How Is Bladder Cancer Diagnosed
Anyone with blood in the urine should have other testing done. Often, the first thing that is done is a urine cytology, which looks at the urine under a microscope to find abnormal appearing cells. If these cells are seen, a diagnosis of cancer may be made. However, the test does not detect all cases of bladder cancer.
- An X-ray of the upper urinary tract may be done to diagnose bladder cancer or to see if these structures contain cancer.
- Ultrasound can be used to study the kidneys.
- A CT scan is used to look at the entire urinary tract.
- An intravenous pyelogram can be used to study the urinary tract. An IVP puts a dye into a patients vein and then an x-ray is done a short time later. The dye exits the body via the kidneys and urine and can be seen on the x-ray, showing the kidney collecting system, ureters, and often the bladder.
Though the above tests are useful, the most important test for diagnosis and staging is a cystoscopy. A fiberoptic camera is placed into the bladder, going through the urethra. Cystoscopy allows the provider to see the entire bladder and biopsy any suspicious lesions. If the biopsy reveals cancer, a repeat cystoscopy and resection is done to see the whole tumor and if it has started to spread.
If you are diagnosed with cancer, you will also have a complete physical done. Your provider will tell you what tests you need to have done to help determine the extent of the cancer and if it has spread.
What Does Your Bladder Do
Your bladder is part of your urinary system. The job of the urinary system is to filter waste products from your blood and transport the waste products or urine, out of your body. The diagram below shows the organs of the urinary system.
Most of the urinary tract is lined with a special layer of cells called transitional cells. The primary machines in the human filtering system are the two kidneys located close to the backbone and protected by the ribs. The kidneys work independently. They have the significant task of filtering approximately 20% of total blood volume each minute and removing the by-products of digestion and of other body functions.
Once produced, the urine is stored in the central part of the kidney called the renal pelvis. At regular intervals, the renal pelvis contracts and propels the urine through the ureters. These narrow, thin-walled tubes extend from inside the renal pelvis to the bladder. The bladder is a thick-walled structure, consisting of a relatively thin inner layer with a thick muscle covering.
Stage Iii Bladder Cancer
Stage III bladder cancers have started to spread away from the bladder itself into either local or regional organs or into lymph nodes in the pelvis. Its divided into stage IIIA and stage IIIB.
Stage IIIA bladder cancer has either:
- Spread into the fat around the bladder or into the reproductive organs, but not to the lymph nodes
- Spread from the bladder to one lymph node in the pelvis
Stage IIIB cancer has also spread. To be defined as stage IIIB, cancer needs to be found in either:
- More than one lymph node far from major arteries
- One or more lymph nodes near the major arteries
According to SEER, 7% of bladder cancer cases are diagnosed when theyve reached stage III, or regional stage.
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What Are The Treatment Options For Bladder Cancer
There are four types of treatment for patients with bladder cancer. These include:
Sometimes, combinations of these treatments will be used.
Surgical options
Surgery is a common treatment option for bladder cancer. The type of surgery chosen will depend on the stage of the cancer.
- Transurethral resection of the bladder is used most often for early stage disease . It is done under general or spinal anesthesia. In this procedure, a special telescope called a resectoscope is inserted through the urethra into the bladder. The tumor is then trimmed away with the resectoscope, using a wire loop, and the raw surface of the bladder is then fulgurated .
- Partial cystectomy is the removal of a section of the bladder. At times, it is used for a single tumor that invades the bladder wall in only one region of the bladder. This type of surgery retains most of the bladder. Chemotherapy or radiation therapy is often used in combination. Only a minority of patients will qualify for this bladder-sparing procedure.
- Radical cystectomy is complete removal of the bladder. It is used for more extensive cancers and those that have spread beyond the bladder .
Chemotherapy
Stage I Bladder Cancer
Stage I bladder cancers are cancerous tumors that have spread from the inner layer of the bladder into the connective tissue layer just under it.
These tumors havent yet reached the muscular layers of the bladder, so theyre often called non-muscle-invasive bladder cancer. Some cases of non-muscle-invasive bladder cancer progress to muscle-invasive bladder cancer, which is more serious.
According to SEER, a third of bladder cancers are diagnosed when theyre local, when they havent spread beyond the organ they developed in, stage I and II.
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Risk Factors Of Bladder Cancer
By far, smoking is the biggest risk factor to be concerned about when it comes to bladder cancer. According to the National Institutes of Health, about 50% of women diagnosed with bladder cancer are smokers. Because the rate of occurrence is so much higher for smokers, if you notice any of the above symptoms and you smoke, let your doctor know as soon as possible.
Another major risk factor is previously having bladder cancer. Bladder cancer has a 50-80% recurrence rate, which is among the highest of any form of cancer. This is why it is imperative to continue to see your physician and be on the lookout for any symptoms of bladder cancer if youve had it before. When in doubt, get it checked out.
