Chemotherapy

Bladder cancer originates in the cells that line the urinary tract and is the fourth most common cancer in men and the tenth most common cancer in women. Most men and women are diagnosed at older ages, and the disease is considered rare in those under age forty.

Cigarette smoking is the number one environmental risk factor for the development of bladder cancer, and certain industrial chemicals increase one’s risk, particularly among dye workers. The parasitic worm schistosomiasis also represents a major cause of bladder cancer in countries where it is prevalent. Genetic abnormalities account for a small percent of the cases.

The most common presenting symptom is blood in the urine, but patients often report other complaints, such as frequent urination or burning with urination. Diagnosis is made with cystoscopy and biopsy. A cystoscopy is a procedure in which growths are detected when the bladder is viewed through a special instrument. Other tests, such as an intravenous pyelogram, CT scan, or MRI, may be helpful in determining whether the disease is invasive or has spread.

Fortunately, most patients are found to have superficial bladder cancer, which means the cancerous cells are confined to the lining of the bladder and have not invaded the underlying bladder muscle tissue. In many cases the urologist can estimate if invasion is present during cystoscopy, but the final determination is made when the pathologist examines the biopsy specimen. The pathologist also grades the tumor from low- to high-grade, depending on how abnormal and aggressive the cancer cells look. Prognosis and treatment depend on tumor grade and the presence or absence of invasion or spread.


Treatment depends on whether the tumor is superficial or invasive, low- or high-grade, and whether there is local or distant spread. Superficial tumors are treated with transurethral resection, a procedure in which a urologist inserts an instrument into the bladder through the urethra that allows him or her to see the tumor, scrape it away, and then cauterize the underlying tissue. In most cases of superficial bladder cancer, this is the only treatment required.

If the tumor is very large, high-grade, and/or multifocal (meaning that more than one tumor exists in more than one location of the bladder), some specialists might recommend an additional treatment. This would consist of six weekly “instillations” of bacille Calmette-Guerin (BCG) delivered through a catheter inserted into the bladder. Interestingly, BCG is also an immunization vaccine against TB. These instillations are usually done once a week for six weeks; however, some physicians believe in repeated doses for three weeks every three months over the course of a year.

Unfortunately, superficial tumors have a high rate of reoccurrence, 40 to 80 percent, depending on the grade. This means that the patient must be cystoscoped every three to six months for three to five years. Once a patient has been diagnosed with a bladder tumor, there is risk of new tumors in the same part of the bladder or different parts. If there are multiple recurrences or grade progression, then it is advisable to have BCG or chemotherapy instillations into the bladder.

Fortunately, only a small percent of superficial cancers progress to an invasive cancer. When this occurs, though, more aggressive treatment is necessary. The gold standard for invasive bladder cancer is now considered to be a cystectomy, the surgical removal of the bladder. Prior to surgery, a patient will be evaluated to see if there is any evidence of spread. This evaluation is limited, however, and it is often not until after surgery that a more accurate assessment of disease can be made. At the time of surgery for invasive bladder cancers, lymph nodes are also removed and reviewed by the pathologist. Adjuvant chemotherapy may be recommended prior to surgery to shrink the tumor, or after surgery depending on the findings.

Ten years ago doctors believed that a bladder-sparing procedure consisting of chemotherapy concurrent with radiation therapy yielded the same results as surgery, but long-term follow-up revealed a higher rate of recurrences with this approach compared to cystectomy. The good news is that in most cases a patient does not need a ureterostomy bag. A neobladder can be reconstructed utilizing a length of colon; thus, most patients remain continent and can urinate in a normal manner.

Radiation and medical oncologists have not given up on developing a bladder-sparing procedure, and research goes on.

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