the kidneys or ureter.
Earliest stage bladder cancers (which have not invaded the muscle layers of the bladder wall) can be treated with resection and fulguration (destruction by cauterization of the area) at the time of cystoscopy. This treatment is often followed by chemotherapy or immunotherapy with the installation of a substance called BCG (bacillus Calmette-Guerin), which reduces recurrences. This treatment may be instilled into the bladder for six consecutive weeks, and there are maintenance doses given over the course of a year which help overall outcome success. If the cancer has grown into the muscle layers of the bladder wall, complete removal of the bladder is usually recommended. To replace the bladder, a short piece of intestine can be used. In some cases, chemotherapy and radiation are used as an alternative to bladder removal.
The prognosis for those with superficial cancers treated by resection and BCG installation is favorable, but close surveillance, rapid recognition and prompt treatment of recurrences is necessary. Those with multiple or recurrent low grade tumors do a little less well, and removal of the bladder is usually the treatment of choice in these cases. Muscular invasion and aggressive spread have much lower survival and cure rates. Likewise, the overall prognosis is less favorable in older age individuals (above age 70).
Low grade histology with no spread and complete and early treatment often result in standard mortality. Those who need recurrent treatment may be insurable after a disease free interval. Those where muscle has been invaded or extension has occurred do the least well. Most bladder cancers because of their nature are not eligible for preferred issues.