Age is another major factor. The average age of diagnosis in women is 73. Any woman over the age of 55 years old should keep an extra eye out for symptoms.
Treating Stage Iii Bladder Cancer
These cancers have reached the outside of the bladder and might have grown into nearby tissues or organs and/or lymph nodes . They have not spread to distant parts of the body.
Transurethral resection is often done first to find out how far the cancer has grown into the bladder wall. Chemotherapy followed by radical cystectomy is then the standard treatment.Partial cystectomy is rarely an option for stage III cancers.
Chemotherapy before surgery can shrink the tumor, which may make surgery easier. Chemo can also kill any cancer cells that could already have spread to other areas of the body and help people live longer. It can be especially useful for T4 tumors, which have spread outside the bladder. When chemo is given first, surgery to remove the bladder is delayed. The delay is not a problem if the chemo shrinks the cancer, but it can be harmful if it continues to grow during chemo. Sometimes the chemo shrinks the tumor enough that intravesical therapy or chemo with radiation is possible instead of surgery.
Some patients get chemo after surgery to kill any cancer cells left after surgery that are too small to see. Chemo given after cystectomy may help patients stay cancer-free longer, but so far its not clear if it helps them live longer. If cancer is found in nearby lymph nodes, radiation may be needed after surgery. Another option is chemo, but only if it wasn’t given before surgery.
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Bladder Cancer Clinical Trials
What about Clinical Trials?
You may hear about clinical trials for your bladder cancer. Clinical trials are research studies that test if a new treatment or procedure is safe and effective.
Through clinical trials, doctors find new ways to improve treatments and the quality of life for people with disease. Trials are available for all stages of cancer. The results of a clinical trial can make a major difference to patients and their families. Please visit our clinical trials research webpage to learn more.
How Does Recurrence Of Bladder Cancer Affect Survival Rate
Recurrent bladder cancer is cancer that has returned after initial treatment. Recurrence rates for bladder cancer depend on the stage of the original tumor, with 5-year recurrence rates of approximately 65% in patients with non-invasive or in situ tumors and 73% in patients with slightly more advanced disease at first diagnosis.16
Many patients with non-invasive bladder cancer have recurrences that are typically not life threatening however, the prognosis is generally worse if the disease has spread into deeper layers of the bladder wall or beyond to the lymph nodes or other organs.
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What Stages Have To Do With Cancer Spread
Cancers are staged according to tumor size and how far it has spread at the time of diagnosis. Stages help doctors decide which treatments are most likely to work and give a general outlook.
There are different types of staging systems and some are specific to certain types of cancer. The following are the basic stages of cancer:
- In situ. Precancerous cells have been found, but they havent spread to surrounding tissue.
- Localized. Cancerous cells havent spread beyond where they started.
- Regional. Cancer has spread to nearby lymph nodes, tissues, or organs.
- Distant. Cancer has reached distant organs or tissues.
- Unknown. Theres not enough information to determine the stage.
- Stage 0 or CIS. Abnormal cells have been found but have not spread into surrounding tissue. This is also called precancer.
- Stages 1, 2, and 3. The diagnosis of cancer is confirmed. The numbers represent how large the primary tumor has grown and how far the cancer has spread.
- Stage 4. Cancer has metastasized to distant parts of the body.
Your pathology report may use the TNM staging system, which provides more detailed information as follows:
T: Size of primary tumor
- TX: primary tumor cant be measured
- T0: primary tumor cant be located
- T1, T2, T3, T4: describes the size of the primary tumor and how far it may have grown into surrounding tissue
N: Number of regional lymph nodes affected by cancer
M: Whether cancer has metastasized or not
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Treating Stage Iv Bladder Cancer
These cancers have reached the pelvic or abdominal wall , may have spread to nearby lymph nodes , and/or have spread to distant parts of the body . Stage IV cancers are very hard to get rid of completely.
Chemotherapy is usually the first treatment if the cancer has not spread to distant parts of the body . The tumor is then rechecked. If it appears to be gone, chemo with or without radiation or cystectomy are options. If there are still signs of cancer in the bladder, chemo with or without radiation, changing to another kind of chemo, trying an immunotherapy drug, or cystectomy may be recommended.
Chemo is typically the first treatment when bladder cancer has spread to distant parts of the body . After this treatment the cancer is rechecked. If it looks like its gone, a boost of radiation to the bladder may be given or cystectomy might be done. If there are still signs of cancer, options might include chemo, radiation, both at the same time, or immunotherapy.
In most cases surgery cant remove all of the cancer, so treatment is usually aimed at slowing the cancers growth and spread to help people live longer and feel better. If surgery is a treatment option, its important to understand the goal of the operation whether its to try to cure the cancer, to help a person live longer, or to help prevent or relieve symptoms from the cancer.
Because treatment is unlikely to cure these cancers, many experts recommend taking part in a clinical trial.
