Bladder cancer is a cancer that starts in the bladder. The bladder is the body part that holds and releases urine. It is in the center of the lower belly area.

Transitional cell carcinoma of the bladder; Urothelial cancer

In the United States, bladder cancers usually start from the cells lining the bladder (called transitional cells).

These tumors are classified based on the way they grow:

• Papillary tumors have a wart-like appearance and are attached to a stalk.
• Nonpapillary (sessile) tumors are flat. They are much less common. However, they are more invasive and have a worse outcome.

The exact cause of bladder cancer is uncertain. However, several things may make you more likely to develop it:

• Cigarette smoking. Smoking greatly increases the risk of developing bladder cancer. Up to half of all bladder cancers in men and several in women may be caused by cigarette smoke.
• Chemical exposure at work. About one in four cases of bladder cancer is caused by coming into contact with to cancer-causing chemicals at work. These chemicals are called carcinogens. Dye workers, rubber workers, aluminum workers, leather workers, truck drivers, and pesticide applicators are at the highest risk.
• Chemotherapy: The chemotherapy drug cyclophosphamide (Cytoxan) may increase the risk of bladder cancer. Your doctor may prescribe a medicine to reduce this risk.
• Radiation treatment: Women who had radiation therapy to treat cervical cancer have an increased risk of developing bladder cancer.
• Bladder infection: A long-term (chronic) bladder infection or irritation may lead to a certain type of bladder cancer.

Some research has suggested a link between artificial sweeteners and bladder cancer. The evidence is weak.

Symptoms of bladder cancer can include:

• Abdominal pain
• Blood in the urine
• Bone pain or tenderness if the cancer spreads to the bone
• Fatigue
• Painful urination
• Urinary frequency
• Urinary urgency
• Urine leakage (incontinence)
• Weight loss

Note: Other diseases and conditions can cause similar symptoms. It is important to see a doctor to rule out all other possible causes.

The health care provider will perform a physical examination, including a rectal and pelvic exam.

Tests that may be done include:

• Abdominal CT scan
• Abdominal MRI scan
• Bladder biopsy (usually performed during cystoscopy)
• Cystoscopy (examining the inside of the bladder with a camera)
• Intravenous pyelogram - IVP
• Pelvic CT scan
• Urinalysis
• Urine cytology

If tests confirm you have bladder cancer, additional tests will be done to see if the cancer has spread. This is called staging. Staging helps guide future treatment and follow-up and gives you some idea of what to expect in the future.

The TNM (tumor, nodes, metastatis) staging system is used to stage bladder cancer:

• Ta: The cancer is in the lining of the bladder only and has not spread
• T1: The cancer goes through the bladder lining, but does not reach the bladder muscle
• T2: The cancer spreads to the bladder muscle
• T3: The cancer spreads past the bladder into the fatty tissue surrounding it
• T4: The cancer has spread to nearby structures such as the prostate gland, uterus, vagina, rectum, abdominal wall, or pelvic wall

Tumors are also grouped based on how they appear under a microscope. This is called grading the tumor. A high-grade tumor is fast growing and more likely to spread. Bladder cancer can spread into nearby areas, including the:

• Lymph nodes in the pelvis
• Bones
• Liver
• Lungs

Treatment depends on the stage of the cancer, the severity of your symptoms, and your overall health.

Stage 0 and I treatments:

• Surgery to remove the tumor without removing the rest of the bladder
• Chemotherapy or immunotherapy placed directly into the bladder

Stage II and III treatments:

• Surgery to remove the entire bladder (radical cystectomy) and nearby lymph nodes
• Surgery to remove only part of the bladder, followed by radiation and chemotherapy
• Chemotherapy to shrink the tumor before surgery
• A combination of chemotherapy and radiation (in patients who choose not to have surgery or who cannot have surgery)

Most patients with stage IV tumors cannot be cured and surgery is not appropriate. In these patients, chemotherapy is often considered.

CHEMOTHERAPY

Chemotherapy may be given to patients with stage II and III disease either before or after surgery to help prevent the tumor from returning.

For early disease (stages 0 and I), chemotherapy is usually given directly into the bladder.

A Foley catheter can be used to deliver the medication into the bladder. Common side effects include bladder wall irritation and pain when urinating. For more advanced stages (II-IV), chemotherapy is usually given by vein (intravenously).

IMMUNOTHERAPY

Bladder cancers are often treated with immunotherapy. In this treatment, a medication triggers your immune system to attack and kill the cancer cells. Immunotherapy for bladder cancer is usually performed using the Bacille Calmette-Guerin vaccine (commonly known as BCG).  A medicine called Interferon is sometimes used. It is given through a Foley catheter directly into the bladder. If BCG does not work, patients may receive interferon.

As with all treatments, side effects are possible. Ask your doctor what side effects you might expect, and what to do if they occur.

SURGERY

Surgery for bladder cancer includes:

• Transurethral resection of the bladder (TURB): Cancerous bladder tissue is removed through the urethra.
• Partial or complete removal of the bladder: Many people with stage II or III bladder cancer may need to have their bladder removed (radical cystectomy). Sometimes only part of the bladder is removed. Radiation and chemotherapy is usually given after this surgery.

Surgery may also be done to help your body drain urine after the bladder is removed. This may include:

• Ileal conduit: A small urine reservoir is surgically created from a short piece of your small intestine. The ureters that drain urine from the kidneys are attached to one end of this piece. The other end is brought out through an opening in the skin (a stoma). The stoma allows the patient to drain the collected urine out of the reservoir.
• Continent urinary reservoir: A pouch to collect urine is created inside your body using a piece of your intestine. You will need to insert a tube into an opening in your skin (stoma) into this pouch to drain the urine.
• Orthotopic neobladder: This surgery is becoming more common in patients who had their bladder removed. A part of your bowel is folded over to make a pouch that collects urine. It is attached to the place in the body where the urine normally empties from the bladder. This procedure allows you to maintain some normal urinary control.

After treatment for bladder cancer, you will be closely monitored by a doctor. This may include:

• Bone scans and CT scans to check for the spread or return of cancer
• Monitoring symptoms that might suggest the disease is getting worse, such as fatigue, weight loss, increased pain, decreased bowel and bladder function, and weakness
• Complete blood count (CBC) to monitor for anemia
• Bladder exams every 3 to 6 months after treatment
• Urinalysis if you did not have your bladder removed

How well a patient with bladder cancer does depends on the initial stage and response to treatment of the bladder cancer.

The outlook for stage 0 or I cancers is fairly good. Although the risk of the cancer returning is high, most bladder cancers that return can be surgically removed and cured.

The cure rates for people with stage III tumors are less than 50%. Patients with stage IV bladder cancer are rarely cured.

Bladder cancers may spread into the nearby organs. They may also travel through the pelvic lymph nodes and spread to the liver, lungs, and bones. Additional complications of bladder cancer include:

• Anemia
• Swelling of the ureters (hydronephrosis)
• Urethral stricture
• Urinary incontinence

Call your health care provider if you have blood in your urine or other symptoms of bladder cancer, including:

• Frequent urination
• Painful urination
• Urgent need to urinate

If you smoke, quit. Smoking can increase your risk of bladder cancer. Avoid exposure to chemicals linked to bladder cancer.

Bajorin D. Tumors of the kidney, bladder, ureters, and renal pelvis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 24th ed. Philadelphia , Pa : Saunders Elsevier; 2011: chap 203.

National Comprehensive Cancer Network. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Bladder Cancer, Including Upper Tract Tumors and Urothelial Carcinoma of the Prostate. 2012.