1.What is bladder ?


The bladder is a component of the urinary tract located at the lower abdomen. It stores urine, which is expelled through a tube called the urethra. In men, the urethra passes through the prostate gland and penis, while in women, it is shorter and opens just above the vagina. The bladder’s inner lining consists of transitional or urothelial cells. The outer bladder wall has a
thick layer of muscle tissue that contracts periodically to push out urine.


Structure of the Bladder

Location: The bladder is located in the lower abdomen, just above and behind the pubic bone.

Shape and Size: It is a hollow, muscular organ that resembles a balloon. When empty, it is about the size and shape of a pear, but it can expand significantly when filled with urine.

Function of the Bladder

The primary role of the bladder is to store urine until it is ready to be excreted from the body.


2.What is bladder cancer?


Introduction

Bladder cancer is a type of cancer that begins in the cells of the bladder. The bladder is a hollow, muscular organ in the lower abdomen that stores urine before it is excreted from the body. Understanding the basics of bladder cancer can help you and your loved ones navigate the journey ahead with greater confidence and clarity.


The bladder is composed of four layers:

1) Urothelium: This layer lines the bladder, stretching as it fills and preventing urine from being reabsorbed into the body.
2) Lamina Propria: A thin layer of connective tissue situated just beneath the urothelium.
3) Muscularis Propria: A layer of muscle tissue responsible for bladder contractions.
4) Fatty Connective Tissue: This layer separates the bladder from surrounding organs and provides cushioning.


The majority of bladder cancers are urothelial carcinomas, which originate from the cells of the urothelium and then grow and spread into the deeper layers of the bladder. Less common types of bladder cancer include squamous cell carcinoma, which aMects the flat, skin-like tissues lining the bladder, and adenocarcinoma, which arises from mucus- producing cells. This guide will concentrate on urothelial carcinoma.

Types of Bladder Cancer

  1. Transitional Cell Carcinoma (TCC): This is the most common type of bladder cancer, starting in the cells that line the inside of the bladder.


Transitional cell bladder cancer is categorized into two types:

  • Superficial Tumors: These make up about 80% of cases and are limited to the inner lining or just below it in the bladder. Sometimes, the cells that form these cancers multiply and create small growths that protrude like warts from the bladder lining.
  • Muscle-Invasive Tumors: These occur in about 20% of cases and have spread to the bladder’s muscle layer or through the bladder wall.

The treatment and prognosis for these two types diMer significantly. Superficial tumors rarely spread and are typically curable. However, if untreated, they can sometimes develop into muscle-invasive tumors. Muscle-invasive tumors have a high likelihood of metastasizing to other parts of the body, making them less likely to be curable.

  1. Squamous Cell Carcinoma: This type can develop after long-term irritation or infection in the bladder.
  2. Adenocarcinoma: This is a rare type that begins in the glandular cells of the bladder.

3.What are the symptoms of bladder cancer?

The most common symptom of bladder cancer is painless blood in the urine. Other potential symptoms include:

  • Painful urination
  • Frequent urination
  • Urgent need to urinate
  • Weight loss
  • Pain in the back, lower abdomen, or bones
  • Feeling tired and unwell

If you experience any of these symptoms, you should consult your doctor. However, it’s important to remember that these symptoms can also be caused by other conditions, such as a urinary infection, and not necessarily bladder cancer.

4.How common is bladder cancer?


Bladder cancer is a significant health concern in India. According to recent statistics:


Incidence: Bladder cancer is among the top 10 most common cancers in India. It is more prevalent in men than in women.
Statistics: The estimated incidence rate is approximately 4-5 per 100,000 people annually. It is estimated that there are around 20,000 new cases of bladder cancer each year in India.


(Source: National Cancer Registry Programme (NCRP), Indian Council of Medical Research (ICMR)) Source: Esmo

5.What causes bladder cancer?

