Bladder Cancer

Bladder cancer can be a daunting diagnosis, but our team of experts at the UofL Health – Brown Cancer Center can help you through this process with a compassionate, knowledgeable approach.

Our Multidisciplinary Genitourinary Cancer Clinic team includes a specially trained urological oncologist, radiation oncologists and medical oncologists. Patients are treated with a collaborative approach to provide comprehensive, personalized care.

Our surgical expertise is one of a kind in the region, with specially trained surgeons providing cutting-edge surgical techniques including robotic procedures and neo-bladder (fashioning a new bladder) construction.

We also provide experienced care in treating advanced bladder cancers with chemotherapy and immunotherapy.

Facts

Smoking is a major risk factor for bladder cancer.

Each year, almost 71,000 new cases of bladder cancer are diagnosed in this country. Men, Caucasians and smokers have twice the risk of bladder cancer as the general population. Almost all people who develop bladder cancer are older than 55. When it is diagnosed and treated in the early stages, bladder cancer is usually highly treatable.

The bladder is a hollow organ in the lower abdomen. It stores urine, the waste that is produced when the kidneys filter the blood. The bladder has an elastic and muscular wall that allows it to get larger and smaller as urine is stored or emptied.

Urine passes from the two kidneys into the bladder through tubes called ureters. Urine leaves the bladder through another tube called the urethra. The urethra is longer in men than women.

Bladder cancer begins in the inside layer of the bladder and grows into the walls, becoming more difficult to treat.

Bladder cancer types

Bladder cancer is classified based on the type of cells it contains. The main types of bladder cancer are:

• Transitional cell bladder cancer: About 90 percent of bladder cancers are transitional cell carcinomas – cancers that begin in the urothelial cells, which line the inside of the bladder. Cancer that is confined to the lining of the bladder is called non-invasive bladder cancer.
• Squamous cell bladder cancer: This type of bladder cancer begins in squamous cells, which are thin, flat cells that may form in the bladder after long-term infection or irritation. These cancers occur less often than transitional cell cancers, but they may be more aggressive.
• Adenocarcinoma: Bladder cancer that develops in the inner lining of the bladder as a result of chronic irritation and inflammation. This type of bladder cancer tends to be aggressive.

In rare cases, bladder cancer can be passed down from one generation to the next. Genetic counseling may be right for you.

Risk factors

Anything that increases your chance of getting bladder cancer is a risk factor. These include:

• Smoking tobacco: This is the greatest risk factor for bladder cancer. Smokers, including pipe and cigar smokers, are two to three times more likely than nonsmokers to get bladder cancer. Chemicals in tobacco smoke are absorbed into the blood, and then they pass through the kidneys and collect in the urine. These chemicals can damage the inside of the bladder and increase your chances of getting bladder cancer.
• Age: The chance of developing bladder cancer increases with age, and it is uncommon in people under 40.
• Race: Bladder cancer occurs twice as often in Caucasians as it does in African-Americans and Hispanics. Asians have the lowest rate of developing the disease.
• Gender: Men are up to four times as likely as women to get bladder cancer.
• Personal history of bladder cancer: Bladder cancer has a 50 to 80 percent chance of returning after treatment. This is the highest of any cancer, including skin cancer.
• Exposure to chemicals: People who work around certain chemicals are more likely to get bladder cancer. These include:
  • People who work in the rubber, chemical and leather industries
  • Hairdressers
  • Machinists and metal workers
  • Printers
  • Painters
  • Textile workers
  • Truck drivers
  • People who work in dry cleaning businesses
• Infections: People infected with certain parasites, which are more common in tropical climates, have an increased risk of bladder cancer.
• Treatment with cyclophosphamide or arsenic: These drugs, which are used in the treatment of cancer and other conditions, raise the risk of bladder cancer. Arsenic in drinking water may increase risk too.
• Chronic bladder problems: Infections and kidney stones may be risk factors, but no direct link has been established.
• History of taking a fangchi, a Chinese herb
• Having a kidney transplant
• Hereditary nonpolyposis colon cancer (HNPCC, also called Lynch syndrome)

Not everyone with risk factors gets bladder cancer. However, if you have risk factors, it’s a good idea to discuss them with your doctor.

Symptoms

The most frequent bladder cancer symptom is blood in the urine (hematuria), which causes the urine to appear rusty or deep red in color. However, hematuria cannot always be detected by the naked eye, and it can be a symptom of other conditions such as kidney or bladder stones or a urinary tract infection.

Other bladder cancer symptoms may include:

• Changes in bladder habits
• Painful urination
• Frequent urination
• Having the urge to urinate

These symptoms do not always mean you have bladder cancer. However, it is important to discuss any symptoms with your doctor, since they may signal other health problems.

In rare cases, bladder cancer can be passed down from one generation to the next. Genetic counseling may be right for you.

Diagnosis

If you have symptoms that may signal bladder cancer, your doctor will examine you and ask you questions about your health; your lifestyle, including smoking and drinking habits; and your family medical history.

Treatment

At the Brown Cancer Center, you receive personalized bladder cancer care from some of the nation’s leading specialists. They focus extraordinary expertise on your treatment and recovery.

