Bladder cancer

What is bladder cancer?

Bladder cancer (also called transitional cell cancer of the bladder) starts in the lining of the bladder. It is fairly common. Smoking is by far the most important cause, so for any patient diagnosed with bladder cancer, stopping smoking is one of the most important things to do.

How it is usually found

Most people are first seen because they have blood in the urine. The next step is a cystoscopy: a thin telescope is passed through the urethra and the bladder is inspected. A tumour can usually be seen on the bladder lining. Frond-like (polyp-shaped) tumours are more common; flatter, more solid (sessile) tumours are usually more concerning.

Other tests usually include a CT scan, a chest x-ray, and blood tests, to check the rest of the urinary system and look for spread.

The first procedure: TURBT

A telescope is passed into the bladder under anaesthetic, and the tumour is removed in small pieces (a "transurethral resection of bladder tumour", or TURBT). A deeper sample of the bladder wall is also taken, to find out whether the cancer has invaded into the muscle layer. What happens next depends on this pathology.

If the cancer is superficial

If the cancer is confined to the inner lining of the bladder, the main job is careful follow up. Once you have had a bladder tumour, the chance of another tumour appearing somewhere else on the bladder lining is around 80%, because the whole lining has been exposed to the same risk.

Cystoscopy checks are usually:

• Every 3 to 4 months in the first year.
• Every 4 to 6 months in the second year.
• Yearly thereafter.

For higher-risk superficial cancers, or when tumours keep coming back, extra treatment can be given inside the bladder:

• BCG. A weakened tuberculosis-related organism is placed into the bladder through a catheter, usually once a week for six weeks. The body's immune response to it also kills the cancer cells, which reduces recurrence. Side effects include urinary urgency and frequency, and (rarely) joint pains or BCG sepsis (where the organism enters the bloodstream); BCG is reserved for selected patients.
• Intravesical chemotherapy. A chemotherapy agent is placed into the bladder through a catheter. It reduces recurrence but probably does not change progression. In suitable patients, Dr Kooner's preferred option is BCG.

If the cancer is muscle-invasive

If the cancer has invaded into the muscle of the bladder wall, more aggressive treatment is needed. The usual option is cystectomy (removing the bladder), and a new way for urine to drain has to be made:

• Neobladder. A new bladder is built from a piece of bowel and joined onto the urethra. You still pass urine through the natural outlet.
• Ileal conduit. The ureters are joined to a piece of bowel that drains urine through the abdominal wall into a bag.

Bladder cancer is sensitive to chemotherapy, so for more aggressive cancers chemotherapy may be combined with surgery.