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Treating Stage 0 Bladder Cancer
Stage 0 bladder cancer includes non-invasive papillary carcinoma and flat non-invasive carcinoma . In either case, the cancer is only in the inner lining layer of the bladder. It has not invaded the bladder wall.
This early stage of bladder cancer is most often treated with transurethral resection with fulguration followed by intravesical therapy within 24 hours.
Gleason Score For Grading Prostate Cancer
Prostate cancer is also given a grade called a Gleason score. This score is based on how much the cancer looks like healthy tissue when viewed under a microscope. Less aggressive tumors generally look more like healthy tissue. Tumors that are more aggressive are likely to grow and spread to other parts of the body. They look less like healthy tissue.
The Gleason scoring system is the most common prostate cancer grading system used. The pathologist looks at how the cancer cells are arranged in the prostate and assigns a score on a scale of 3 to 5 from 2 different locations. Cancer cells that look similar to healthy cells receive a low score. Cancer cells that look less like healthy cells or look more aggressive receive a higher score. To assign the numbers, the pathologist determines the main pattern of cell growth, which is the area where the cancer is most obvious, and then looks for another area of growth. The doctor then gives each area a score from 3 to 5. The scores are added together to come up with an overall score between 6 and 10.
Gleason scores of 5 or lower are not used. The lowest Gleason score is 6, which is a low-grade cancer. A Gleason score of 7 is a medium-grade cancer, and a score of 8, 9, or 10 is a high-grade cancer. A lower-grade cancer grows more slowly and is less likely to spread than a high-grade cancer.
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Treating Stage Ii Bladder Cancer
These cancers have invaded the muscle layer of the bladder wall , but no farther. Transurethral resection is typically the first treatment for these cancers, but it’s done to help determine the extent of the cancer rather than to try to cure it.
When the cancer has invaded the muscle, radical cystectomy is the standard treatment. Lymph nodes near the bladder are often removed as well. If cancer is in only one part of the bladder, a partial cystectomy may be done instead. But this is possible in only a small number of patients.
Radical cystectomy may be the only treatment for people who are not well enough to get chemo. But most doctors prefer to give chemo before surgery because it’s been shown to help patients live longer than surgery alone. When chemo is given first, surgery is delayed. This is not a problem if the chemo shrinks the bladder cancer, but it might be harmful if the tumor continues to grow during chemo.
If cancer is found in nearby lymph nodes, radiation may be needed after surgery. Another option is chemo, but only if it wasn’t given before surgery.
For people who have had surgery, but the features of the tumor show it is at high risk of coming back, the immunotherapy drug, nivolumab, might be offered. When given after surgery, nivolumab is given for up to one year.
For patients who cant have surgery because of other serious health problems, TURBT, radiation, chemotherapy, or some combination of these may be options.
Selecting And Testing Gemcitabine
When Dr. Messing began research on gemcitabine as a possible way to reduce recurrences more than a decade ago, the drug was not widely used for bladder cancer. We tried to pick an agent that we thought would be safe and effective, he said.
The researchers decided to compare gemcitabine against placebo rather than mitomycin C, based on studies showing how infrequently patients received some form of chemotherapy following surgery despite guidelines recommending this approach.
If the new procedure were adopted widely, we could spare patients a lot of suffering from repeated surgeries and save health care costs associated with those surgeries, Dr. Messing said.
Now that we have the results of the trial, he went on, we hope that patients and physicians will embrace this approach to treatment.
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Substantial Improvement In Survival
Dr. Powles and his colleagues enrolled 700 people with locally advanced or metastatic bladder cancer in the international JAVELIN Bladder 100 study, which was funded by Pfizer, the drug’s manufacturer.
All trial participants had already received chemotherapywith either cisplatin and gemcitabine or carboplatin and gemcitabine, if their health did not allow them to receive cisplatinand their disease had not worsened during chemotherapy.
Participants were then randomly assigned to receive either maintenance treatment with avelumab plus supportive care or supportive care alone. People in the maintenance group received infusions of avelumab every 2 weeks until their cancer started growing again or they left the study for other reasons. Supportive care for both groups included pain management, nutritional support, and treatment of infections.
People in the supportive care group whose cancer got worse did not receive avelumab as part of the trial. However, they could receive it or any other immunotherapy drug after leaving the study.
Maintenance treatment with avelumab after chemotherapy turned out to have substantial benefits. The median overall survival for people who received maintenance avelumab was more than 21 months, compared with about 14 months for people who received only supportive care until their cancer got worse.
What Is Cancer Staging
Staging is a way of describing where the cancer is located, if or where it has invaded or spread, and whether it is affecting other parts of the body.
Doctors use diagnostic tests to find out the cancers stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor recommend the best kind of treatment, and it can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.
For bladder cancer, the stage is determined based on examining the sample removed during a transurethral resection of bladder tumor and finding out whether the cancer has spread to other parts of the body.
This page provides detailed information about the system used to find the stage of bladder cancer and the stage groups for bladder cancer, such as stage II or stage IV.
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