Your bladder cancer care is customized to include the most advanced therapies. Many of these are available at only a few locations in the United States, including:

• Advanced surgical and reconstructive procedures
• Laparoscopic robotic surgery
• Conformal 3D and IMRT radiotherapy
• Immunotherapy, including Bacillus Calmette-Guérin (BCG)
• Latest chemotherapy options

Our skilled surgeons, who utilize the latest bladder cancer and reconstruction techniques, are among the most experienced in the nation. This can make an essential difference in the success of your treatment and recovery.

If you are diagnosed with bladder cancer, your doctor will discuss the best options to treat it. This depends on several factors, including the type and stage of the cancer and your general health.

Your treatment for bladder cancer at Brown Cancer Center will be customized to your particular needs. One or more of the following therapies may be recommended to treat the cancer or help relieve symptoms.

Surgery

Surgery is part of almost every bladder cancer patient’s treatment. Other types of treatment often are given before or after surgery.

Transurethral resection (TUR) may be used for early-stage or superficial bladder cancer. A resectoscope, which is a thin tool with a wire loop on the end, is threaded through the urethra to the bladder, and then the tumor is scraped from the bladder wall. Fluorescence cystoscopy, a special way of looking at the bladder wall, may be used to enhance bladder cancer detection.

Cystectomy, which is the removal of the bladder, is often used in more advanced bladder cancer. Usually, the entire bladder is removed, but partial cystectomies may be appropriate for a small number of patients. Lymph nodes near the bladder also will be removed. The prostate is removed in men, and in women the uterus, ovaries, fallopian tubes and often a small part of the vagina are removed.

Minimally invasive surgical techniques such as laparoscopy and robotic procedures are available at Brown Cancer Center for some bladder cancer patients.

Bladder reconstruction surgery

When the bladder is removed to treat bladder cancer, surgical procedures known as urinary diversions are performed to give your body a way to store and remove urine. Urinary diversions are done at the same time as a cystectomy. There are three types of urinary diversion:

• Ilealneobladder: Part of the ileum (small intestine) is used to make a new bladder, allowing for "normal" urination. This procedure is more successful for men. It provides good daytime urinary control, with about a 20% chance of nighttime incontinence. Some women may have trouble completely emptying the neobladder and may sometimes need to use a catheter.
• Ileal conduit: A piece of the small intestine is used to create a “pipe” that connects the ureters to the surface of the skin in the navel. Urine is continuously drained into a urostomy bag worn on the outside of the body. It is a simple and efficient procedure, but some patients may have issues with wearing an external bag.
• Continent reservoir: Intestinal tissue is used to create an internal pouch that is connected to the navel. The patient uses a catheter to drain the pouch every three to four hours. This procedure is done less frequently.

Chemotherapy

Chemotherapy plays a major role in the treatment of bladder cancer that has spread (metastasized) to the lymph nodes, lungs, liver and other parts of the body. In these patients, chemotherapy is the frontline treatment.

The main chemotherapy for metastatic bladder cancer is a combination of four drugs known as MVAC: methotrexate, vinblastine, adriamycin and cisplatin. MVAC has provided good response rates since the 1980s. In recent years, the MVAC treatment regimen has been decreased from four weeks to two weeks, with less impact on the body and an improved response rate of 50% and higher.

Another chemotherapy regimen for bladder cancer is a combination of gemcitabine and cisplatinum. It has less impact on the body than MVAC, with similar response rates. Both chemotherapies have an average survival rate of 14 months.

Chemotherapy also is used with surgery when bladder cancer has a high risk of metastasis. Bladder tumors that have invaded the muscle wall and have the potential to spread can benefit from chemotherapy before surgery (neoadjuvant therapy).

Researchers are continuing to study chemotherapy combinations and dosages to improve response rates, slow tumor regrowth and decrease side effects for bladder cancer patients.

Radiation therapy

Although surgery is the frontline treatment for bladder cancer, radiation treatment has a role in certain patients. Simultaneous radiation and chemotherapy with cisplatin may be used instead of surgery in an effort to save the bladder. However, only about 40 percent of patients who have this treatment will be able to keep their bladders and not have the cancer come back.

The best candidates for radiation therapy:

• Have tumors that are localized in the bladder and have not spread
• Have only one tumor site
• Can tolerate chemotherapy and 35 radiation treatments
• Are willing to undergo rigorous follow-up after treatment

New radiation therapy techniques and remarkable skills allow our doctors to target bladder cancer tumors more precisely, delivering the maximum amount of radiation with the least damage to healthy cells.

Brown Cancer Center provides the most advanced radiation treatments for bladder cancer, including:

• 3D-conformal radiation therapy: Several radiation beams are given in the exact shape of the tumor
• Intensity-modulated radiotherapy (IMRT): Treatment is tailored to the specific shape of the tumor

Immunotherapy

Bacillus Calmette-Guérin (BCG), a bacterial organism used to treat tuberculosis, is the standard immunotherapy for superficial bladder cancer. First, the bladder wall is scraped to remove superficial tumor cells. Then, the bladder is filled with a solution containing BCG. The BCG, delivered through a catheter, stimulates an immune response within the bladder to destroy any remaining cancer cells. BCG is the most effective agent for keeping bladder cancer from spreading or coming back, and the success rate is 70 to 80 percent.

Gene therapy

We have the expertise to examine each bladder cancer tumor carefully to determine gene-expression profiles. Ongoing research will help us determine the most effective and least invasive treatment targeted to specific cancers. This personalized medicine approach sets us above and beyond most cancer centers and allows us to attack the specific causes of each cancer for the best outcomes.