Bladder Cancer (Part 1)

Introduction

Each year in the United States, bladder cancer is diagnosed in 38,000 men and 15,000 women. This is the fourth most common type of cancer in men and the eighth most common in women. This discusses possible causes, symptoms, diagnosis, treatment, and rehabilitation. It also has information to help patients cope with bladder cancer. For other incontinence bladder problems, see Bladder Problems. For information on how your medicines affect bladder control, see Your Medicines and Bladder Control. Research is increasing what we know about bladder cancer. Scientists are learning more about its causes. They are exploring new ways to prevent, detect, diagnose, and treat this disease. Because of research, people with bladder cancer have an improved quality of life and less chance of dying from this disease. Information specialists at the NCI's Cancer Information Service can answer callers' questions about cancer and can send National Cancer Institute publications. The number to call is 1-800-4-CANCER.

The Bladder

The bladder is a hollow organ in the lower abdomen. It stores urine, the liquid waste produced by the kidneys. Urine passes from each kidney into the bladder through a tube called a ureter.

An outer layer of muscle surrounds the inner lining of the bladder. When the bladder is full, the muscles in the bladder wall can tighten to allow urination. Urine leaves the bladder through another tube, the urethra.

Understanding Cancer

Cancer is a group of many related diseases. All cancers begin in cells, the body's basic unit of life. Cells make up tissues, and tissues make up the organs of the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old and die, new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

Tumors can be benign or malignant:

• Benign tumors are not cancer. Usually, doctors can remove them. Cells from benign tumors do not spread to other parts of the body. In most cases, benign tumors do not come back after they are removed. Most important, benign tumors are rarely a threat to life.
• Malignant tumors are cancer. They are generally more serious. Cancer cells can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or the lymphatic system. That is how cancer cells spread from the original (primary) tumor to form new tumors in other organs. The spread of cancer is called metastasis.

The wall of the bladder is lined with cells called transitional cells and squamous cells. More than 90 percent of bladder cancers begin in the transitional cells. This type of bladder cancer is called transitional cell carcinoma. About 8 percent of bladder cancer patients have squamous cell carcinomas.

Cancer that is only in cells in the lining of the bladder is called superficial bladder cancer. The doctor might call it carcinoma in situ. This type of bladder cancer often comes back after treatment. If this happens, the disease most often recurs as another superficial cancer in the bladder.

Cancer that begins as a superficial tumor may grow through the lining and into the muscular wall of the bladder. This is known as invasive cancer. Invasive cancer may extend through the bladder wall. It may grow into a nearby organ such as the uterus or vagina (in women) or the prostate gland (in men). It also may invade the wall of the abdomen.

When bladder cancer spreads outside the bladder, cancer cells are often found in nearby lymph nodes. If the cancer has reached these nodes, cancer cells may have spread to other lymph nodes or other organs, such as the lungs, liver, or bones.

When cancer spreads (metastasizes) from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if bladder cancer spreads to the lungs, the cancer cells in the lungs are actually bladder cancer cells. The disease is metastatic bladder cancer, not lung cancer. It is treated as bladder cancer, not as lung cancer. Doctors sometimes call the new tumor "distant" disease.

Bladder Cancer: Who's at Risk?

No one knows the exact causes of bladder cancer. However, it is clear that this disease is not contagious. No one can "catch" cancer from another person.

People who get bladder cancer are more likely than other people to have certain risk factors. A risk factor is something that increases a person's chance of developing the disease.

Still, most people with known risk factors do not get bladder cancer, and many who do get this disease have none of these factors. Doctors can seldom explain why one person gets this cancer and another does not.

Johns Hopkins Patients' Guide to Bladder Cancer

Studies have found the following risk factors for bladder cancer:

• Age. The chance of getting bladder cancer goes up as people get older. People under 40 rarely get this disease.
• Tobacco. The use of tobacco is a major risk factor. Cigarette smokers are two to three times more likely than nonsmokers to get bladder cancer. Pipe and cigar smokers are also at increased risk.
• Occupation. Some workers have a higher risk of getting bladder cancer because of carcinogens in the workplace. Workers in the rubber, chemical, and leather industries are at risk. So are hairdressers, machinists, metal workers, printers, painters, textile workers, and truck drivers.
• Infections. Being infected with certain parasites increases the risk of bladder cancer. These parasites are common in tropical areas but not in the United States.
• Treatment with cyclophosphamide or arsenic. These drugs are used to treat cancer and some other conditions. They raise the risk of bladder cancer.
• Race. Whites get bladder cancer twice as often as African Americans and Hispanics. The lowest rates are among Asians.
• Being a man. Men are two to three times more likely than women to get bladder cancer.
• Family history. People with family members who have bladder cancer are more likely to get the disease. Researchers are studying changes in certain genes that may increase the risk of bladder cancer.
• Personal history of bladder cancer. People who have had bladder cancer have an increased chance of getting the disease again.

Chlorine is added to water to make it safe to drink. It kills deadly bacteria. However, chlorine by-products sometimes can form in chlorinated water. Researchers have been studying chlorine by-products for more than 25 years. So far, there is no proof that chlorinated water causes bladder cancer in people. Studies continue to look at this question.

Some studies have found that saccharin, an artificial sweetener, causes bladder cancer in animals. However, research does not show that saccharin causes cancer in people.

