WHAT'S UP DOC? Learning about bladder cancer

Q: My father was diagnosed with bladder cancer. What is his prognosis?

A: Bladder cancer is the most common cancer of the urinary system, affecting over 70,000 Americans a year. In countries where the urinary form of schistosomiasis (a parasitic disease) is prevalent, the most common type of bladder cancer is squamous cell carcinoma, accounting for 75 percent of cases. However, more than 90 percent of bladder cancers in the U.S. are transitional cell cancers, and over 80 percent of these are associated with environmental exposures, most commonly tobacco use but also exposure to certain chemicals.

The classic symptom of bladder cancer is painless hematuria (blood in the urine), typically throughout the entire urine stream and often intermittent (clearing and recurring).

Hematuria can cause irritation, so some patients have urgency, frequency and/or discomfort as well. However, less than 20 percent of people with gross hematuria have bladder cancer; most have no abnormality identified (60 percent), and many others are diagnosed with urine infections, interstitial cystitis, prostatitis, kidney stones or other kidney diseases.

The prognosis and recommended treatment for bladder cancer depend on whether it invades the muscles of the bladder and/or extends beyond the bladder or has distant metastases, and this is evaluated during staging of the extent of the disease.

The first step in staging is a cystourethroscopy, where a long tube-like instrument is inserted through the urethra to directly visualize the bladder (and ureters) and to remove any tumors (called transurethral resection of bladder tumors or TURBT). Microscopic evaluation of the tumor specimens, as well as the urine, is also done.

Examination of the regional lymph nodes (N0 is no nodes, N1 is only one diseased node within the pelvis, multiple diseased nodes within the pelvis is N2 and nodes outside the pelvis N3) and evaluation for more distant metastases (such as lung, liver and bone) are also part of disease staging. However, the main factor is whether the tumor is confined to just the bladder so TURBT may be curative, or if it has progressed outside the bladder.

Although 70 percent of new transitional cell bladder cancer cases are initially classified as Ta, Tis or T1, up to 40 percent of these are later reclassified. Over half of these will recur if managed only with TURBT, and up to a quarter of these will progress through to the muscular layer or beyond to adjacent tissue or even more distant metastases, hence adjuvant therapy with treatments directly into the bladder (intravesicular) is often recommended (depending on the details of the cell type and other specifics).

The intravesicular treatments may be chemotherapy or more commonly BCG (the same bacteria as in the tuberculosis vaccine) which is used to stimulate an immune reaction to help fight the cancer.

More invasive stages may be treated with complete removal of the bladder and any adjacent affected organs, as well as chemotherapy. Radiation therapy may also be considered, sometimes to shrink the tumor before resection or sometimes in addition to chemotherapy after resection. When the bladder is removed another method to evacuate the urine is needed, sometimes a tube to a bag outside the body, or sometimes construction of a "new" bladder using a piece of intestine.

Up to 80 percent of bladder cancer patients have at least one recurrence, even though the 5-year survival rate of Ta, TIS and T1 disease is over 80 percent. The 5-year survival drops as the extent of disease increases, with a 60 percent to 80 percent 5-year survival for T2 disease, a 20 percent to 70 percent (wide variability with other factors key to a specific patient's prognosis) for T3 disease, and a less than 20 percent survival for those with T4 disease.

Even though most hematuria patients do not have bladder cancer, since early diagnosis of bladder cancer can improve outcomes, all patients with hematuria should see their health care provider to be evaluated.