BLADDER CANCER
Cancer of the bladder usually presents with blood in the urine or a sudden change in your bladder habit, perhaps with pain. If you have any of these symptoms and a simple bladder infection has been ruled out, you need urgent specialist assessment.
Cancers can be grouped largely into whether they sit within the bladder (75%) or invade into it's muscular wall (25%). Their treatment is very different based on this and their potential to spread around the body. See below for more information and advice.
SOME FACTS ABOUT BLADDER CANCER
There are 18,000 cases of bladder cancer per year in the UK, making it one of the more common cancers. It is more common in older people, men, and in people who have been frequently exposed to certain chemical such as aniline dyes. The major risk factor you can do something about, including your risk of disease recurrence if you've already had bladder cancer, is to stop smoking, as smokers have a four-fold risk of the condition. The reason is that the cancer causing chemicals (carcinogens) in smoke are concentraed in the urine and directly act on the bladder wall. It is estimated that about half of all bladder cancers are directly attributable to smoking. The link below will offer you advice if you need to quit.
Assessment and initial treatment
Initial assessment is with a narrow flexible telescope inserted up the water pipe into the bladder (flexible cystoscopy), and a CT scan. Thereafter if a tumour is confirmed, a further procedure to try to remove it telescopically will be arranged. This is called a transurethral resection of bladder tumour (TURBT), and it can be curative if the cancer is early. It gives vital information as to how the cancer is likely to behave too. The T stage tells us whether or not it is invading into the bladder wall, and the grade tells us how aggressive the cells look. Together, as well has how big the tumour is, this information dictates what options are best. The link below takes you to a leaflet about TURBT.
TREATMENT OF NON-MUSCLE INVASIVE DISEASE
Transurethral resection
The majority of bladder tumours can be treated by telescope inserted up into the bladder under anaesthetic (transurethral resection of bladder tumour TURBT, see section above). This is often combined at the first operation with the chemical Mitomycin C being instilled into the bladder via a catheter left in at the end. This helps kill off any remaining cells, thereby reducing the likelihood of the cancer returning.
The main problem with non-invasive bladder cancers is their tendency to return in the bladder again, either because cells have seeded around the bladder from the original tumour, or because the cell damage which causes cancer at the genetic level is present in many areas all over the bladder. The second problem, which is more of a concern if there are more aggressive (high grade) cells present, is the risk of the tumour turning from the superficial, non-muscle invasive type, into the potentially more dangerous solid, muscle invasive variety. These invasive cancers have a much higher likelihood of going on to spread around the body if not caught and treated early. The button below links to a risk calculator which predicts the likelihood of tumour recurrence and progression to muscle invasion.
Intravesical Therapy
Chemicals can be put into the bladder in order to reduce the risk of both tumour returning (recurrence) and turning into an invasive tumour (progression). The two most commonly used treatments are Mitomycin C, and BCG. Both are instilled into the bladder via a temporarily inserted catheter, and are drained out or voided an hour later.
Mitomocyin C is a chemotherapy drug, which can cause irritation if spilled on the skin, but otherwise has very few side effects. Being given into the bladder, it is not normally absorbed into the blood stream in significant amounts, and therefore does not have the widespread side effects of normal chemotherapy. It can be given as a single dose immediately after TURBT, or as a 6 week (once weekly) course at a later stage to reduce the likelihood of tumour recurrence.
BCG (Bacille Calmette Guerin) is a live vaccine, and uses the body's immune system to fight bladder cancer. It is a weakened form of Tuberculosis (TB) bacteria,and is the same as can be used as injection to vaccinate against TB. The bacteria are taken up into the cancer cells which are then recognised as infected by the body's immune system, and killed off. Not surprisingly, cystitis / bladder infection symptoms are commonly experienced for a couple of days after each treatment, and occasionally other more serious side effects can develop, including fever, swelling of joints, and very occasionally a more widespread infection requiring anti-TB treatment. It is not unusual to get some shrinkage of bladder capacity with BCG, and in a small proportion of people this can be permanent. The full course of BCG lasts 3 years, starting with a 6 week (once weekly) course followed by intermittent maintenance courses of 3 doses each, totalling 27 doses over 3 years. Some people find they cannot tolerate the full course due to side effects, and evidence would suggest that the majority of benefit is gained in the first year of use, particularly in preventing tumour progression to muscle invasion.
Despite these treatment options, there remains with all bladder tumours a risk of recurrence and in higher grade cases, progression. Therefore all patients undergo a prolonged period of flexible cystoscopy surveillance. If high grade recurrences occur, or if from the outset it looks like the disease is very high risk, sometimes it becomes necessary to move on to more invasive treatment, with removal of the bladder (cystectomy) recommended to prevent disease spread.
TREATMENT OF MUSCLE INVASIVE DISEASE
Robotic Cystectomy
If the cancer is invasive, it is unlikely to be cured by TURBT alone, and has a much higher risk of spreading around the body. Survival rates unfortunately are significantly worse with increasing stage of disease (how far it's invaded or spread). There are two options which can cure the disease so long as it has not spread away from the bladder, namely removing the bladder entirely (cystectomy) or radiotherapy to the bladder. Both are often combined with an initial course of chemotherapy.
Mr Streeter introduced Robotic Cystectomy to Kent in 2012, and is one of the Country's most experienced surgeons in the technique. The advantages of robotic surgery include lower blood loss, smaller incisions, less pain, and faster recovery, with average length of stay of 4 days compared to 10 days around the region for open surgery. This is very complex surgery though, carried out entirely telescopically inside the body (intra-corporeal), and has risks of potentially very serious complications which your surgeon will explain.
Clearly, there has to be somewhere for the urine to go after the operation, and the alternatives are to have a small section of bowel isolated to carry the urine to a small spout on the skin for a bag (ileal conduit), or alternatively a reconstruction of a longer section of bowel into an internal reservoir, which you can then empty through the urethra (water pipe) by straining. This is called a neobladder. Unfortunately, they do not behave as well as a normal bladder, and problems with leakage, especially at night, and having to use catheters in and out several times a day to empty them can be encountered. For this reason, 90% of people in the UK choose the ileal conduit option.
The button below takes to East Kent Hospitals leaflet on Robotic Cystectomy, and Cancer Research UK website about invasive bladder cancer.
Chemo-Radiotherapy
If your bladder symptoms aren't too bad, and the tumour is not too bulky and is not affecting the drainage of the kidneys, then radiotherapy combined with chemotherapy is to be considered to allow you to keep your bladder functioning. You would be managed by an Oncologist, who would discuss this further with you, and talk you through potential side effects on bladder, bowel and sexual function as well as occasional more serious risks. Following radiotherapy you would continue bladder telescopic surveillance under a Urologist as well. Long term effects on bladder function, such as reduced capacity and bleeding, are not uncommon following radiotherapy.