Over 80,000 new cases of bladder cancer are diagnosed every year. Of the new cases, over 62,000 are men, and over 18,000 are women. Whites have higher incidence rates than blacks, although black patients have higher mortality rates, particularly black women. The majority of cases are found with painless gross hematuria (although most patients with gross painless hematuria don’t have bladder cancer). Nearly 80 percent of patients diagnosed with bladder cancer will survive beyond five years. When confronting bladder cancer, these are the ten questions that are essential to ask your urologist:
1. What (cell) type of bladder cancer is present?
There are various cell/tumor types with different biological behavior and risk factors. The majority of bladder cancers that we deal with are urothelial cancers (previously known as transitional cell cancer, named after the cell type prevalent along the lining of the bladder). Smoking is the greatest risk factor for this tumor, and a small but significant percentage of these patients can have tumor sites within the kidneys and ureters (tubes that bring urine down from the bladder). Other variants seen less commonly in the U.S. include squamous cell cancer, although patients who have chronic catheters or self catheterize are at increased risk to develop this variant.
2. How large is the tumor?
Like any other cancer, the size of the tumor has implications for treatment success. Tumors above 3 to 4 cm will likely need multiple procedures, are more likely to recur and will need additional therapy.
3. Are there multiple tumors?
Similar to the size, the number of tumors is an indicator of the need for multiple procedures and recurrence risk.
4. How does the tumor look?
The morphological features of bladder cancer are distinct. Its gross appearance gives us clues about its aggressiveness. Tumors that are on a broad base and sessile (immobile) are higher risk and worrisome, while tumors that appear papillary (or finger-like) or pedunculated (having a stalk) are lower risk and more curable.
5. Is the tumor high grade or low grade?
Cancer grade is reflective of how close the cancer cells are to their original cell. The closer the cells look to a normal cell and the more organized their growth pattern, the lower the grade of cancer and hence less likely to spread or return. The converse is true as well – the more different or bizarre cells appear and the more disorderly the growth pattern, the higher the grade, and the more likely the tumor is to recur and spread to other sites.
6. How deep is the tumor?
The bladder is made up of 4 concentric layers (in order from superficial to deep): mucosa, lamina propria (connective tissue layer), muscle, and fat. Tumors that have invaded into the muscle layer are considered high risk, more likely to spread, and become metastatic. These tumors generally require systemic chemotherapy followed by radical surgery to remove the bladder. Tumors within mucosa and lamina propria are considered superficial.
7. Is there carcinoma in situ?
Carcinoma in situ is a flat, superficial lesion which is high grade. It is counterintuitive in a sense because although superficial, it is considered aggressive cancer and requires adjuvant treatment (see below).
8. What are the chances the tumor recurs?
Tumors that are high grade, more penetrating (at least into the lamina propria or second layer), larger than 2 cm and multiple in nature are likely to recur. The natural history of bladder cancer is for recurrence, so low-grade cancers can recur as well. As a result, frequent cystoscopies (fiber-optic scope placed into the bladder, done in the office) are in order, usually for a lifetime (I have seen tumors come back after 15 years of indolence); every 3 to 6 months in the first three years.
Smoking cessation for those who are still actively smoking has been shown to decrease recurrence rates.
9. What are the risks of treatment?
Initial treatment is surgical via a transurethral resection (endoscopic treatment via the urethra to cut and shave the tumor out in piecemeal fashion). Risks include tearing the bladder wall, need for a catheter to help heal and decompress the bladder, bloody urine output requiring observation and irrigation, and several weeks of urinary burning.
10. Do I need adjuvant therapy?
The need for adjuvant therapy is predicated by the aggressiveness of the cancer. Tumors that are classified as superficial (haven’t invaded into the muscle layer of the bladder) but are high grade or have had a quick recurrence need adjuvant bladder instillation therapy. The standard of care is to administer Bacillus Calmette-Guerin (or BCG) into the bladder at weekly intervals after the bladder has healed from surgery (usually 2 to 4 weeks). BCG is an attenuated form of tuberculosis (once used as a vaccine in Europe and Asia, less so in the U.S.), administered into the bladder at weekly intervals usually for six weeks (induction course). Maintenance protocols after initial therapy are often indicated as well. For muscle-invasive cancers, referral to a medical oncologist for chemotherapy is indicated, usually followed by radical surgery.
Naeem Rahman is a urologist and can be reached at his self-titled site, Naeem Rahman, M.D.
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