A cancerous tumor begins with a single abnormal cell, but the precise reason for this cell’s transformation into cancerous tissue is not fully understood. It is believed that damage or changes to specific genes in the cell lead to uncontrolled cell growth. The exact cause of bladder cancer is often unknown. However, several known factors can
increase the risk of developing bladder cancer:

  • Age: Bladder cancer is most commonly seen in individuals over 50 years old and is rare in those under 40.
  • Smoking: Smokers are 2-6 times more likely to develop bladder cancer compared to non-smokers. Chemicals from tobacco that are excreted in the urine can be carcinogenic to bladder cells. Smoking is estimated to be related to about half of all bladder cancer cases.
  • Chemical Exposure: Certain chemicals used in industries such as rubber and dyes have been linked to bladder cancer. Although many of these substances are now banned in the UK, bladder cancer may still occur 10-25 years after exposure.
  • Gender: Men are about three times more likely to develop bladder cancer than women.
  • Ethnicity: Bladder cancer is more prevalent among white individuals compared to black individuals.
  • Previous Treatments: A history of radiotherapy or chemotherapy can slightly increase the risk of bladder cancer.
  • Schistosomiasis: This parasitic bladder infection, found in certain hot countries, raises the risk of bladder cancer.
  • Frequent Bladder Infections: Recurrent infections of the bladder may also slightly increase the risk in some individuals.

6. How is bladder cancer diagnosed?

  • Comprehensive Metabolic Panel (CMP): This test is used to assess whether your blood work is within normal ranges.
  • Cystoscopy: This procedure allows your doctor to view the inside of your bladder. A tube called a cystoscope is inserted through your urethra into the bladder. The cystoscope has a light at its end to enhance visibility. There are two types of
    cystoscopy:
    • Flexible Cystoscopy: A thin, flexible cystoscope is used and is typically performed in the oMice with local anesthesia. This procedure is used to check for unusual lumps or to perform a biopsy.
    • Rigid Cystoscopy: A larger, straight cystoscope is used, which includes space for additional instruments. This type of cystoscopy is generally performed in the operating room under general anesthesia, allowing for sample collection or tumor removal.
  • Positron Emission Tomography (PET) Scan: This imaging test uses a tracer to detect the presence and extent of cancer.
  • Retrograde Pyelogram: An X-ray is performed to examine your ureters and kidneys.
  • Transurethral Resection of Bladder Tumor (TURBT): This surgical procedure, often conducted during a rigid cystoscopy, involves the removal of bladder tumors and is part of the diagnostic process.
  • Urine Cytology: This lab test analyzes a urine sample for the presence of cancer cells.
  • X-rays, CT Scan, or MRI: These imaging tests are used to scan and examine diMerent parts of your body.

7.Assessing the extent and spread of bladder cancer


If initial tests show that the cancer is a superficial tumor, additional tests may not be needed, as superficial bladder tumors have a low risk of spreading to other parts of the body. However, if the cancer is identified as muscle-invasive, further tests may be recommended to determine if it has spread. These tests could include a CT scan, MRI, or other imaging procedures. This process is known as staging the cancer.


Staging aims to determine:

  • How extensively the tumor has grown within the bladder, including whether it has reached the bladder wall’s outer edge or penetrated through it.
  • If the cancer has spread to nearby lymph nodes.
  • Whether the cancer has metastasized to other parts of the body.

Stages of Bladder Cancer:

  • Stage 0: Non-invasive cancer (carcinoma in situ). The cancer is confined to the bladder lining.
  • Stage I: The cancer has spread into the connective tissue layer beneath the bladder lining but has not reached the muscle layer.
  • Stage II: The cancer has invaded the muscle layer of the bladder.
  • Stage III: The cancer has spread through the bladder wall to the surrounding fatty tissue or nearby organs.
  • Stage IV: The cancer has spread to distant organs or lymph nodes.

8. Treating superficial bladder tumours


Superficial bladder tumors are cancers that start in the lining of the bladder but haven’t grown into the deeper layers. The good news is that these tumors are often treated successfully. Here are the main ways to treat them:

Transurethral Resection (TURBT): This is a common procedure where a special tool is inserted through the urethra (the tube you pee through) to remove the tumor. It’s usually done under anesthesia, so you won’t feel pain during the procedure.

  • Intravesical chemotherapy: Intravesical chemotherapy is usually given right after surgery. Mitomycin-C and gemcitabine are the most common chemotherapy drugs used for intravesical therapy. These drugs are known to kill cancer cells and are placed directly into the bladder. Because these drugs only reach the bladder lining, this type of treatment is only recommended for NMIBC. They help stop cancer cells from going to another place and growing. They also reduce the cancer recurrence rates. These drugs can be given at the time of TURBT and also can be given as a six- week induction course similar to BCG. Some people need more than one course.
  • Intravesical Therapy: Immunotherapy enhances your immune system’s ability to combat cancer. Bacillus Calmette-Guerin (BCG) is a type of immunotherapy used for treating bladder cancer. This treatment may be administered multiple times, with some patients needing several courses. The initial course typically lasts about six weeks and is usually given in your doctor’s oMice rather than a hospital or operating room. Once the bladder is clear of cancer, your doctor might recommend additional treatments with the same medication to prevent the tumor from returning.
  • Follow-Up Care: Regular check-ups and bladder tests (like cystoscopy) are important to make sure the tumor hasn’t come back and to monitor your bladder health.

