About 10,000 people a year in the UK get bladder cancer. It is more common in men than women and rare below the age of 50 years. Cigarette smoking is the biggest risk factor although often there does not appear to be any obvious cause. It is thought that cancer causing chemicals from the cigarettes are absorbed into the blood and then excreted in the urine where they are concentrated and lead to the cancer. Transitional cell carcinoma is the commonest type of bladder cancer and it starts in the waterproof lining on the inside of the bladder. Less common types include squamous cell carcinoma which can be associated with longstanding infection and adenocarcinoma.
Most of the cancers occur just in the lining on the inside of the bladder Sometimes they grow deeper into the muscle of the bladder wall and become invasive in which case their management is more complicated. Carcinoma-in-situ is an aggressive type of bladder cancer that again occurs just on the surface but has a much greater chance of becoming invasive.
What are the symptoms of bladder cancer?
The appearance of blood in the urine is called haematuria and this is the commonest way bladder cancer is found. This symptom should always be reported to a doctor. Sometimes the blood can’t be seen in which case it is picked up on a simple urine stick test as part of a screening test. Usually the haematuria is painless and it can be intermittent so if it stops it doesn’t mean the problem has gone away. Other causes of haematuria include infection, bladder or kidney stones or bleeding from veins over the prostate gland. Painful urination, voiding frequently and urinary urgency are usually symptoms of infection but if these symptoms don’t settle with antibiotics investigations will be necessary.
How is bladder cancer diagnosed?
Your GP will send you to see one of our specialists if there is an episode of unexplained haematuria or some other indication that there might be an underlying cancer. We will ask you questions about the bleeding and also about your general health and any medication you are taking. You will then require an examination including a prostate check in men. We can test your urine with a special NMP22 bladder check test immediately in the clinic- this test detects abnormal proteins in the urine and gives a good early indication that there might be a bladder cancer present. Usually blood tests are arranged including tests of kidney function and a PSA test. Scans of the kidneys are important and this can be either an ultrasound or CT scan. Finally we will schedule an appointment to look into the bladder with a flexible cystoscope. This is usually done under a local anaesthetic with a lubricant jelly that is gently squeezed into the urethra (at the tip of the penis or opening of the vagina) allowing the telescope to be easily passed into the bladder. The procedure takes just a few minutes but allows excellent views of the inside of the bladder and will diagnose most problems. Patients can normally go home a short while after the procedure.
How is bladder cancer treated?
If a bladder cancer is discovered during the initial tests the next step will be to arrange an admission to either Goring Hall Hospital or The Nuffield Hospital for an operation. Under a general anaesthetic ‘key hole’ techniques are used to pass an instrument through the urethra and scrape away the tumour with a hot wire loop. After the operation a catheter is required to drain the urine for one or two days until it clears. The catheter can then be removed and once voiding normally the patient can go home. Specimens obtained are sent away for histological analysis where they are examined under a microscope to determine what sort of tumour was present and how deeply it has spread into the bladder wall. Most tumours are just on the surface lining of the inside of the bladder so this initial operation will cure the problem although they have a tendency to recur so regular follow up bladder checks will be required. Often a solution called Mitomycin is instilled into the bladder for an hour after the surgery to try and prevent these recurrences in the future. Once the results of the histology are available the patients case will be discussed with a team of specialists called the Multidisciplinary Team who will determine the extent of the cancer and make a plan for any future treatment that may be required.
What if the cancer is more advanced?
Cancers that appear to be more aggressive but haven’t put down roots– so called high grade G3pT1 or CIS- often require a course of weekly bladder instillations with a substance called BCG. This is put into the bladder with a temporary catheter and again needs to be retained for about an hour. Tumours that are found to invade deeply into the wall of the bladder will require further treatment either in the form of radiotherapy or surgery (a cystectomy) to remove the bladder. A course of chemotherapy may be given first to shrink the tumour. If the bladder does have to be removed then the urine will be brought out into a bag that attaches to the skin of the abdomen (a urostomy). Alternatively we can fashion a new bladder using the patient’s bowel so that they can void the normal way after the operation (a bladder reconstruction or neobladder). We are fortunate that in our group we have a team of three surgeons who specialise in this complex operation so that two of us can operate at the same time on each case.
Luckily most tumours are just on the inner surface lining of the bladder and can be cured with simple keyhole surgery. For the more advanced cancers we are fortunate to have a team of specialists who can offer the very best treatment available. Further information can be found at http://www.macmillan.org.uk.