People who think they may be at risk for bladder cancer should discuss this concern with their doctor. The doctor may suggest ways to reduce the risk and can plan an appropriate schedule for checkups.

Symptoms

Common symptoms of bladder cancer include:

• Blood in the urine (making the urine slightly rusty to deep red),
• Pain during urination, and
• Frequent urination, or feeling the need to urinate without results.

These symptoms are not sure signs of bladder cancer. Infections, benign tumors, bladder stones, or other problems also can cause these symptoms. Anyone with these symptoms should see a doctor so that the doctor can diagnose and treat any problem as early as possible. People with symptoms like these may see their family doctor or a urologist, a doctor who specializes in diseases of the urinary system.

Diagnosis

If a patient has symptoms that suggest bladder cancer, the doctor may check general signs of health and may order lab tests. The person may have one or more of the following procedures:

• Physical exam -- The doctor feels the abdomen and pelvis for tumors. The physical exam may include a rectal or vaginal exam.
• Urine tests -- The laboratory checks the urine for blood, cancer cells, and other signs of disease.
• Intravenous pyelogram -- The doctor injects dye into a blood vessel. The dye collects in the urine, making the bladder show up on x-rays.
• Cystoscopy -- The doctor uses a thin, lighted tube (cystoscope) to look directly into the bladder. The doctor inserts the cystoscope into the bladder through the urethra to examine the lining of the bladder. The patient may need anesthesia for this procedure.

The doctor can remove samples of tissue with the cystoscope. A pathologist then examines the tissue under a microscope. The removal of tissue to look for cancer cells is called a biopsy. In many cases, a biopsy is the only sure way to tell whether cancer is present. For a small number of patients, the doctor removes the entire cancerous area during the biopsy. For these patients, bladder cancer is diagnosed and treated in a single procedure.

A patient who needs a biopsy may want to ask the doctor some of the following questions:

• Why do I need to have a biopsy?
• How long will it take? Will I be awake? Will it hurt?
• How soon will I know the results?
• Are there any risks? What are the chances of infection or bleeding after the biopsy?
• If I do have cancer, who will talk with me about treatment? When?

Staging

If bladder cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out whether the cancer has invaded the bladder wall, whether the disease has spread, and if so, to what parts of the body.

The doctor may determine the stage of bladder cancer at the time of diagnosis, or may need to give the patient more tests. Such tests may include imaging tests -- CT scan, magnetic resonance imaging (MRI), sonogram, intravenous pyelogram, bone scan, or chest x-ray. Sometimes staging is not complete until the patient has surgery.

These are the main features of each stage of the disease:

• Stage 0 -- The cancer cells are found only on the surface of the inner lining of the bladder. The doctor may call this superficial cancer or carcinoma in situ.
• Stage I -- The cancer cells are found deep in the inner lining of the bladder. They have not spread to the muscle of the bladder.
• Stage II -- The cancer cells have spread to the muscle of the bladder.
• Stage III -- The cancer cells have spread through the muscular wall of the bladder to the layer of tissue surrounding the bladder. The cancer cells may have spread to the prostate (in men) or to the uterus or vagina (in women).
• Stage IV -- The cancer extends to the wall of the abdomen or to the wall of the pelvis. The cancer cells may have spread to lymph nodes and other parts of the body far away from the bladder, such as the lungs.

Treatment

Many people with bladder cancer want to take an active part in decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress that people often feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some patients also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

The doctor may refer patients to doctors who specialize in treating cancer, or patients may ask for a referral. Treatment generally begins within a few weeks after the diagnosis. There will be time for patients to talk with the doctor about treatment choices, get a second opinion, and learn more about bladder cancer.

Getting a Second Opinion

Before starting treatment, a patient may want to get a second opinion about the diagnosis, the stage of cancer, and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient requests it. Gathering medical records and arranging to see another doctor may take a little time. In most cases, a brief delay does not make treatment less effective.

There are a number of ways to find a doctor for a second opinion:

• The doctor may refer patients to one or more specialists. Specialists who treat bladder cancer include surgeons, urologists, medical oncologists, radiation oncologists, and urologic oncologists. At cancer centers, these doctors often work together as a team.
• The Cancer Information Service, at 1-800-4-CANCER, can tell callers about treatment facilities, including cancer centers and other programs supported by the National Cancer Institute.
• People can get the names of specialists from their local medical society, a nearby hospital, or a medical school.
• The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries.

Preparing for Treatment

The doctor develops a treatment plan to fit each patient's needs. Treatment depends on the type of bladder cancer, the stage of the disease, and the grade of the tumor. (The grade tells how closely the cancer cells resemble normal cells. It suggests how fast the cancer is likely to grow. Low-grade cancers usually grow and spread more slowly than high-grade cancers.) The doctor also considers other factors, including the patient's age and general health.

These are some questions a patient may want to ask the doctor before treatment begins:

• What kind of bladder cancer do I have?
• What is the stage of the disease? Has the cancer spread?
• What is the grade of the tumor?
• What are my treatment choices? Which do you recommend for me? Why?
• What are the expected benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment?
• What is the treatment likely to cost? Is this treatment covered by my insurance plan?
• How will treatment affect my normal activities?

People do not need to ask all of their questions or understand all of the answers at once. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.

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