    Source: ESMO

    Treating muscle-invasive tumour


    Muscle-invasive bladder cancer (MIBC) requires more aggressive treatment than superficial bladder cancer due to its potential to spread to other parts of the body. The main treatment options for MIBC include surgery, chemotherapy, radiation therapy, and immunotherapy. The choice of treatment depends on several factors, including the stage and grade of the cancer, the patient’s overall health, and personal preferences.

    1. Surgery

    • Radical Cystectomy:
      This is the most common treatment for MIBC and involves removing the entire bladder, nearby lymph nodes, and possibly parts of nearby organs that may contain cancer cells (such as the prostate in men or the uterus and part of the vagina in women).
    • Urinary Diversion: After removing the bladder, the surgeon creates a new way for urine to leave the body. Options include an ileal conduit, a continent reservoir, or a neobladder.
    • Partial Cystectomy: In some cases, only part of the bladder is removed. This is less common and usually suitable for patients with a single tumor that can be completely removed without aMecting bladder function significantly.


    2.Radiotherapy :


    Radiotherapy is frequently used as a curative treatment alternative to surgery. It can also be beneficial for individuals experiencing symptoms like pain or bleeding that are not responding to other treatments. Radiotherapy involves the use of high-energy radiation beams targeted at cancerous tissue, which either kills the cancer cells or prevents them from multiplying.


    3.Chemotherapy for Muscle-Invasive Bladder Cancer (MIBC) :


    For MIBC, chemotherapy is typically administered before bladder removal to improve the chances of survival. This pre-surgical treatment is known as neoadjuvant cisplatin-based chemotherapy (NAC). Bladder surgery is usually scheduled around 6-8 weeks after completing chemotherapy.

    If chemotherapy is not given before surgery, it may be required post-surgery depending on the tumor stage, which is referred to as adjuvant chemotherapy. However, if you have poor kidney function, hearing loss, heart problems, or certain other conditions, your doctor may advise against chemotherapy.

    Source : ESMO


    4.Immunotherapy

    Immunotherapy involves medications administered into the bloodstream through an infusion. These medications stimulate the immune system to identify and attack cancer cells.


    • Nivolumab: This drug is given to individuals with muscle-invasive bladder cancer after bladder removal surgery (cystectomy) to reduce the risk of the cancer returning. This is known as adjuvant treatment.
    • Avelumab: This medication is used as a maintenance treatment following chemotherapy for patients with metastatic cancer (cancer that has spread to other parts of the body) to help extend their life.
      Atezolizumab: Atezolizumab is administered to patients with metastatic cancer if their cancer has
      continued to progress after chemotherapy.

    10. What is the outlook for bladder cancer?

    Outlook for Bladder Cancer
    The outlook for bladder cancer depends on several factors, including the stage and grade of the cancer, the patient’s overall health, and how well the cancer responds to treatment.

    Here are some general points:

    • Early-Stage Bladder Cancer:
      Superficial or Non-Muscle Invasive Bladder Cancer (NMIBC): This type of cancer has a good prognosis when detected early. Treatment often involves surgery to remove the tumor (transurethral resection of bladder tumor, TURBT) followed by intravesical therapy. Regular follow-up is crucial to monitor for recurrence, as NMIBC can recur in about 50- 70% of cases.
    • Muscle-Invasive Bladder Cancer (MIBC):
      More Advanced Cancer: This type has a higher risk of spreading and requires more aggressive treatment, including surgery (radical cystectomy), chemotherapy, radiation therapy, or a combination of these. The prognosis depends on how far the cancer has spread. If it is confined to the bladder or nearby tissues, the chances of long-term survival are higher.
    • Metastatic Bladder Cancer:
      Cancer Spread to Other Parts of the Body: This stage is more challenging to treat and has a poorer prognosis. However, advances in treatment, including immunotherapy and targeted therapies, have improved survival rates for some patients. These treatments aim to extend life and improve quality of life.
    • Advances in Treatment:
      Innovative Therapies: Research and clinical trials are continuously improving treatment options, leading to better outcomes for many patients. Personalized medicine and targeted therapies oMer new hope for those with advanced stages of the disease.